Ld

Failure to Progress

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Failure to Progress, Labor Dystocia, Cephalopelvic Disproportion, CPD

  • Epidemiology
  1. Labor Dystocia is responsible for 50% of Cesereans
    1. Primary Ceserean rate: 20% in U.S.
  • 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
  2. Protracted labor (slow rate of dilation and descent)
    1. Nulliparous women
      1. Fetal Descent: <1 cm/hour
      2. Cervical Dilation: <1 cm/hour
    2. Multiparous women
      1. Cervical Dilation: <1.5 cm/hour
      2. Fetal Descent: <2 cm/hour
  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]
  • Risk Factors
  • Failure to Progress
  1. 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]
  • Causes
  • Failure to Progress
  1. Consider Macrosomia
    1. Gestational Diabetes
    2. Excess weight gain
    3. Older patient
    4. Multiparous
  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)
  • 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)
  • 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
  • References