Abnormal Labor

To define abnormal labor, a definition of normal labor must be understood and

accepted. Normal labor is defined as uterine contractions that result in
progressive dilation and effacement of the cervix. By following thousands of
labors resulting in uncomplicated vaginal deliveries, time limits and progress
milestones have been identified that define normal labor. Failure to meet these
milestones defines abnormal labor, which suggests an increased risk of an
unfavorable outcome. Thus, abnormal labor alerts the obstetrician to consider
alternative methods for a successful delivery that minimize risks to both the
mother and the infant.
Dystocia of labor is defined as difficult labor or abnormally slow progress of labor.
Other terms that are often used interchangeably with dystocia are dysfunctional
labor, failure to progress (lack of progressive cervical dilatation or lack of
descent), and cephalopelvic disproportion (CPD).
Friedman's original research in 1955 defined the following 3 stages of labor[1] :
1. The first stage starts with uterine contractions leading to complete cervical
dilation and is divided into latent and active phases. In the latent phase,
irregular uterine contractions occur with slow and gradual cervical
effacement and dilation. The active phase is demonstrated by an
increased rate of cervical dilation and fetal descent. The active phase
usually starts at 3-4 cm cervical dilation and is subdivided into the
acceleration, maximum slope, and deceleration phases.
2. The second stage of labor is defined as complete dilation of the cervix to
the delivery of the infant.
3. The third stage of labor involves delivery of the placenta.
See images below for the normal labor curves of both nulliparas and multiparas.
The following table shows abnormal labor indicators.

Table. Abnormal Labor Indicators

Indication
Nullipara
Multipara
Prolonged latent phase
>20 h
>14 h
Average second stage
50 min
20 min
Prolonged second stage without (with) >2 h (>3 h)
>1 h (>2 h)
epidural
Protracted dilation
< 1.2 cm/h
< 1.5 cm/h
Protracted descent
< 1 cm/h
< 2 cm/h
Arrest of dilation*
>2 h
>2 h
Arrest of descent*
>2 h
>1 h
Prolonged third stage
>30 min
>30 min
*Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours.
(Please refer to the Pathophysiology for information regarding adequate
contractions.)
Abnormal labor constitutes any findings that fall outside the accepted normal
labor curve. However, the authors hesitate to apply the diagnosis of abnormal
labor during the latent phase because it is easy to confuse prodromal
contractions for latent labor. In addition, the original labor curve, as defined by
Friedman, may not be completely applicable today.[2, 3, 4, 5]
Contemporary practice with supporting data suggest that the duration of labor
appears longer today than in the past. For both nulliparous and multiparous
women, labor may take longer than 6 hours to progress from 4 cm to 5 cm and
longer than 3 hours to progress from 5 cm to 6 cm of dilation. Cervical dilation of
6 cm appears to be a better landmark for the start of the active phase. The 95th
percentile for duration of the second stage in a nulliparous woman with
conduction anesthesia is closer to 4 hours.[6]

First stage of labor

Definitions for prolonged latent phase are outlined in the Table above. Diagnosis
of abnormal labor during the latent phase is uncommon and likely an incorrect
diagnosis.
Around the time uterine contractions cause the cervix to become 3-4 cm
dilated, the patient usually enters the active phase of the first stage of labor.
Abnormalities of cervical dilation (protracted dilation and arrest of dilation) as
well as descent abnormalities (protracted descent and arrest of descent) are
outlined in the Table above.
Both American College of Obstetrics and Gynecology (ACOG) and the
Consortium on Safe Labor have proposed extending the minimum period

before diagnosing active-phase arrest. The Consortium on Safe Labor defines 6

hours as the 95th percentile of time to go from 4 cm to 5 cm dilation, with the
active phase defined as beginning at 6 cm (instead of 4 cm).[7] The ACOG has
also stated that extending the time from 2 to 4 hours with oxytocin
augmentation appears effective. Irrespective of the duration, maternal and
fetal well-being status must be confirmed.
The maternal risk of a first stage greater than the 95th percentile (>30 h) is
associated with a higher cesarean delivery rate (adjusted odds ratio [aOR]:
2.28) and chorioamnionitis (aOR: 1.58). The neonatal risk is associated with a
higher incidence of neonatal ICU admissions in the absence of any other of the
major morbidities (aOR: 1.53).[6]

