Failure to Progress

Aka: Failure to Progress, Labor Dystocia, Cephalopelvic Disproportion, CPD

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II. Definitions

  1. Labor Dystocia (Failure to Progress)
    1. Abnormally slow or protracted labor affecting the first and second stages of labor

III. Epidemiology

  1. Labor Dystocia is responsible for 50% of Ceserean Sections
    1. Primary Ceserean Section rate: 20% in U.S.
    2. First Stage of Labor dystocia: 15-30% of cesarean delivery indications
    3. Second Stage of Labor dystocia: 10-25% of cesarean delivery indications

IV. Criteria: Active phase delay or arrest

  1. Background
    1. Based on Friedman Curve
    2. Assumes Active Phase of Labor
      1. Cervix dilated to 6 cm and (prior criteria was 4 cm)
      2. Frequent contractions
      3. Zhang (2010) Obstet Gynecol 116(6): 1281-7 [PubMed]
    3. Duration of the latent First Stage of Labor should not be used to indicate Cesarean Section
      1. Considered to be protracted latent phase if >20 hours nullip (>14 hours multip)
      2. Despite duration definitions for protracted latent phase, it is not used to define arrest of labor
  2. Protracted labor (slow rate of dilation and descent)
    1. Nulliparous women
      1. Active First Stage (6 cm to full 10 cm dilation)
        1. Fetal Descent: <1 cm/hour
        2. Cervical Dilation: <1 cm/hour
        3. Duration >8.6 hours
      2. Second Stage (full dilation to delivery)
        1. Duration >3 hours (>4 hours with Epidural Anesthesia)
        2. Less than 25% of Nulliparous women will deliver vaginally after 3 hours of second stage
    2. Multiparous women
      1. Active First Stage (6 cm to full 10 cm dilation)
        1. Cervical Dilation: <1.5 cm/hour
        2. Fetal Descent: <2 cm/hour
        3. Duration >7.5 hours
      2. Second Stage (full dilation to delivery)
        1. Duration >2 hours (>3 hours with Epidural Anesthesia)
  3. Arrest of Labor - Newer Definition
    1. Cervical dilation 6 cm AND
    2. Ruptured membranes AND
    3. No cervical change
      1. At 4 hours if adequate contractions (>200 Montevideo Units) or
      2. At 6 hours if inadequate contractions
  4. Arrest of Labor - Older Definition
    1. Active labor without change in descent for 1 hour
    2. Active labor without change in dilation for 2 hours
      1. Pause for 2 hours in dilation is common <7 cm
        1. Zhang (2002) Am J Obstet Gynecol 187:824-8 [PubMed]
      2. Consider extending C-Section indication to 4 hours
        1. Would decrease cesarean rate from 26 to 8%
        2. Rouse (2001) Obstet Gynecol 98:550-4 [PubMed]

V. Causes: Failure to Progress

  1. Consider Macrosomia
    1. Gestational Diabetes
    2. Excess weight gain
    3. Older patient
    4. Multiparous
    5. Obesity in Nulliparous women
      1. Increased risk of ceserean delivery
      2. Decreased cervical dilation risk
      3. Increased labor duration
      4. Nuthalapaty (2004) Obstet Gynecol 103:452-6 [PubMed]
  2. Consider Cephalopelvic Disproportion (CPD)
    1. Pelvic Inlet AP <10 cm
    2. Midpelvis Interspinous <9 cm
    3. Outlet intertuberosity <8 cm
  3. Consider Fetal Malpresentation
    1. Occiput Posterior (consider manual rotation)

VI. Evaluation

  1. Confirm that patient is in Active Phase of Labor
    1. Cervix at least 6 cm dilated and
    2. Regular contractions
  2. 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)
  3. Confirm Fetal Presentation
    1. Digital cervical exam
    2. Consider Ultrasound if unsure of Fetal Presentation
  4. Empty Bladder (consider catheterization)
  5. Evaluate maternal hydration status
  6. Evaluate for adequate pushing or Powers
    1. Consider IUPC to document adequate contractions
    2. Adequate contractions: 200-300 montevideo Units
      1. Cumulative contraction amplitudes for 10 minutes
  7. Consider graphing labor curve (partograph)

VII. Management

  1. See Active Management of Labor
  2. Indications for cesarean delivery
    1. Cervical dilation 6 cm AND
    2. Ruptured membranes AND
    3. No cervical change
      1. At 4 hours if adequate contractions (>200 Montevideo Units) or
      2. At 6 hours if inadequate contractions

VIII. Prevention

  1. See Prevention of Labor Dystocia

IX. References

  1. Shields (2000) ALSO, F:1-14
  2. Dresang (2015) Am Fam Physician 92(3): 202-8 [PubMed]
  3. LeFevre (2021) Am Fam Physician 103(2): 90-6 [PubMed]

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