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 0.5-1 mUnit/min IV, titrate 1-2 mUnit/min q15-60min until contraction pattern established similiar to normal labor The uterine myometrium contains receptors specific to oxytocin {10} {13} {25} {30} {46} {47} {51} {52}. Oxytocin stimulates contraction of uterine smooth muscle by increasing intracellular calcium concentrations, thus mimicking contractions of normal, spontaneous labor and transiently impeding uterine blood flow {02} {03} {10} {13} {52}. Amplitude and duration of uterine contractions are increased, leading to dilation and effacement of the cervix {02} {03} {10} {21} {25} {40} {50} {51}. The number of oxytocin receptors and, therefore, uterine response to oxytocin increases gradually throughout pregnancy, reaching its peak at term I. Epidemiology A. Labor dystocia is responsible for 50% of Cesereans 1. Primary Ceserean rate: 20% in U.S. II. Criteria for active phase delay or arrest . Background 1. Based on Friedman Curve 2. Assumes Active Phase of Labor a. Cervix dilated to 4 cm and b. Frequent contractions A. Protracted labor (slow rate of dilation and descent) 1. Nulliparous women . Fetal Descent: <1 cm/hour a. Cervical Dilation: <1 cm/hour 2. Multiparous women . Cervical Dilation: <1.5 cm/hour a. Fetal Descent: <2 cm/hour B. Arrest of Labor (complete cessation of progress) 1. Active labor without change in descent for 1 hour 2. Active labor without change in dilation for 2 hours . Pause for 2 hours in dilation is common <7 cm i. Zhang (2002) Am J Obstet Gynecol 187:824 a. Consider extending c-section indication to 4 hours . Would decrease cesarean rate from 26 to 8% i. Rouse (2001) Obstet Gynecol 98:550 III. Risk factors for failure to progress . Obesity in nulliparous women 1. Increased risk of ceserean delivery 2. Decreased cervical dilation risk 3. Increased labor duration 4. Nuthalapaty (2004) Obstet Gynecol 103:452 Etiologies for failure to progress . Consider Macrosomia 1. Gestational Diabetes 2. Excess weight gain

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3. Older patient 4. Multiparous Consider Cephalopelvic Disproportion (CPD) 1. Pelvic Inlet AP <10 cm 2. Midpelvis Interspinous <9 cm 3. Outlet intertuberosity <8 cm Consider Fetal Malpresentation 1. Occiput Posterior (consider manual rotation) Evaluation . Confirm that patient is in Active Phase of Labor 1. Cervix at least 4 cm dilated and 2. Regular contractions Confirm cervical dilatation 1. No anterior lip if "complete" 2. Check cervix q1-2 hours if membranes intact 3. Assess for fetal malposition (e.g. Occiput Posterior) Confirm Fetal Presentation 1. Digital cervical exam 2. Consider Ultrasound if unsure of Fetal Presentation Empty bladder (consider catheterization) D. Evaluate maternal hydration status E. Evaluate for adequate pushing or Powers 1. Consider IUPC to document adequate contractions 2. Adequate contractions: 200-300 montevideo Units Cumulative contraction amplitudes for 10 minutes F. Consider graphing labor curve (partograph)

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Management: Stage One A. See Labor Coaching B. Consider Active Management of Labor 1. See Oxytocin Augmentation C. Consider amniotomy D. Consider extending definitions of arrested labor 1. Delaying C-section until 4 hours without dilation 2. Typically were indicated at 2 hours without change II. Management: Stage 2 Consider Oxytocin Augmentation A. Avoid exhausting mother early 1. Consider not pushing until involuntary urge to push 2. Consider waiting until vertex approaches introitus B. Consider Assisted Delivery 1. Vacuum Assisted Delivery 2. Forceps Assisted Delivery C. Consider correction of malposition: Occiput Posterior 1. Maternal position change a. Position mother curling forward from hips 2. Manual Rotation in Occipitoposterior Presentation III. Management: Dystocia refractory to above management Consider Cesarean section IV. Preventive Measures See Labor Dystocia Prevention

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Cervical Dilation 1. Cervix dilated < 1 cm: 0 2. Cervix dilated 1-2 cm: 1 3. Cervix dilated 2-4 cm: 2 4. Cervix dilated > 4 cm: 3 Cervical Length (Effacement) 1. Cervical Length > 4 cm (0% effaced): 0 2. Cervical Length 2-4 cm (0 to 50% effaced): 1 3. Cervical Length 1-2 cm (50 to 75% effaced): 2 4. Cervical Length < 1 cm (>75% effaced): 3 Cervical Consistency 1. Firm cervical consistency: 0 2. Average cervical consistency: 1 3. Soft cervical consistency: 2 Cervical Position 1. Posterior cervical position: 0 2. Middle or anterior cervical position: 1 Zero Station Notation (presenting part level) 1. Presenting part at ischial spines -3 cm: 0 2. Presenting part at ischial spines -1 cm: 1 3. Presenting part at ischial spines +1 cm: 2 4. Presenting part at ischial spines +2 cm: 3 Interpretation

Indications for Cervical Ripening with prostaglandins 1. Bishop Score <5 2. Membranes intact 3. No regular contractions B. Indications for Labor Induction with Pitocin 1. Bishop Score >= 5 2. Rupture of Membranes Preparation: Pitocin in Normal Saline Pitocin 10 units in 1000 ml Normal Saline 1. Starting rate of 6-12 ml/hour delivers 1-2 mU/minute 2. Increasing rate 6 ml/hour delivers another 1 mU/min B. Pitocin 20 units in 1000 ml Normal Saline 1. Starting rate of 3-6 ml/hour delivers 1-2 mU/minute 2. Increasing rate 3 ml/hour delivers another 1 mU/min
Monitoring

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Intrauterine pressure catheter 1. Adequate contraction pattern indicators a. Montevideo units >50 mmHg per contraction b. Montevideo units 200-300 mmHg per 10 minutes 2. Observe for signs of hyperstimulation . Fetal Distress a. Tetanic contractions B. Maternal vital signs C. Continuous Electronic Fetal Monitoring (CEFM)