Second stage of labor

The Consortium on Safe Labor also addressed the 95th percentile for the second
stage for nulliparous women; it was 2.8 hours (168 min) without regional
anesthesia and 3.6 hours (216 min) with regional anesthesia. For multiparous
women, the 95th percentiles for second-stage duration with and without
regional anesthesia remained around 2 hours and 1 hour, respectively.[6, 7]
However, other studies demonstrate the risks of both maternal and perinatal
adverse outcomes rising with increased duration of the second stage,
particularly for durations longer than 3 hours in nulliparous women and 2 hours in
multiparous women.[8] Thus, careful clinical assessment of fetal and maternal
well-being must be confirmed when extending the duration of the first and
second stages of labor.
In general, abnormal labor is the result of problems with one of the 3 P' s.

Passenger (infant size, fetal presentation [occiput anterior, posterior, or

transverse])
Pelvis or passage (size, shape, and adequacy of the pelvis)
Power (uterine contractility)

Pathophysiology
A prolonged latent phase may result from oversedation or from entering labor
early with a thickened or uneffaced cervix. It may be misdiagnosed in the face
of frequent prodromal contractions. Protraction of active labor is more easily
diagnosed and is dependent upon the 3 P' s.
The first P, the passenger, may produce abnormal labor because of the infant's
size (eg, macrosomia) or from malpresentation.

The second P, the pelvis, can cause abnormal labor because its contours may
be too small or narrow to allow passage of the infant. Both the passenger and
pelvis cause abnormal labor by a mechanical obstruction, referred to as
mechanical dystocia.
With the third P, the power component, the frequency of uterine contraction
may be adequate, but the intensity may be inadequate. Disruption of
communication between adjacent segments of the uterus may also exist,
resulting from surgical scarring, fibroids, or other conduction disruption.
Whatever the cause, the contraction pattern fails to result in cervical
effacement and dilation. This is called functional dystocia. Uterine contractile
force can be quantified by the use of an intra-uterine pressure catheter. Use of
this device allows for direct measurement and calculation of uterine contractility
per each contraction and is reported in Montevideo units (MVUs). For uterine
contractile force to be considered adequate, the force produced must exceed
200 MVUs during a 10-minute contraction period. Arrest disorders cannot be
properly diagnosed until the patient is in the active phase and had no cervical
change for 2 or more hours with the contraction pattern exceeding 200 MVUs.
Uterine contractions must be considered adequate to correctly diagnose arrest
of dilation.[9]

Epidemiology
Frequency
United States
Of all cephalic deliveries, 8-11% are complicated by an abnormal first stage of
labor. Dystocia occurs in 12% of deliveries in women without a history of prior
cesarean delivery. Dystocia may account for as many as 60% of cesarean
deliveries.

Mortality/Morbidity
Both maternal and fetal mortality and morbidity rates increase with abnormal
labor. This is probably an effect-effect relationship rather than a cause-effect
relationship. Nonetheless, identification of abnormal labor and initiation of
appropriate actions to reduce the risks are matters of some urgency.
Evaluate every pregnant patient who presents with contractions in the labor
and delivery unit. Any patient in labor is at risk for abnormal labor regardless of
the number of previous pregnancies or the seemingly adequate dimensions of

the pelvis. Plot the progress of any patient in labor, and evaluate it on a labor
curve (see images below).

Presentation
Physical
Upon admission to the labor and delivery unit, determine and document clinical
findings.
Clinical pelvimetry, which is best performed at the first prenatal care visit, is
important in order to assess the pelvic type (eg, android, gynecoid, platypelloid,
anthropoid). Evaluate the position of the fetal head in early labor because
caput and moulding complicate correct assessment as labor progresses.
Establish and document an estimated fetal weight. Monitor fetal heart rate and
uterine contraction patterns to assess fetal well-being and adequacy of labor.
Perform a cervical examination to determine whether the patient is in the latent
or active phase of labor.
Addressing these issues allows for an assessment of the current phase of labor
and anticipation of whether abnormal labor from any of the 3 P' s may be
encountered.

