Abnormal labor: Protraction and arrest disorders

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Andrew J Satin, MD
Christian Macedonia, MD

UpToDate performs a continuous review of over 330 journals and other resources. Updates are added
as important new information is published. The literature review for version 12.2 is current through
April 2004; this topic was last changed on March 23, 2004.

INTRODUCTION Labor refers to uterine contractions resulting in progressive

dilation and effacement of the cervix and accompanied by descent and expulsion
of the fetus. Abnormal labor, dystocia, and failure to progress are terms used to
describe a difficult labor pattern that deviates from that observed in the majority
of women who have spontaneous vaginal deliveries. This problem is the most
common indication for primary cesarean birth, accounting for three times more
cesarean deliveries than malpresentation or fetal heart rate abnormalities [1]. As
an example, one study of 733 women with unplanned cesareans reported 68
percent were due to lack of progress in labor; the diagnosis was made after four
centimeters dilation in 75 percent of the patients [2].
NORMAL LABOR Friedman, in his classic studies, divided labor into three stages
[3]:
First stage: time from the onset of labor until complete cervical dilatation
Second stage: time from complete cervical dilatation to expulsion of the fetus
Third stage: time from expulsion of the fetus to expulsion of the placenta
The first stage was further subdivided into the latent and active phases, and the
active phase subdivided into three additional phases: acceleration phase, phase of
maximum slope, and deceleration phase (show figure 1).
Numerous investigations have confirmed that a rapid change in the rate (slope) of
cervical dilation occurs at 3 to 4 centimeters when cervical dilatation is plotted
against time. This is the beginning of the active phase. The existence of a latent
phase and subphases of active labor are more controversial. Latent phase is
typically characterized by mild, infrequent, irregular contractions with gradual
change in cervical dilation (usually <1 cm per hour) and effacement. By
comparison, the active phase is characterized by painful contractions of increasing
frequency, intensity, and duration accompanied by more rapid (usually >1 cm
hour) cervical change. (See "Prolonged latent phase of labor").
The median duration of the second stage of labor in nulliparous and multiparous
women is 50 and 20 minutes, respectively. The upper limit of duration associated
with a normal perinatal outcome had been defined as two hours [4], but was
subsequently lengthened [5,6]. Epidural analgesia, duration of the first stage,
parity, maternal size, birth weight, and station at complete dilation all play a role
in predicting duration of the second stage [7]. However, a stepwise multiple linear
regression demonstrated that these factors together accounted for less than 25
percent of observed variation in duration of the second stage [7]. For these
reasons, the American College of Obstetricians and Gynecologists (ACOG)
recommends that the normal duration of second stage of labor be based upon
parity and presence of regional anesthesia, with no intervention as long as the

