Abnormal Labor and Delivery

UNC School of Medicine

Obstetrics and Gynecology Clerkship
Case Based Seminar Series

Objectives
Review abnormal labor patterns
Describe the causes and methods of evaluating
abnormal labor patterns
Discuss fetal and maternal complications of
abnormal labor
Review indications and contraindications for
oxytocin administration
Review risks and benefits of trial of labor after
Cesarean delivery
Review strategies for emergency management of
Breech, shoulder dystocia and cord prolapse

THE 5 Ps
The factors that contribute to normal labor
Passageway: maternal pelvis
Power: uterine contractions
Passenger: fetus
Placenta: perfusion
Psyche: mothers readiness

Abnormal Labor Patterns

Remember the 3 stages of normal labor
First stage time from onset of regular contractions
to complete cervical dilation
Latent gradual cervical change
Active rapid cervical change

Second stage time from complete cervical dilation

to expulsion of the fetus
Third stage time from expulsion of fetus to delivery
of placenta

Abnormal labor patterns can be divided into two

general types
Protraction
Arrest

Friedman Labor Curve

Slope of the curve
changes with
parity
A multipara will
exhibit more rapid
cervical dilation

The diagnosis of
protraction and
arrest disorders is
based on
deviations from
this norm

First and Second Stage Disorders

First stage
Protraction slower than acceptable cervical dilation
<1.2 cm/hr for nulliparous women
<1.5 cm/hr for multiparous women

Arrest no cervical change

No cervical change for >/= 4 hours despite adequate contractions
No cervical change for >/= 6 hours with inadequate contractions

Second stage
Protraction
Nulliparas
Longer than 2 hours (3 with regional anesthesia)
Multiparas
Longer than 1 hour (2 when regional anesthesia)

Arrest
Nulliparas
No progress after >/= 4 hours with epidural (3 without)
Multiparas
No progress after >/= 3 hours with epidural (2 without)

Disorders of the Active Phase

Secondary Arrest: cessation of previously

normal rate of dilation for two hours
Combined Disorder: cessation of dilation
when patient has previously exhibited a
primary dysfunctional labor

Risk factors for abnormal labor

Older maternal age
Non-reassuring FHR
Epidural anesthesia
Macrosomia
Maternal obesity
Post-term pregnancy
Cephalopelvic disproportion
Occiput posterior position
High station at full dilatation
Nulliparity
Inadequate contractions

Management of Abnormal Labor

First stage, active phase disorders
Augmentation of labor

Second stage disorders

Operative vaginal delivery

Bishop Score will labor induction be successful?

Dilation

Closed

1-2

34

>5

Effacement

0 30

40 50

60 70

> 80

Station

-3

-2

-1

+1, +2

Consistency

Firm

Medium

Soft

Position

Posterior

Mid

Anterior

Augmentation/Induction of Labor
Before augmentation assess: maternal pelvis and
cervix, fetal position/station/well-being
Augmentation can be achieved using:
Amniotomy
Allows the fetal head to be the dilating force

Oxytocin administration
Foley bulb

Oxytocin
Synthetic analog of peptide secreted from posterior
pituitary
Diluted in crystalloid and delivered IV via infusion
pump
10 units/ml; dilute in 1000 cc LR
IV bolus hypotension
At high doses, cross reacts with ADH receptors
hyponatremia and excessive water retention

Dosing various accepted protocols, dosed to effect

Routine dose: Start at 2mu/min, 2 mu/min every 1530 minutes to 36 IU/min
Active management of labor: start at 6 mu/min, by 6
mu/min every 15 minutes to 36 mu/min

Oxytocin
Indications
Labor induction in patient with high Bishop score

Contraindications

Prior classical or high-risk cesarean incision

Prior uterine rupture
Active genital herpes
Placenta previa
Umbilical cord prolapse
Transverse fetal lie
Category III fetal heart rate tracing

Misoprostol (Cytotec)
PGE1 (prostaglandin_
Has several clinical uses
Prevention of NSAID-induced gastric ulcers
Medical termination of pregnancy
Treatment of postpartum hemorrhage

Unlabeled use for labor induction or cervical

ripening
25 mcg (1/4 of 100mcg tablet) in vagina Q 4
hours X 4 doses
Wait 6 hours after last dose to start oxytocin
Contraindicated with uterine eschar

Foley Bulb
Place special foley through cervix and inflate
balloon to 30cc
Tape to thigh remove by 12 hours
Mechanism: mechanical/local release of
prostaglandins
Frequently used with Oxytocin

Forceps Assisted Vaginal Delivery

Outlet forceps:
Scalp visible at the introitus w/o parting the labia
Sagittal suture < 45 degrees

Low forceps:
Leading point of skull at +2 or below
< 45 degrees
> 45 degrees

Mid-forceps:
Head is engaged but presenting part is above +2 station
Rarely done

Vacuum versus Forceps

Forceps
More maternal trauma
Minimal fetal trauma (bruising)
Vacuum
Less maternal trauma
Potential for increased fetal trauma
(subgaleal bleeding)

