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.1–3
WHAT'S NEW ON THIS TOPIC
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.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
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.1–3,6–8
Large cohort data and American College of Obstetricians and Gynecologists guidelines
Large retrospective study and Cochrane review
American College of Obstetricians and Gynecologists guideline and small retrospective study
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.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
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