Abnormal Labor Medication

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

Medication Summary

A protocol called active management of labor can be applied to nulliparous women with singleton cephalic presentations at term. This method involves the use of high-dose oxytocin, with a starting rate of 6 mU/min and increasing by 6 mU/min every 15 min to a maximum of 40 mU/min. The goal is no more than 7 uterine contractions per 15 min. Under this protocol, cesarean delivery is performed if vaginal delivery has not occurred or is not imminent 12 hours after admission or for fetal compromise. Initially, cesarean delivery rates were quoted at 4.8%, but it has since doubled, which is attributed to widespread use of epidural anesthesia. Other studies using the active management protocol describe cesarean delivery rates similar to that of the low-dose protocol. Randomized clinical trials have shown that the high-dose oxytocin regimens result in shorter labors than low-dose regimens without adverse effects for the fetus.[15]

Dinoprostone and misoprostol are prostaglandin analogs used to stimulate cervical dilation and uterine contractions; they are pharmacologic alternatives to using laminaria or placing a Foley bulb in the cervix. Using prostaglandin analogs with a scarred uterus (eg, from prior cesarean or myomectomy) for labor induction is absolutely contraindicated due to the significant risk for uterine rupture.

A randomized clinical trial testing the safety and efficacy of prostaglandin E2 (PgE2) as a treatment for dystocia in spontaneous labor revealed that a single 1-mg dose of PgE2 vaginal gel is more effective than placebo in resolving dystocia without increasing uterine hyperstimulation, but it may be associated with an increase in the incidence of second stage cesarean delivery.[16]

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Oxytocics

Class Summary

Oxytocin is the only US Food and Drug Administration (FDA)–approved medication recommended for labor augmentation. Other options include dinoprostone and misoprostol.

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Oxytocin (Pitocin)

 

Produces rhythmic uterine contractions and can stimulate the gravid uterus. Has vasopressive and antidiuretic effects. Can also control postpartum bleeding or hemorrhage. Has a half-life of 3-5 min, and reaches steady state in approximately 40 min.

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Beta-adrenergic blocking agents

Class Summary

Another option for abnormal labor secondary to inadequate uterine contractility is a beta-blocker.

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Propranolol (Inderal)

 

Nonselective beta-adrenergic receptor blocker.

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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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  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].

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

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

  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].

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  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].

  26. 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].

  27. 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].

  28. 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].

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

  30. 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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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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