Labor Dystocia in Nulliparous Patients

 

Am Fam Physician. 2021 Jan 15;103(2):90-96.

Author disclosure: No relevant financial affiliations.

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Labor dystocia refers to abnormally slow or protracted labor. It may be diagnosed in the first stage of labor (onset of contractions until complete cervical dilation) or the second stage of labor (complete cervical dilation until delivery). Dystocia is responsible for most cesarean deliveries. First- and second-stage arrest of labor may account for as many as 15% to 30% and 10% to 25%, respectively, of all primary cesarean deliveries.1  Table 1 defines protracted and arrested labor for each stage of labor.13

WHAT'S NEW ON THIS TOPIC

Labor Dystocia

A U.S. cohort study of 62,415 patients between 2002 and 2008 showed that the rate of cervical dilation in the active phase of labor was slower than that described by Friedman and that the transition point from latent to active labor was 6 cm rather than 4 cm.

A Cochrane review encompassing more than 15,000 patients reported that continuous labor support shortens labor by 35 minutes on average, reduces the risk of cesarean or operative vaginal delivery, and improves patients' satisfaction with their labor experience.

A 2017 meta-analysis of intravenous fluid administration showed that an infusion rate of 250 mL per hour in nulliparous patients may reduce the duration of labor and the cesarean delivery rate compared with 125 mL per hour.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Arrest of labor should not be diagnosed before active labor begins (i.e., cervix is dilated to 6 cm). Cesarean delivery should be reserved for patients meeting criteria for arrest of labor and who have undergone an adequate attempt at labor augmentation including oxytocin (Pitocin) and amniotomy.13,68

C

Large cohort data and American College of Obstetricians and Gynecologists guidelines

Use low-dose, rather than high-dose, oxytocin regimens when labor augmentation is required.15,16

A

Large retrospective study and Cochrane review

Consider manual rotation of occiput posterior presentation; it reduces rates of cesarean delivery and severe perineal lacerations.3,30

C

American College of Obstetricians and Gynecologists guideline and small retrospective study

One-on-one assistance from a trained labor support person (e.g., a doula) leads to improved outcomes.33

A

Cochrane review

Consider offering elective induction of labor to low-risk nulliparous patients at 39 weeks' gestation.34,37

B

American College of Obstetricians and Gynecologists guideline and Cochrane review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

NICHOLAS M. LEFEVRE, MD, is a faculty physician at the John Peter Smith Hospital Family Medicine Residency Program and Maternal-Child Health Fellowship, Fort Worth, Tex. Dr. LeFevre is also an assistant professor in the Department of Family Medicine at the Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth....

ELLISA KRUMM, MD, is director of the John Peter Smith Hospital Maternal-Child Health Fellowship and a faculty physician at the John Peter Smith Hospital Family Medicine Residency Program.

WILLIAM JACOB COBB, MD, is a senior resident at the John Peter Smith Hospital Family Medicine Residency Program and a fellow at the John Peter Smith Hospital Maternal-Child Health Fellowship.

Address correspondence to Nicholas M. LeFevre, MD, JPS Health Network, 1500 S. Main St., Fort Worth, TX 76104 (email: NLefevre@jpshealth.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Spong CY, Berghella V, Wenstrom KD, et al. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists workshop. Obstet Gynecol. 2012;120(5):1181–1193....

2. Zhang J, Landy HJ, Branch DW, et al.; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281–1287.

3. Caughey AB, Cahill AG, Guise J-M, et al.; American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179–193.

4. Friedman E. The graphic analysis of labor. Am J Obstet Gynecol. 1954;68(6):1568–1575.

5. Friedman EA. An objective approach to the diagnosis and management of abnormal labor. Bull N Y Acad Med. 1972;48(6):842–858.

6. Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol. 1999;93(3):323–328.

7. Rouse DJ, Owen J, Savage KG, et al. Active phase labor arrest: revisiting the 2-hour minimum. Obstet Gynecol. 2001;98(4):550–554.

8. Henry DEM, Cheng YW, Shaffer BL, et al. Perinatal outcomes in the setting of active phase arrest of labor. Obstet Gynecol. 2008;112(5):1109–1115.

9. Smyth RMD, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev. 2013;(6):CD006167.

10. Wei S, Wo BL, Qi H-P, et al. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database Syst Rev. 2013;(8):CD006794.

11. ACOG Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 107: induction of labor Obstet Gynecol. 2009;114(2 pt 1):386–397.

12. O'Driscoll K, Meagher D, Robson M. Active Management of Labour: The Dublin Experience. 4th ed. Mosby; 2003.

13. Merrill DC, Zlatnik FJ. Randomized, double-masked comparison of oxytocin dosage in induction and augmentation of labor. Obstet Gynecol. 1999;94(3):455–463.

14. Xenakis EM, Langer O, Piper JM, et al. Low-dose versus high-dose oxytocin augmentation of labor—a randomized trial. Am J Obstet Gynecol. 1995;173(6):1874–1878.

15. Prichard N, Lindquist A, Hiscock R, et al. High-dose compared with low-dose oxytocin for induction of labour of nulliparous women at term. J Matern Fetal Neonatal Med. 2019;32(3):362–368.