fetal heart rate pattern is normal and some degree of progress is observed (show
table 1) [6].
The total duration of labor also varies between nulliparous and parous parturients.
One report of 25,000 women at term revealed the average duration of active labor
(onset defined as 3 cm dilation) in nulliparous and parous women was 6.4 and 4.6
hours, respectively [8]. In addition, the labor curve of grand multiparas (para 5 or
more) appears to differ from that of lower parity women: progress is slower prior
to 6 cm [9].
Normal uterine activity Uterine activity can be monitored by palpation,
external tocodynamometry, or internal uterine pressure catheters. External and
intrauterine monitoring devices appear to perform equally well, although the latter
may work better in obese women [10].
Ninety-five percent of women in labor will have three to five contractions per 10
minutes. Although numerous methods for quantifying uterine activity have been
reported, Montevideo units (ie, the peak strength of contractions in mmHg
measured by an internal monitor multiplied by their frequency per 10 minutes) are
most often employed. In a retrospective report, 91 percent of women in
spontaneous active labor achieved contractile activity greater than 200 Montevideo
units and 40 percent reached 300 Montevideo units [11].
CLASSIFICATION One practical classification system to categorize labor
abnormalities is shown in Table 1 (show table 1) [6]:
Protraction disorders refer to slower-than-normal labor progress
Arrest disorders refer to complete cessation of progress.
It is important to emphasize that the rates of cervical change listed in Table 1 are
two standard deviations from the mean and thereby used to define abnormal; they
do not represent the mean or median rates.
Progressive dilation slower than the rate shown in Table 1 is suggestive of a
protraction disorder. An arrest disorder can be diagnosed when the cervix ceases
to dilate after reaching four or more centimeters dilation despite a uterine
contraction pattern of greater than or equal to 200 Montevideo units for two or
more hours [6]. Protraction and arrest disorders may occur in both the first and
second stage of labor.
INCIDENCE In one large series, the incidence or protraction or arrest disorders
in the first stage of labor was 13 percent [12], second stage abnormalities
appeared to be as common [6].
Arrest disorders in the second stage of labor have received attention in the United
States as a possible reason for differences in the cesarean delivery rates between
the United States and Ireland, where active management of labor is practiced. As
an example, four American trials of active management of labor (AML) found that
the incidence of cesarean birth in the second stage was higher in the United States
than at the National Maternity Hospital in Dublin (over 3 and 0.2 percent,
respectively) [13-16]. Although active management of labor at the National
Maternity Hospital has been associated with shorter labors and a cesarean delivery
rate lower than that found at most hospitals in the United States, the cesarean

delivery rate at that Institution has increased somewhat in recent years and the
best controlled randomized trials to date do not show a decrease in cesarean birth
associated with implementation of active management. (See "Active management
of labor").
ETIOLOGY OF PROTRACTION AND ARREST DISORDERS Abnormal labor can
be the result of one or more abnormalities of the cervix, uterus, maternal pelvis,
or fetus (ie, power, passenger, or pelvis). Risk factors for abnormal labor are
shown in Table 2 (show table 2). Hypocontractile uterine activity is the most
common cause of protraction or arrest disorders in the first stage of labor. This
entity refers to uterine activity that is either not sufficiently strong or not
appropriately coordinated to dilate the cervix and expel the fetus. It occurs in 3 to
8 percent of parturients and can be quantified as uterine contraction pressures less
than 200 Montevideo units.
Dystocia related to epidural analgesia The potential impact of epidural
analgesia on uterine activity, fetal malposition, and, ultimately, arrest disorders
has received much attention as a possible source of increasing rates of cesarean
delivery. In a meta-analysis of eleven studies involving more than 3000 women,
epidural analgesia was associated with an increased duration of the first and
second stages of labor, incidence of fetal malposition, use of oxytocin, and
operative vaginal delivery [17]. However, epidural anesthesia was not shown to
increase the cesarean rate. This report was unable to determine whether certain
types of epidural (narcotic or low-dose anesthetics) could decrease the incidence
of dystocia. Consequences of withdrawing the block before the second stage of
labor, appropriate use of oxytocin, delayed pushing in the second stage, and
timing of administration also need to be considered. (See "Prevention and
treatment of adverse effects of neuraxial anesthesia-I" section on Areas of
controversy).
The American College of Obstetricians and Gynecologists has stated that the
decision to place an epidural anesthetic depends upon the patient's wishes with
consideration of factors, such as parity, also taken into account [18]. In particular,
women should not be required to reach an arbitrary cervical dilation such as 4 to 5
cm before receiving epidural anesthesia.
Dystocia due to cephalopelvic disproportion The disproportion between the
size of the fetus relative to the mother can lead to a diagnosis of dystocia due to
cephalopelvic disproportion (CPD). This diagnosis is currently based upon slow or
arrested labor during the active phase. However, it is usually do to fetal
malposition (eg, extended or asynclitic fetal head) or malpresentation (mentum
posterior, brow), rather than a true disparity between fetal and maternal pelvic
dimensions. (See "Fetal presentation in labor").
Prediction of CPD requiring cesarean delivery based upon clinical assessment of
maternal (show figure 4A-B) versus fetal size (show figure 4C) has been
disappointing . In a recent decision analysis and subsequent clinical study, a group
of investigators found that in women without diabetes, the level of intervention
and economic costs of prophylactic cesarean delivery for fetal macrosomia
diagnosed by ultrasound are excessive [19,20]. A prophylactic cesarean delivery
policy with either a 4000 or 4500 gram definition of macrosomia threshold would
require more than 10,000 cesarean births and millions of dollars to prevent a
single permanent brachial plexus injury. In addition, four trials of pelvimetry for