Causes
Prolonged latent phase
The latent phase of labor is defined as the period of time starting with the onset
of regular uterine contractions and ending with the onset of the active phase
(usually 3-4 cm cervical dilation).
A prolonged latent phase is defined as exceeding 20 hours in patients who are
nulliparas or 14 hours in patients who are multiparas.
The most common reason for prolonged latent phase is entering labor without
substantial cervical effacement.

Power
Power is defined as uterine contractility multiplied by the frequency of
contractions.

Montevideo units (MVUs) refer to the strength of contractions in millimeters of

mercury multiplied by the frequency per 10 minutes as measured by intrauterine
pressure transducer.
The uterine contraction pattern should repeat every 2-3 minutes.
The uterine contractile force produced must exceed 200 MVUs/10 min for active
labor to be considered adequate. For example, 3 contractions in 10 minutes
that each reach a peak of 60 mm Hg are 60 X 3 = 180 MVUs.
An arrest disorder of labor cannot be diagnosed until the patient is in the active
phase and the contraction pattern exceeds 200 MVUs for 2 or more hours with
no cervical change. Extending the minimum period of oxytocin augmentation
for active-phase arrest from 2 up to 4 hours may be considered as long as fetal
reassurance is noted with fetal heart rate monitoring.

Pelvis or the size of the passageway inhibiting delivery

The shape of the bony pelvis (eg, anthropoid or platypelloid) can result in
abnormal labor.
A patient who is extremely short or obese, or who has had prior severe trauma to
the bony pelvis, may also be at increased risk of abnormal labor.

Size and/or presentation of the infant

Abnormal labor could also be secondary to the passenger, the size of the infant,
and/or the presentation of the infant. In addition to problems caused by the
differential in size between the fetal head and the maternal bony pelvis, the
fetal presentation may include asynclitism or head extension. Asynclitism is
malposition of the fetal head within the pelvis, which compromises the
narrowest diameter through the pelvis. Fetal macrosomia and other anomalies
(including hydrocephalus, encephalocele, fetal goiter, cystic hygroma, hydrops,
or any other abnormality that increases the size of the infant) are likely to cause
deviation from the normal labor curve.

Other factors
Other factors include either a low-dose epidural or combined spinal-epidural
anesthetics that minimize motor block and may contribute to a prolonged
second stage. These have also been associated with an increase in oxytocin
use and operative vaginal delivery. However, use of epidural for analgesia
during labor does not result in a statistically significant increase in cesarean

delivery.[10] Intravenous oversedation has also been implicated as prolonging

labor in both the latent and active phases.
An 11-year review by Zuo et al found significant correlation of reactive,
infectious, atypical, and dysplastic cytologic changes during pregnancy with
abnormal placental findings; all but dysplastic cytologic changes had
significant association with preterm birth. The study also found that the presence
of high-risk human papillomavirus (HPV) DNA was associated with placental
abnormalities and preterm birth. This suggests that cervical infection of HPV is a
risk factor for preterm birth; thus, cervical cytology is an effective tool for
screening women.[11]

Differential Diagnoses

Abruptio Placentae
Amnionitis
Malpresentation
Obstruction (eg, myomas, cervical stenosis)
Uterine anomaly (eg, mllerian, bands)

Other Tests
The simplest test used to evaluate abnormal labor is to plot the patient's labor
progress (cervical dilation vs duration in hours) on a labor curve.
A second test used to address adequate labor is the review of the uterine
contraction pattern by determining adequacy of contractions with use of an
intrauterine pressure catheter.
Most importantly, the fetal heart tracing must be reassuring throughout the labor
course.

Procedures
Clinical pelvimetry, at a minimum, must address the angles of the spinous
processes (convergent, divergent, straight), the bi-ischial diameter (>8 cm), the
distance to the sacral promontory from the symphysis pubis (>12 cm), and the
relation of the bony pelvis to the fetal head.
Clinical pelvimetry requires experience and deliberate attention to the question
of pelvic adequacy. It cannot account for fetal size or strength/frequency of
contractions, but, in experienced hands, it may reliably identify a pelvis as
adequate, borderline, or contracted.

An estimate of the fetal weight must be documented in the hospital chart early
in the labor course. If concern for macrosomia exists, this must be addressed
with the patient and the labor/delivery team in order to anticipate and prepare
for labor dystocia.

