Abnormal Labor Clinical Presentation

  • Author: Saju Joy, MD, MS; Chief Editor: Thomas Chih Cheng Peng, MD   more...
 
Updated: Aug 12, 2011
 

History

  • 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).Labor curve for nulliparas. Labor curve for nulliparas. Labor curve for nulliparas versus multiparas. Labor curve for nulliparas versus multiparas.
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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.
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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.
  • 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 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.[7] 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.[8]
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Contributor Information and Disclosures
Author

Saju Joy, MD, MS  Associate Director, Division Chief of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Carolinas Medical Center

Saju Joy, MD, MS is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Patricia L Scott, MD  Fellow in Maternal-Fetal Medicine, Wake Forest University, Bowman Gray School of Medicine

Patricia L Scott, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Deborah Lyon, MD  Director, Division of Gynecology, Associate Professor, Department of Obstetrics and Gynecology, University of Florida Health Science Center at Jacksonville

Deborah Lyon, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of American Medical Colleges, Association of Professors of Gynecology and Obstetrics, and Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert K Zurawin, MD  Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association

Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; ConMed Consulting fee Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard S Legro, MD  Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center

Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, and Society of Reproductive Surgeons

Disclosure: Korea National Institute of Health and National Institute of Health (Bethesda, MD) Honoraria Speaking and teaching; Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) Honoraria Speaking and teaching; American College of Obstetrics and Gynecologists (Washington, DC) Honoraria Speaking and teaching; National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Think Tank Panel (Bethesda, MD) Honoraria Speaking and teaching; University of Illinois (Chicago, IL) Honoraria Speaking and teaching; Georgetown University Hospital (Washington, DC) Honoraria Speaking and teaching; Heilongjiang University (Harbin, China) Speaking and teaching; New England Fertility Society (Nashua, NJ) Honoraria Speaking and teaching; William Beaumont Hospital Division of Reproductive Endocrinology and Infertility (Detroit, MI) Honoraria Speaking and teaching; Wayne State University School of Medicine (Detroit MI) Honoraria Speaking and teaching

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Thomas Chih Cheng Peng, MD  Professor (Collateral), Department Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, VCU Health System

Thomas Chih Cheng Peng, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

References

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  2. Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol. Oct 2002;187(4):824-8. [Medline].

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  5. Rinehart BK, Terrone DA, Hudson C, et al. Lack of utility of standard labor curves in the prediction of progression during labor induction. Am J Obstet Gynecol. Jun 2000;182(6):1520-6. [Medline].

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  7. Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. Oct 19 2005;CD000331. [Medline].

  8. Zuo Z, Goel S, Carter JE. Association of Cervical Cytology and HPV DNA Status During Pregnancy With Placental Abnormalities and Preterm Birth. Am J Clin Pathol. Aug 2011;136(2):260-5. [Medline].

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  10. Sanchez-Ramos L, Quillen MJ, Kaunitz AM. Randomized trial of oxytocin alone and with propranolol in the management of dysfunctional labor. Obstet Gynecol. Oct 1996;88(4 Pt 1):517-20. [Medline].

  11. Mitrani A, Oettinger M, Abinader EG, et al. Use of propranolol in dysfunctional labour. Br J Obstet Gynaecol. Aug 1975;82(8):651-5. [Medline].

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  14. Mehta SH, Bujold E, Blackwell SC, et al. Is abnormal labor associated with shoulder dystocia in nulliparous women?. Am J Obstet Gynecol. Jun 2004;190(6):1604-7; discussion 1607-9. [Medline].

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  16. [Best Evidence] Oppenheimer LW, Labrecque M, Wells G, Bland ES, Fraser WD, Eason E. Prostaglandin E vaginal gel to treat dystocia in spontaneous labour: a multicentre randomised placebo-controlled trial. BJOG. May 2005;112(5):612-8. [Medline].

  17. [Best Evidence] Allen VM, Baskett TF, O'Connell CM, McKeen D, Allen AC. Maternal and perinatal outcomes with increasing duration of the second stage of labor. Obstet Gynecol. Jun 2009;113(6):1248-58. [Medline].

  18. Treacy A, Robson M, O'Herlihy C. Dystocia increases with advancing maternal age. Am J Obstet Gynecol. Sep 2006;195(3):760-3. [Medline].

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  20. American College of Obstetricians and Gynecologists. ACOG technical bulletin. Dystocia and the augmentation of labor. Number 218--December 1995 (replaces no. 137, December 1989, and no. 157, July 1991). American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. Apr 1996;53(1):73-80. [Medline].

  21. American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol. Dec 2003;102(6):1445-54. [Medline].

  22. Cheng YW, Hopkins LM, Laros RK Jr, et al. Duration of the second stage of labor in multiparous women: maternal and neonatal outcomes. Am J Obstet Gynecol. Jun 2007;196(6):585.e1-6. [Medline].

  23. Creasy RK, Resnik R, Iams J. Clinical aspects of normal and abnormal labor. In: Maternal-Fetal Medicine. 5th ed. 2003:543-549.

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  25. Gardberg M, Stenwall O, Laakkonen E. Recurrent persistent occipito-posterior position in subsequent deliveries. BJOG. Feb 2004;111(2):170-1. [Medline].

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Labor curve for nulliparas.
Labor curve for nulliparas versus multiparas.
Abnormal labor curve.
Table. Abnormal Labor Indicators
IndicationNulliparaMultipara
Prolonged latent phase>20 h>14 h
Average second stage50 min20 min
Prolonged second stage without (with) epidural>2 h (>3 h)>1 h (>2 h)
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.)
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