fetal cephalic presentation at term in over 1000 women found that those
undergoing pelvimetry were twice as likely to be delivered by cesarean [21]; no
impact on perinatal outcome was detected. Thus, there is no evidence to support
the use of radiographic pelvimetry in women with cephalic presentations.
Dystocia due to malposition Over 95 percent of fetuses present in cephalic
presentation at term. Approximately 5 percent of these experience malposition
with persistent occiput posterior (OP) position or transverse arrest. In two studies
including over 10,000 deliveries, persistent OP position was associated with a
longer duration of active labor and second stage [22,23]. In another series of
16,781 nulliparas, persistent OP position was related to arrest of descent requiring
operative delivery [24]. The rates of instrumental vaginal or cesarean delivery for
OP position compared to occiput anterior (OA) were 44 and 24 percent rates (OP
and OA instrumental deliveries) or 42 and 14 percent (OP and OA cesarean
deliveries). Multiparous women with persistent OP are more likely to achieve
spontaneous vaginal delivery than nulliparas (55 to 57 versus 26 to 29 percent)
[23,25,26].
Pregnant women are often advised to perform exercises to facilitate anterior
rotation of the fetus, but there is no good evidence that these maneuvers are
effective. The lack of benefit was best illustrated by a large, multicenter,
randomized, controlled trial that assigned 2547 women at 36 to 37 weeks of
gestation to one of two exercise programs [27]. Group 1 was told to take a daily
walk and Group 2 was asked to assume a hands and knees position with slow
pelvic rocking for 10 minutes twice a day until labor began. The incidence of
persistent OP position at birth or before instrumental rotation was similar in both
groups (about 8 percent).
APPROACH TO THE PATIENT WITH ABNORMAL LABOR Management of
labor includes several components: a disciplined approach to the diagnosis of
labor, careful monitoring of labor progress, and assessment of maternal and fetal
well-being. Women should undergo cervical examination every one to two hours
once active labor is diagnosed to determine whether progression is adequate [3].
Progress can be noted on a partogram (show figure 2).
Dystocia in the first stage:
Amniotomy
Hypo contractile uterine activity is treated with oxytocin
Numerous protocols varying in initial dose, incremental dose increases, and time
intervals between doses have been studied (show table 2).
Oxytocin is typically infused to titrate dose to effect, as prediction of a women's
response to a particular dose is not possible
Low dose regimens: (to avoid uterine hyperstimulation)
High dose regimens: (shorten labor )

Active phase arrest is diagnosed when a protraction disorder persists despite

oxytocin therapy to achieve > or = 200 Montevideo units for greater than two

hours; cesarean delivery is typically performed at this point. However, a trial in

