eMedicine Specialties > Obstetrics and Gynecology > Labor and Delivery
Abnormal Labor: Treatment & Medication
Updated: Aug 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
A prolonged latent phase (see Table in Background) is not indicative of dystocia in itself because this diagnosis cannot be made in the latent phase. Gabbe and colleagues state the following:8
For those in the latent phase, the treatment of choice is rest for several hours. During this interval, uterine activity, fetal status, and cervical effacement must be evaluated to determine if progress to the active phase has occurred. Approximately 85% of patients so treated progress to the active phase. Approximately 10% will cease to have contractions, and the diagnosis of false labor may be made. For the approximately 5% of patients in whom therapeutic rest fails and in patients for whom expeditious delivery is indicated, oxytocin infusion may be used.
Use of oxytocin for active management of labor is described in the Medication section.
Limited studies have shown improvement in dysfunctional labor with use of a beta-blocker. In cases of dysfunctional labor resulting from functional dystocia or an abnormal uterine contractility pattern and in which oxytocin implementation has not improved the outcome, a beta-blocker may be considered. Low-dose administration of intravenous propranolol in abnormal labor augmented with oxytocin reduced the need for cesarean delivery, particularly among patients with inadequate uterine contractility.9,10
Anecdotal reports have stated that simply repositioning the patient frequently relieves a seemingly obstructed labor. Although not studied rigorously, there appears to be little harm in this maneuver. In theory, it may unseat an asynclitic or malrotated presenting part and allow it to engage in the pelvis more effectively.
Surgical Care
Amniotomy is often used and has become an accepted practice once the patient has reached the active phase of labor, although it has not been shown to result in shorter labor.11 This practice is not recommended in the latent phase of labor because it may only serve to increase the risk of intrauterine infection or cord prolapse.
If one of the arrest or protraction disorders is identified and fails to respond to conservative measures, or if the fetal heart pattern is nonreassuring, expedient delivery is justified; this includes operative vaginal delivery (if appropriate) or cesarean delivery as indicated. Operative delivery with use of forceps or vacuum must be performed by an experienced provider. One should be aware of the increased associations for shoulder dystocia and neonatal injury with operative vaginal delivery in the setting of abnormal labor.12,13
Diet
- Most institutions have standing orders that patients in labor have nothing by mouth as a precaution should the need for an emergent cesarean delivery arise.
- Some institutions permit ice chips, and others permit a clear liquid diet.
- If patients have been carefully selected as low risk for labor obstruction, a regular diet may be ordered.
- Pregnant women have delayed gastric emptying, and aspiration is a very serious concern in the event of an anesthetic induction.
Activity
- For patients in labor, remaining active and mobile while in the latent and early active phase is best.
- However, once rupture of membranes has occurred or signs of fetal nonreassurance exist, then bed rest and continuous fetal monitoring is appropriate.
- Some clinicians allow ambulation throughout labor as long as the fetal head is well applied (minimizing risk of cord prolapse) and evidence of fetal well-being exists (monitoring for 20 min/h without signs of fetal compromise).
Medication
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.14
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.15Oxytocics
Oxytocin is the only US Food and Drug Administration (FDA)–approved medication recommended for labor augmentation. Other options include dinoprostone and misoprostol.
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.
Adult
Common protocol: Start infusion at 1-2 mU/min IV and increase by 1-2 mU/min q30 min; continue until adequate contractions (>200 MVUs/10 min) achieved or (at some institutions) maximum rate of 20 mU/min achieved
Pediatric
Not established
Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension
Documented hypersensitivity; unfavorable fetal positions; a contracting uterus with hypertonic or hyperactive patterns; labor when vaginal delivery should be avoided such as invasive cervical carcinoma, cord presentation or prolapse, active herpes genitalis, placenta previa, and vasa previa
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
An overstimulated uterus can be hazardous to both mother and fetus; hypertonic contractions can occur in a patient whose uterus is hypersensitive to oxytocin, regardless of whether it was administered appropriately; has intrinsic antidiuretic effect that when administered by continuous infusion and patient is receiving fluids by mouth, can cause water intoxication
Beta-adrenergic blocking agents
Another option for abnormal labor secondary to inadequate uterine contractility is a beta-blocker.
Propranolol (Inderal)
Nonselective beta-adrenergic receptor blocker.
Adult
2 mg IV; repeat one time only in 1 h if no progress observed
Pediatric
Not established
Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol; toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines may increase with propranolol
Documented hypersensitivity; uncompensated congestive heart failure; bradycardia; cardiogenic shock; AV conduction abnormalities
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely
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
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Further Reading
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
