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Abnormal Labor Follow-up

  • Author: Saju Joy, MD, MS; Chief Editor: Thomas Chih Cheng Peng, MD  more...
 
Updated: Dec 30, 2015
 

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 (see the Apgar Score calculator), 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.[8]

Nerve injury is more common in nulliparous women and is associated with long labor, fetal macrosomia, and certain positions that women assume during labor. Peripheral nerve injuries typically manifest as weakness or numbness in the distribution of the affected nerve(s), and most authors describe an uncomplicated resolution of the neuropathy within approximately 6 months. The development of a complex regional pain syndrome has also been described.[21]

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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.[22] 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.[23] 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.

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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 patient education resources, see Women's Health Center and Pregnancy Center, as well as Labor Signs.

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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, Society for Maternal-Fetal Medicine, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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, Florida Medical Association

Disclosure: Nothing to disclose.

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, Tennessee Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

John G Pierce, Jr, MD Associate Professor, Departments of Obstetrics/Gynecology and Internal Medicine, Medical College of Virginia at Virginia Commonwealth University

John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Christian Medical and Dental Associations, Medical Society of Virginia, Society of Laparoendoscopic Surgeons

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, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert K Zurawin, MD Associate Professor, Chief, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

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

Disclosure: Received consulting fee from Ethicon for consulting; Received consulting fee from Bayer for consulting; Received consulting fee from Hologic for consulting.

References
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Labor curve for nulliparas.
Labor curve for nulliparas versus multiparas.
Abnormal labor curve.
Average labor curves by parity in singleton term pregnancies with spontaneous onset of labor. Reprinted from Seminars in Perinatology, Vol 36(5), El-Sayed YY, Diagnosis and Management of Arrest Disorders: Duration to Wait, pgs 374-8, Oct 2012, with permission from Elsevier.
The 95th percentiles of cumulative duration of labor from admission among singleton term nulliparous women with spontaneous onset of labor, vaginal delivery, and normal neonatal outcomes. Reprinted from Seminars in Perinatology, Vol 36(5), El-Sayed YY, Diagnosis and Management of Arrest Disorders: Duration to Wait, pgs 374-8, Oct 2012, with permission from Elsevier.
Table. Abnormal Labor Indicators
Indication Nullipara Multipara
Prolonged latent phase >20 h >14 h
Average second stage 50 min 20 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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