542 women with an arrest or protraction disorder in which the obstetrician waited
four to six hours (instead of two) before operating reported high vaginal delivery
rates [31]. Vaginal deliveries occurred in 91 percent of parous women and 74
percent of nulliparas with an arrest or protraction disorder lasting two hours
despite oxytocin administration and in 88 and 56 percent of multiparas and
nulliparas, respectively, in whom the disorder lasted for four hours of oxytocin
infusion. The authors concluded that extending the minimum period of oxytocin
augmentation for active phase labor arrest from two to at least four hours was
both effective and safe.
The same group subsequently used a standardized protocol to manage 501
consecutive term spontaneously laboring women with a protraction or arrest
disorder [32]. The protocol involved use of an intrauterine pressure catheter and
administration of oxytocin to achieve at least 200 Montevideo units for four hours
before considering cesarean delivery. Vaginal delivery occurred in 85 percent of
nulliparous women who sustained this threshold of uterine activity, 74 percent of
those who achieved but were unable to sustain it, and in 83 percent of women
who never achieved it. Corresponding figures for parous women were 94, 94, and
97 percent. Mean and 5th percentile rates of cervical dilatation were 1.4 and 0.5
cm/h in nulliparas and 1.8 and 0.5 cm/h in multiparas. This study confirmed that
augmentation of a protraction disorder for at least four hours is both safe an
effective for achieving vaginal delivery. It also showed that success was often
possible despite levels of uterine activity and rates of cervical dilatation that were
below the normal range considered effective.
Other interventions, such as ambulation [33] and continuous labor support, may
increase the comfort of the parturient, but have not been shown to be clinically
effective interventions for treatment of protraction or arrest disorders [6]. (See
"Continuous intrapartum support").
Dystocia in the second stage Risk factors include nulliparity, diabetes,
macrosomia, epidural anesthesia, oxytocin usage, and chorioamnionitis [34].

Continued observation.
Attempt at operative vaginal delivery.
Cesarean delivery.
Observation Most women with a prolonged second stage ultimately deliver
vaginally. In one study of 532 term singleton pregnancies with second stage over
two hours, over 96 percent of patients who reached the second stage of labor
delivered vaginally within 240 minutes [34] .The rates of vaginal delivery at 121 to
240 minutes and after 240 minutes were 90 and 66 percent, respectively [34].
Neonatal outcome was similar in pregnancies with second stages less than and
greater than 120 minutes.
Dense motor blocks from epidural analgesia may impair a woman's ability to push.
Thus, some authors have advocated turning down the epidural to facilitate
progress during a prolonged second stage. As an example, one study of epidural
anesthesia compared 0.125 percent bupivicaine versus saline infusion in the

second stage and found saline was associated with a shorter second stage, fewer
operative deliveries, but more pain [35].
Other noninvasive interventions that have been proposed include changes in
maternal position [36,37], continuous emotional support of the parturient [38],
delaying pushing if the fetal head is high in the pelvis at full dilatation and the
woman has no urge to do so [39,40], and active management using high dose
oxytocin. (See "Active management of labor").
Assisted vaginal delivery (eg, extraction or rotation) Operative vaginal
delivery and choice of instrument require careful assessment of the mother and
fetus. Furthermore, success is dependent upon the training and skill of the
obstetrician. A discussion of the indications, contraindications, use, and
complications of instrumental deliveries is presented separately.
Occiput posterior position Occiput posterior (OP) position is associated with
a longer second stage, higher incidence of operative delivery, larger episiotomies,
and more severe perineal lacerations than occiput anterior position [22,24,25]. A
small increase in second stage length in the presence of a reassuring fetal heart
rate, favorable clinical assessment of fetal relative to maternal size, and progress
in the second stage does not mandate rotation or operative delivery.
The management of a definite arrest of descent of the OP fetus is not clear. No
randomized trial of rotation to occiput anterior versus operative delivery from the
OP position has been performed. Treatment options include operative delivery from
OP position, manual or instrumental rotation to occiput anterior, or cesarean
delivery. Our algorithm for managing these patients is shown in figure 4.
RECOMMENDATIONS A general labor management algorithm is outlined in
Figure 3 (show figure 3). The key points are listed below:
Monitor progress in active labor with cervical exams at 1 to 2 hour intervals.
If the patient in active labor fails to progress adequately for two hours, then
intact membranes should be ruptured and oxytocin administered to achieve
uterine contractions greater than 200 Montevideo units. These patients can be
observed for two to four hours as long as clinical assessment of fetal and maternal
size is favorable and the fetal heart rate is reassuring.
The decision to perform an operative vaginal delivery (eg, extraction or
rotation) in the second stage versus continued observation or cesarean birth is
based upon clinical assessment of mother and fetus and the skill and training of
the obstetrician.
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