16. Budden A, Chen LJY, Henry A. High-dose versus low-dose oxytocin infusion regimens for induction of labour at term. Cochrane Database Syst Rev. 2014;(10):CD009701.

17. Ehsanipoor RM, Saccone G, Seligman NS, et al. Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2017;96(7):804–811.

18. Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013;(10):CD003934.

19. Zipori Y, Grunwald O, Ginsberg Y, et al. The impact of extending the second stage of labor to prevent primary cesarean delivery on maternal and neonatal outcomes. Am J Obstet Gynecol. 2019;220(2):191.e1–191.e7.

20. Shields SG, Ratcliffe SD, Fontaine P, et al. Dystocia in nulliparous women. Am Fam Physician. 2007;75(11):1671–1678. Accessed July 16, 2020. https://www.aafp.org/afp/2007/0601/p1671.html

21. Gupta JK, Sood A, Hofmeyr GJ, et al. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;(5):CD002006.

22. Walker KF, Kibuka M, Thornton JG, et al. Maternal position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2018;(11):CD008070.

23. Lemos A, Amorim MM, Dornelas de Andrade A, et al. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2017;(3):CD009124.

24. Cahill AG, Srinivas SK, Tita ATN, et al. Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: a randomized clinical trial. JAMA. 2018;320(14):1444–1454.

25. ACOG committee opinion no. 766: approaches to limit intervention during labor and birth Obstet Gynecol. 2019;133(2):e164–e173.

26. Werner EF, Janevic TM, Illuzzi J, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol. 2011;118(6):1239–1246.

27. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 209: obstetric analgesia and anesthesia Obstet Gynecol. 2019;133(3):e208–e225.

28. Anim-Somuah M, Smyth RM, Cyna AM, et al. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;(5):CD000331.

29. Chou MR, Kreiser D, Taslimi MM, et al. Vaginal versus ultrasound examination of fetal occiput position during the second stage of labor. Am J Obstet Gynecol. 2004;191(2):521–524.

30. Shaffer BL, Cheng YW, Vargas JE, et al. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med. 2011;24(1):65–72.

31. Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database Syst Rev. 2007;(4):CD001063.

32. Lagrew DC, Kane Low L, Brennan R, et al. National Partnership for Maternal Safety: consensus bundle on safe reduction of primary cesarean births—supporting intended vaginal births. J Obstet Gynecol Neonatal Nurs. 2018;47(2):214–226.

33. Bohren MA, Hofmeyr GJ, Sakala C, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017;(7):CD003766.

34. Middleton P, Shepherd E, Crowther CA. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2018;(5):CD004945.

35. American College of Obstetricians and Gynecologists. Practice bulletin no. 146: management of late-term and postterm pregnancies Obstet Gynecol. 2014;124(2 pt 1):390–396.

36. Grobman WA, Rice MM, Reddy UM, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513–523.

37. American College of Obstetricians and Gynecologists. Clinical guidance for integration of the findings of the ARRIVE Trial: labor induction versus expectant management in low-risk nulliparous women. August 2018. Accessed January 2019. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2018/08/clinical-guidance-for-integration-of-the-findings-of-the-arrive-trial

38. de Vaan MD, Ten Eikelder ML, Jozwiak M, et al. Mechanical methods for induction of labour. Cochrane Database Syst Rev. 2019;(10):CD001233.

39. Alfirevic Z, Aflaifel N, Weeks A. Oral misoprostol for induction of labour. Cochrane Database Syst Rev. 2014;(6):CD001338.

40. Thomas J, Fairclough A, Kavanagh J, et al. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database Syst Rev. 2014;(6):CD003101.

41. Grobman WA, Bailit J, Lai Y, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. Defining failed induction of labor. Am J Obstet Gynecol. 2018;218(1):122.e1–122.e8.

42. Lee L, Dy J, Azzam H. Management of spontaneous labour at term in healthy women. J Obstet Gynaecol Can. 2016;38(9):843–865.

43. Martin J, Hamilton BE, Osterman MJK, et al. Births: final data for 2018. Natl Vital Stat Rep. 2019;68(13):1–47.

44. Vahratian A, Zhang J, Troendle JF, et al. Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol. 2005;105(4):698–704.

45. Society of Maternal-Fetal (SMFM) Publications Committee. SMFM statement on elective induction of labor in low-risk nulliparous women at term: the ARRIVE Trial. Am J Obstet Gynecol. 2019;221(1):B2–B4.

46. Al-Ibraheemi Z, Brustman L, Bimson BE, et al. Misoprostol with Foley bulb compared with misoprostol alone for cervical ripening: a randomized controlled trial. Obstet Gynecol. 2018;131(1):23–29.

47. Carbone JF, Tuuli MG, Fogertey PJ, et al. Combination of Foley bulb and vaginal misoprostol compared with vaginal misoprostol alone for cervical ripening and labor induction: a randomized controlled trial. Obstet Gynecol. 2013;121(2 pt 1):247–252.

 

 

Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed

MOST RECENT ISSUE


Jul 2021

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article