eMedicine Specialties > Obstetrics and Gynecology > Labor and Delivery

Abnormal Labor: Follow-up

Author: Saju Joy, MD, MS, Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine
Coauthor(s): Patricia L Scott, MD, Fellow in Maternal-Fetal Medicine, Wake Forest University, Bowman Gray School of Medicine; Deborah Lyon, MD, Director, Division of Gynecology, Associate Professor, Department of Obstetrics and Gynecology, University of Florida Health Science Center at Jacksonville
Contributor Information and Disclosures

Updated: Aug 3, 2009

Follow-up

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 labor—in particular, duration longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women—increases 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 5-minute Apgar score, 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.16

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.17 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.18 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 eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Labor Signs.

Miscellaneous

Medicolegal Pitfalls

  • The primary goal in labor is to provide the safest outcome for both mother and infant.
  • The primary medicolegal issue in abnormal labor is failure to diagnose.
    • Any change from the normal labor curve requires reassessment regarding the 3 P' s.
    • Once the cause of labor dysfunction is identified, correct it if possible, and closely monitor the labor.
    • If the corrective measures are unsuccessful in resolving the abnormal labor, then consider an operative delivery after obtaining informed consent.
    • Fetal heart tracing must be reassuring in order to continue with expectant management. However, if fetal compromise exists, anticipate expedited delivery.
 


More on Abnormal Labor

Overview: Abnormal Labor
Differential Diagnoses & Workup: Abnormal Labor
Treatment & Medication: Abnormal Labor
Follow-up: Abnormal Labor
Multimedia: Abnormal Labor
References
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References

  1. Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol. Dec 1955;6(6):567-89. [Medline].

  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].

  3. Rouse DJ, Owen J, Hauth JC. Criteria for failed labor induction: prospective evaluation of a standardized protocol. Obstet Gynecol. Nov 2000;96(5 Pt 1):671-7. [Medline].

  4. Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and neonatal outcomes?. Am J Obstet Gynecol. Sep 2004;191(3):933-8. [Medline].

  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].

  6. Cunningham FG, Leveno KL, Bloom SL, et al. Abnormal labor. In: Williams Obstetrics. 22nd ed. Appleton & Lange; 2007:415-434.

  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. Gabbe SJ, O'Brien WF, Cefalo RC. Labor and delivery. In: Obstetrics: Normal and Problem Pregnancies. 5th ed. 2007:322-326.

  9. 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].

  10. 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].

  11. [Best Evidence] Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev. Oct 17 2007;CD006167. [Medline].

  12. Mollberg M, Hagberg H, Bager B, et al. Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction. Obstet Gynecol. Nov 2005;106(5 Pt 1):913-8. [Medline].

  13. 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].

  14. Shields SG, Ratcliffe SD, Fontaine P, et al. Dystocia in nulliparous women. Am Fam Physician. Jun 1 2007;75(11):1671-8. [Medline].

  15. [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].

  16. [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].

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

  18. Zhu BP, Grigorescu V, Le T, et al. Labor dystocia and its association with interpregnancy interval. Am J Obstet Gynecol. Jul 2006;195(1):121-8. [Medline].

  19. 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].

  20. 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].

  21. 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].

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

  23. Friedman EA. Labor in multiparas; a graphicostatistical analysis. Obstet Gynecol. Dec 1956;8(6):691-703. [Medline].

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

  25. Gifford DS, Morton SC, Fiske M, et al. Lack of progress in labor as a reason for cesarean. Obstet Gynecol. Apr 2000;95(4):589-95. [Medline].

  26. Hoffman MK, Vahratian A, Sciscione AC, et al. Comparison of labor progression between induced and noninduced multiparous women. Obstet Gynecol. May 2006;107(5):1029-34. [Medline].

  27. Saito M, Kozuma S, Kikuchi A, et al. Sonographic assessment of the cervix before, during and after a uterine contraction is effective in predicting the course of labor. Ultrasound Obstet Gynecol. Dec 2003;22(6):604-8. [Medline].

  28. Socol ML, Peaceman AM. Active management of labor. Obstet Gynecol Clin North Am. Jun 1999;26(2):287-94. [Medline].

  29. Vahratian A, Hoffman MK, Troendle JF, et al. The impact of parity on course of labor in a contemporary population. Birth. Mar 2006;33(1):12-7. [Medline].

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Further Reading

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Keywords

dystocia, prolonged labor, arrest of dilation, arrest of descent, cephalopelvic disproportion, protraction disorder, primary dysfunctional labor, failure to progress, lack of progressive cervical dilatation, lack of descent, cephalopelvic disproportion, CPD, pelvimetry, Montevideo units, MVUs, cesarean section, c-section, cesarean birth, cesarean delivery, mechanical dystocia, functional dystocia

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Contributor Information and Disclosures

Author

Saju Joy, MD, MS, Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine
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.

Medical Editor

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; Biosphere Medical Honoraria Speaking and teaching; Eli Lilly Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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: Nothing to disclose.

CME Editor

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

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals Obstetrics/Gynecology Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board; Vice Chair for Research and Education, Department of Obstetrics/Gynecology, Tufts Medical Center
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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