Medical Care
A prolonged latent phase (see Table in Background) is not indicative of dystocia
in itself because this diagnosis cannot be made in the latent phase. Gabbe and
colleagues state the following:[12]
For those in the latent phase, the treatment of choice is rest for several hours.
During this interval, uterine activity, fetal status, and cervical effacement must
be evaluated to determine if progress to the active phase has occurred.
Approximately 85% of patients so treated progress to the active phase.
Approximately 10% will cease to have contractions, and the diagnosis of false
labor may be made. For the approximately 5% of patients in whom therapeutic
rest fails and in patients for whom expeditious delivery is indicated, oxytocin
infusion may be used.
Use of oxytocin for active management of labor is described in the Medication
section.
Limited studies have shown improvement in dysfunctional labor with use of a
beta-blocker. In cases of dysfunctional labor resulting from functional dystocia
or an abnormal uterine contractility pattern and in which oxytocin
implementation has not improved the outcome, a beta-blocker may be
considered. Low-dose administration of intravenous propranolol in abnormal
labor augmented with oxytocin reduced the need for cesarean delivery,
particularly among patients with inadequate uterine contractility.[13, 14]
Anecdotal reports have stated that simply repositioning the patient frequently
relieves a seemingly obstructed labor. Although not studied rigorously, there
appears to be little harm in this maneuver. In theory, it may unseat an asynclitic
or malrotated presenting part and allow it to engage in the pelvis more
effectively.

Induction of labor
In a large cohort of nulliparous women who delivered singleton live births at 3942 weeks, Cheng et al observed that induction of labor was not associated with
an increased risk of cesarean delivery compared with delivery at a later
gestational age.[15] Additionally, the risk of labor dystocia for women who were

induced at 39 weeks (5.93%) was lower than for those expectantly managed
and delivered later (6.71%; aOR, 0.88). Labor dystocia was also less likely for
women who had induction at 40 weeks compared with delivery later.
Additionally, no difference in risk of operative vaginal delivery, including forceps
or vacuum-assisted vaginal delivery, was reported.
While these data support that induction may provide improved perinatal
outcomes, without impacting labor dystocia or increasing cesarean delivery
rate, the authors caution generalized implementation and recommend future
large prospective, randomized, clinical trials to further assess the potential
benefit in low-risk populations.[15]

Medication Summary
A protocol called active management of labor can be applied to nulliparous
women with singleton cephalic presentations at term. This method involves the
use of high-dose oxytocin, with a starting rate of 6 mU/min and increasing by 6
mU/min every 15 min to a maximum of 40 mU/min. The goal is no more than 7
uterine contractions per 15 min. Under this protocol, cesarean delivery is
performed if vaginal delivery has not occurred or is not imminent 12 hours after
admission or for fetal compromise. Initially, cesarean delivery rates were quoted
at 4.8%, but it has since doubled, which is attributed to widespread use of
epidural anesthesia. Other studies using the active management protocol
describe cesarean delivery rates similar to that of the low-dose protocol.
Randomized clinical trials have shown that the high-dose oxytocin regimens
result in shorter labors than low-dose regimens without adverse effects for the
fetus.[19]
Dinoprostone and misoprostol are prostaglandin analogs used to stimulate
cervical dilation and uterine contractions; they are pharmacologic alternatives
to using laminaria or placing a Foley bulb in the cervix. Using prostaglandin
analogs with a scarred uterus (eg, from prior cesarean or myomectomy) for
labor induction is absolutely contraindicated due to the significant risk for
uterine rupture.
A randomized clinical trial testing the safety and efficacy of prostaglandin E2
(PgE2) as a treatment for dystocia in spontaneous labor revealed that a single 1mg dose of PgE2 vaginal gel is more effective than placebo in resolving
dystocia without increasing uterine hyperstimulation, but it may be associated
with an increase in the incidence of second stage cesarean delivery.[20]

Oxytocics

Class Summary
Oxytocin is the only US Food and Drug Administration (FDA)approved
medication recommended for labor augmentation. Other options include
dinoprostone and misoprostol.
View full drug information

Oxytocin (Pitocin)

Produces rhythmic uterine contractions and can stimulate the gravid uterus. Has
vasopressive and antidiuretic effects. Can also control postpartum bleeding or
hemorrhage. Has a half-life of 3-5 min, and reaches steady state in
approximately 40 min.