Mitivac vacuum

Episiotomy

Used for abnormal second stage of labor

Originally thought to protect perineum
Now thought to result in more 3rd and 4th degree
extensions
More perineal pain

ACOG recommends restricted use rather than

routine use
At UNC less that 3% of patients
Mediolateral episiotomy preferable to median due
to higher rate of anal sphincter injury

Third Stage Disorders

Retained placenta
Uterine rupture
Post-partum hemorrhage

Postpartum Hemorrhage
Diagnosis
> 500 mL for vaginal birth
> 1000 mL for C/S

Causes
Uterine atony
Placenta problem
Laceration

Treatment

Pitocin
Cytotec
Hemabate
Methergine

Fourth Stage Disorders

Bonding
Delayed postpartum hemorrhage

Complications of abnormal labor

Maternal
Chorioamnionitis
Post-partum hemorrhage
Operative vaginal delivery
Third/fourth degree perineal lacerations

Fetal
Good neonatal outcomes after protracted first stage
Prolonged second stage not an independent risk factor for
neonatal morbidity either

Shoulder Dystocia
It cannot be predicted or prevented
Associated with prolonged second stage
Conditions that are associated with shoulder
dystocia
Multiparity
Macrosomia
Prior episode of shoulder dystocia

Associated with brachial plexus injuries

Most cases resolve without disability
Less than 2% brachial plexus injuries will be
permanent

Shoulder Dystocia
A subjective clinical diagnosis
Diagnosis
Delivered fetal head retracts against maternal
perineum (turtle sign)

When suspected, goal is to intervene before

asphyxia
Management disimpact the shoulder
McRoberts maneuver application of suprapubic
pressure
Not fundal pressure as this may worsen impaction

Zavanelli maneuver fetal head flexed and reinserted into vagina

Intentional fracture of clavicle
There are several other maneuvers. There have been
no RCTs comparing maneuvers. No maneuver is
clearly superior than the other.

Ritgen Maneuver

Erbs palsey

Breech Presentation
Occurs in 2% of singleton pregnancies
Occurs more frequently in second and early third trimesters
Conditions that are associated with breech presentation

Multiple gestation
Polyhydramnios
Anencephaly
Uterine anomalies

Diagnosed with Leopold maneuvers, pelvic examination, U/S

Morbidity and mortality for both the mother and fetus is
higher is fetus is breech

3 Kinds of Breech Presentation

Frank breech

Complete breech

Incomplete breech

Management of Breech Presentation

External cephalic version applying pressure to
abdomen to turn fetus in a forward or backward
somersault
Successful 50% of the time

Selection Criteria
Preferred candidates have completed 37 weeks gestation

Risks
Rupture of membranes
Placental abruption
Uterine rupture

Procedure
Tocolysis with terbutaline

Cesarean delivery
Vaginal delivery

Cesarean Delivery

Umbilical Cord Prolapse

A rare (<1%) emergency
Can compromise blood flow to fetus

The cord descends alongside or beyond the fetal

presenting part
Possible etiologies
Fetomaternal: malpresentation, low birth weight,
multiple gestation, polyhydramnios
Iatrogenic obstetrical interventions

Umbilical Cord Prolapse

Diagnosis
Sudden, sever, prolonged bradycardia or decelerations
Overt palpable upon vaginal examination
Occult confirmed after cesarean delivery

Management
Immediate cesarean birth
Temporizing measures
Manual elevation of presenting part
Bladder filling

Trial of Labor after Cesarean (TOLAC)

The decision for TOLAC v. scheduled cesarean delivery is
made using clinical judgement and shared decisionmaking.
Risks
Uterine rupture
Peripartum hysterectomy (may be due to uterine rupture or
placenta accreta)
Hemorrhage
Transfusion
Infection
Neonatal morbidity and mortality

Benefits
Avoid risks associated with cesarean delivery

VBAC/Trial of Labor
One previous LTCS (1% rate of
rupture)
Two previous LTCS (2% rupture)
Unknown incision (up to 7%
rupture)
Success of TOLAC = VBAC (vaginal
birth after cesarean section): 60
80%

TOLAC Candidates
Factors to consider:
Prior vaginal birth
Spontaneous labor
Bishop score
Fetal weight
Prior uterine incisions (number and type)

USA TRENDS

Bottom Line Concepts

Historically, the Friedman curve has been accepted as the standard
assessment of the normal progression of labor
Abnormal labor includes both arrest and protraction disorders
Dystocia results from problems with power (uterine contractions),
passenger (size, position, presentation) and passage (pelvis)
The Bishop score can be used to determine whether or not a patient
has a favorable cervix for augmentation of labor.
Oxytocin can be administered to augment labor.
For arrest of the second stage of labor, intervention is not indicated as
long as fetal heart rate pattern is reassuring
Shoulder dystocia cannot be predicted or prevented, so, obstetricians
must be able to quickly recognize it and intervene promptly
Umbilical cord prolapse is a rare obstetrical emergency
Candidates for TOLAC should be chosen carefully based on history.
Providers should also engage in shared decision-making, explaining
the risks and benefits.