DYSTOCIA

- difficult labor or abnormally slow progress of labor

1st Stage of Labor

Latent phase: Definitions for prolonged latent phase are outlined in the table above. Diagnosis of abnormal labor during the latent phase is uncommon and likely an incorrect diagnosis. Active phase: Around the time uterine contractions cause the cervix to become 3-4 cm dilated, the patient usually enters the active phase of the first stage of labor. Abnormalities of cervical dilation (protracted dilation and arrest of dilation) as well as descent abnormalities (protracted descent and arrest of descent) are outlined in the table above.

In general, abnormal labor is the result of problems with one of the 3 P' s. Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse]) Pelvis or passage (size, shape, and adequacy of the pelvis) Power (uterine contractility)

Pathophysiology
A prolonged latent phase may result from oversedation or from entering labor early with a thickened or uneffaced cervix. It may be misdiagnosed in the face of frequent prodromal contractions. Protraction of active labor is more easily diagnosed and is dependent upon the 3 P' s. The first P, the passenger, may produce abnormal labor because of the infant's size (eg, macrosomia) or from malpresentation. The second P, the pelvis, can cause abnormal labor because its contours may be too small or narrow to allow passage of the infant. Both the passenger and pelvis cause abnormal labor by a mechanical obstruction, referred to as mechanical dystocia.

With the third P, the power component, the frequency of uterine contraction may be adequate, but the intensity may be inadequate. Disruption of communication between adjacent segments of the uterus may also exist, resulting from surgical scarring, fibroids, or other conduction disruption.

ASSESSMENT
Upon admission to the labor and delivery unit, determine and document clinical findings. Clinical pelvimetry, which is best performed at the first prenatal care visit, is important in order to assess the pelvic type (eg, android, gynecoid, platypelloid, anthropoid). Evaluate the position of the fetal head in early labor because caput and moulding complicate correct assessment as labor progresses. Establish and document an estimated fetal weight.

Monitor fetal heart rate and uterine contraction patterns to assess fetal well-being and adequacy of labor. Perform a cervical examination to determine whether the patient is in the latent or active phase of labor. Addressing these issues allows for an assessment of the current phase of labor and anticipation of whether abnormal labor from any of the 3 P' s may be encountered.

CAUSES
Prolonged latent phase: The latent phase of labor is defined as the period of time starting with the onset of regular uterine contractions and ending with the onset of the active phase (usually 3-4 cm cervical dilation). yA prolonged latent phase is defined as exceeding 20 hours in patients who are nulliparas or 14 hours in patients who are multiparas. yThe most common reason for prolonged latent phase is entering labor without substantial cervical effacement.

Pelvis or the size of the passageway inhibiting delivery yThe shape of the bony pelvis (eg, anthropoid or platypelloid) can result in abnormal labor. yA patient who is extremely short or obese, or who has had prior severe trauma to the bony pelvis, may also be at increased risk of abnormal labor.

Abnormal labor could also be secondary to the passenger, the size of the infant, and/or the presentation of the infant. yIn addition to problems caused by the differential in size between the fetal head and the maternal bony pelvis, the fetal presentation may include asynclitism or head extension. Asynclitism is malposition of the fetal head within the pelvis, which compromises the narrowest diameter through the pelvis.

yFetal macrosomia and other anomalies (including hydrocephalus, encephalocele, fetal goiter, cystic hygroma, hydrops, or any other abnormality that increases the size of the infant) are likely to cause deviation from the normal labor curve. Other factors include either a low-dose epidural or combined spinal-epidural anesthetics that minimize motor block and may contribute to a prolonged second stage. These have also been associated with an increase in oxytocin use and operative vaginal delivery.

MEDICATIONS

Use of oxytocin for active management of labor 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.

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. Lowdose administration of intravenous propranolol in abnormal labor augmented with oxytocin reduced the need for cesarean delivery, particularly among patients with inadequate uterine contractility. 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.

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).