Beta-adrenergic blocking agents

Class Summary
Another option for abnormal labor
contractility is a beta-blocker.

secondary

to

inadequate

uterine

View full drug information

Propranolol (Inderal)

Nonselective beta-adrenergic receptor blocker.

Complications
Maternal infection is a risk, especially when rupture of membranes occurs for
more than 18 hours. Administer antibiotics for signs and symptoms of
chorioamnionitis.
Fetal compromise can occur from the inability to tolerate labor (eg, uterine
hyperstimulation) or infection, and it must be closely evaluated. Fetal heart
monitoring often reveals signs of compromise with decelerations, and fetal scalp
pH is an option when indicated.

Probably the most common complication of the medical induction of labor is

hyperstimulation of the uterus. If unrecognized and untreated, excessive
stimulation of the uterus can result in fetal compromise, cord compression, and
uteroplacental insufficiency. Uterine rupture, postpartum uterine atony, and
postpartum hemorrhage may occur and can be life-threatening complications
requiring emergent action.
Allen et al found that increased duration of the second stage of laborin
particular, duration longer than 3 hours in nulliparous women and longer than 2
hours in multiparous womenincreases the risk of both maternal and perinatal
adverse outcomes. In their population-based cohort study in 121,517 women
(52% nulliparous), women with a prolonged second stage were at increased risk
for obstetric trauma, postpartum hemorrhage, puerperal febrile morbidity, and
composite maternal morbidity, while their infants were at increased risk for low 5minute Apgar score (see the Apgar Score calculator), birth depression,
admission to the neonatal intensive care unit, and composite perinatal
morbidity. Method of delivery modified the effect of duration of second stage
among nulliparous women only.[8]
Nerve injury is more common in nulliparous women and is associated with long
labor, fetal macrosomia, and certain positions that women assume during labor.
Peripheral nerve injuries typically manifest as weakness or numbness in the
distribution of the affected nerve(s), and most authors describe an
uncomplicated resolution of the neuropathy within approximately 6 months. The
development of a complex regional pain syndrome has also been described. [21]

Prognosis
The prognosis of subsequent pregnancies depends on the cause for abnormal
labor. For example, if abnormal labor occurs from macrosomia, the next infant
may not be macrosomic. However, if the abnormal labor was secondary to a
contracted pelvis with a normal-sized or small infant, then the likelihood for a
recurrence of abnormal labor is high.
In an attempt to determine whether increasing maternal age is more commonly
associated with dystocia, a study by Treacy et al demonstrated that the
incidences of oxytocin augmentation, prolonged labor, instrument delivery, and
intrapartum cesarean delivery (including cesarean for dystocia) all increased
significantly and progressively with increasing maternal age.[22] This study used
an established active management protocol, and oxytocin augmentation
proved a generally effective intervention in all age categories. These findings
have implications for the analysis of intervention rates by health care providers,

particularly in developed countries where the proportion of older nulliparas is

increasing.
A study by Zhu et al revealed that, with increasing interpregnancy intervals, the
risk for labor dystocia increases.[23] Both functional and mechanical dystocia
were more prevalent in first births than in subsequent births. In singleton births to
multiparous mothers, labor dystocia was associated with the interpregnancy
interval in a dose-response fashion. Compared with an interpregnancy interval
of less than 2 years, the adjusted odds ratios that was associated with
interpregnancy intervals of 2-3, 4-5, 6-7, 8-9, and 10+ years were 1.06, 1.15, 1.25,
1.31, and 1.50, respectively, when controlled for other reproductive risk factors.
Functional dystocia was associated more strongly with interpregnancy interval
than mechanical dystocia.

Patient Education
The patient must be aware of all risks involved with labor, including the potential
for emergent cesarean delivery if the fetus appears compromised. Furthermore,
she should be kept informed of her status throughout the labor course,
especially if a change in management is anticipated. Counsel patients early in
pregnancy that maternal weight gain correlates with fetal weight gain, and
excessive gain and prepregnancy obesity are risk factors for abnormal labor.
For excellent patient education resources, visit eMedicineHealth's Pregnancy
Center. Also, see eMedicineHealth's patient education article Labor Signs.