Shields SG, Ratcliffe SD, Fontaine P, Leman L

Am Fam Physician 2007;75:1671-8 Presentant : Irene Ranny K. Rani Manalu Rudy Chandra Nevin Chandra J. Ritsia Anindita W. Abram Pratama Hendrik Sutopo L. Mirna Primasari Prisilla Alvini S. Opponent: David Ong

Moderator : dr. Rimonta F. Gunanegara, SpOG

OBSTETRICS DAN GYNAECOLOGY DEPT. IMMANUEL HOSPITAL MEDICAL FACULTY MARANATHA CHRISTIAN UNIVERSITY BANDUNG - 2007

Dystocia: prolonged or slowly progressing labor a BIG challenge:

Common in nulliparous women

augmentation, op. vag. delivery, CS Accounts for >50% 1 CS

optimal mgmt labor outcomes

SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Evidence rating A References Comments 13 Systematic review

Amniotomy in the first stage of labor results in shorter labor, but it also may be associated with variable fetal heart rate decelerations; therefore, it should be reserved for slowly progressing labors. High-dose oxytocin regimens result in shorter labors than A low-dose regimens without adverse effects for the fetus. Women who receive continuous labor support from a A labor support companion use less analgesia, have lower rates of operative vaginal and cesarean delivery, and are less likely to report dissatisfaction with their childbirth experiences. Epidural analgesia is associated with a prolongation of the A second stage of labor and an increase in oxytocin use and operative vaginal delivery. It is important to follow systematic protocols for C diagnosing labor, assessing its progress, and using oxytocin. Audit and feedback regarding operative deliveries has been associated with lower institutional cesarean delivery rates.

18, 19 35

Systematic review; results for each outcome were derived from at least four trials including at least 1,000 women Systematic reviews and a meta-analysis -

46-49

17, 57, 58

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1605 or http://www.aafp.org/afpsort.xml.

Table 1. Traditional Definitions of Abnormal Labor Labor abnormality Stage of labor Protracted Arrested

Friedman, 1950: Table 1 Today:

Values seems to be more

Latent Nulliparous > 20 hours Multiparous > 14 hours First stage Nulliparous < 1 cm per hour dilation

NA NA

than those of the past Routine intervention for progressive yet protracted labor is questionable

>= 2 hours of active labor without cervical change Multiparous < 1.2 to 1.5 cm >= 2 hours of active per hour dilation labor without cervical change Second stage Nulliparous With no regional No descent after 1 or anesthesia: > 2 hour of pushing multiparous hours duration or < 1 cm per hour descent With regional anesthesia: > 3 hours duration
NA = not applicable.

Consider four issues

Contractions Malposition

Cephalopelvic disproportion
Other coexisting clinical issues

Options for latent phase: observation, sedation, augmentation; no CS Active phase: amniotomy comes first

Not without risk!

IUPC (Fig.2) Augmentation: oxytocin

High dose regimens are more preferable

Figure 2. Inadequate uterine contractions as measured by an intrauterine pressure catheter, with continuous tracing of the FHR (top) and contractions as indicated by uterine pressure (bottom). This representative 10-minute monitor strip shows three contractions totaling 145 MVU. If MVU are less than 200 in 10 minutes, oxytocin augmentation should be considered. (FHR = fetal heart rate; bpm = beats per minute; kPa = kilopascal; MVU = Montevideo units.)

Confirm the cause: Phys. exam, US

POPP: manual rotation?

Options:
Further augmentation Upright/lateral position Delayed pushing

 Prolongation of the second stage of

labor beyond an arbitrary time limit is no longer an indication for operative vaginal or cesarean delivery.
Nonreassuring fetal heart tracing

only indicates a need to consider those two.

To decrease dystocia in nulliparous women:

1. provision of labor support

2. avoidance of hospital admission in latent

stage of labor 3. avoidance of elective induction with an unripe cervix 4. cautious use of epidural analgesia

Using trained labor support companion

Especially doulas and alike

Patient education:
Not going to hospital in latent labor Instead, encourage adequate hydration,

rest, and emotional and physical support

Elective induction vs selective induction

Analgesia ? epidural
The mother factor is the most important

Walk or stay upright during 1st stage Ultimately, permit adequate time to pass before intervening for dystocia

Physicians style Healthcare systems

caregiver continuity

Encourage a pronatalist

cultural attitude Second opinion (Regular) feedbacks between physicians

Given a good reason, the second stage of labor can be permitted to continue for longer than traditional time limits. Dont forget that to prevent is better than to cure.

Given a good reason, the second stage of labor can be permitted to continue for longer than traditional time limits. Dont forget that to prevent is better than to cure.

~ End of show ~

Thank you for your attention