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

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Related Studies

Ontology: Dystocia (C0013418)

Definition (NCI) Uterine contractions (less than 3 in 10 minutes or inadequate strength) that do not result in progressive cervical dilation.(NICHD)
Definition (MSH) Slow or difficult OBSTETRIC LABOR or CHILDBIRTH.
Concepts Finding (T033)
MSH D004420
ICD9 661.9
ICD10 O66.9
SnomedCT 45757002, 199746004, 111448009, 237323007, 289255001, 199816006, 289261003
English Dystocias, Unspecified abnormality of labor, dysfunctional labor (physical finding), dysfunctional labor, dysfunctional labor was observed, Abnormal labor, Labor abnormal, Abnormal labour, Unspecified abnormality of labour, Dystocia NOS, Dystocia [Disease/Finding], delivery problems, difficult labor, delivery problem, abnormal labor, labour problems, dystocias, Dystocia (disorder), Dystocia NOS (finding), Labour abnormal, Labour problem (disorder), Arrest of Dilatation, Failure to Progress, Labor Dystocia, Dysfunctional Labor, Difficult labor, Dysfunctional labor, Dysfunctional labour, Difficult labour, Delivery problem, Labor problem, Labour problem, Delivery problem (finding), Labor problem (finding), Dystocia, dystocia, abnormal; labor, Abnormal labor, NOS, Dystocia, NOS, Dystocia (disorder) [Ambiguous]
Italian Travaglio anormale, Anomalia del travaglio non specificata, Distocia
Dutch niet-gespecificeerde abnormale bevallling, abnormale bevalling, niet-gespecificeerde abnormale bevalling, abnormaal; weeën, abnormale ontsluitingsfase, Dystocie
French Anomalie non précisée du travail, Anomalie du travail non précisée, Travail anormal, Dystocie
German Wehen anomal, unspezifische Wehenanomalie, anomale Wehen, Dystokie
Portuguese Trabalho de parto, Anomalia NE do trabalho de parto, Trabalho de parto anormal, Distocia
Spanish Parto anormal, Anormalidad no especificada del parto, parto anormal, distocia (hallazgo), problema en el trabajo de parto (hallazgo), problema en el parto (hallazgo), problema en el trabajo de parto, problema en el parto, parto disfuncional, parto distócico, trabajo de parto disfuncional, parto difícil, distocia, SAI (hallazgo), distocia (trastorno), distocia, SAI, distocia (concepto no activo), distocia, parto anormal (hallazgo), problema del parto (hallazgo), problema del parto, problema del período expulsivo del parto, Parto distócico, Distocia
Japanese 詳細不明の異常分娩, 分娩異常, 異常分娩, ショウサイフメイノイジョウブンベン, ブンベンイジョウ, イジョウブンベン
Swedish Svår förlossning
Czech dystokie, Abnormální porod, Blíže neurčená abnormalita porodu
Finnish Dystokia
Polish Dystocja, Brak postępu porodu, Niestosunek porodowy
Hungarian Vajúdás nem meghatározott zavara, Abnormális vajúdás, Kóros vajúdás, Vajúdás kóros
Norwegian Dystoci, Dystoki, Vanskelig fødsel, Vanskelig forløsning

Ontology: Cephalopelvic Disproportion (C0085988)

Definition (NCI) After complete dilatation, failure of the fetal presenting part to descend through the pelvis.(NICHD)
Definition (MSH) A condition in which the HEAD of the FETUS is larger than the mother's PELVIS through which the fetal head must pass during a vaginal delivery.
Concepts Finding (T033)
MSH D052178 , D007744
ICD9 653.4
SnomedCT 25749005, 367482008, 156162005, 267329003, 60994005, 199397009
Italian Sproporzione cefalo-pelvica, Sproporzione feto-pelvica, Sproporzione fetopelvica, Sproporzione cefalopelvica
Dutch foetus-bekken wanverhouding, foetus-bekken-wanverhouding, cefalopelvisch; wanverhouding, wanverhouding; cefalopelvisch, hoofd-bekken wanverhouding, Cefalopelvische disproportie
German Becken-Kind-Missverhaeltnis, Missverhaeltnis zwischen fetalem Kopf und Becken der Mutter, Kopf-Becken-Mißverhältnis (Geburtshilfe)
Portuguese Desproporção fetopélvica, Desproporção céfalo-pélvica, Desproporção Cefalopélvica
Spanish Desproporción fetopélvica, desproporción fetopélvica, desproporción de origen fetal y materno mixto con feto normoformado, distocia ósea, desproporción cefalopélvica (ambiguo) (trastorno), Desproporción Cefalopélvica, desproporción cefalopélvica (concepto no activo), desproporción cefalopélvica (trastorno), desproporción cefalopélvica, desproporción de origen materno Y fetal mixto con feto normalmente formado, desproporción entre la pelvis y la cabeza fetal (trastorno), desproporción entre la pelvis y la cabeza fetal, Desproporción pelvicocefálica, Desproporción Cefalopelviana
Japanese 胎児骨盤不均衡, 児頭骨盤不均衡, ジトウコツバンフキンコウ, タイジコツバンフキンコウ
Swedish Bäckenförträngning
English Disproportion between fetus and pelvis, Cephalopelvic disproportion [ambiguous], fetopelvic disproportion, fetopelvic disproportion (diagnosis), CPD - Cephalopelv disproportn, Cephalo-pelvic disproportion, Disproportion between foetal head and pelvis, Foetopelvic disproportion, Disproportion between foetus and pelvis, Cephalopelvic Disproportion [Disease/Finding], cephalo pelvic disproportion, cephalo-pelvic disproportion, cephalopelvic disproportion, Cephalopelvic Disproportion, Cephalo-Pelvic Disproportion, Cephalo-pelvic disp., Disproportion of mixed maternal and fetal origin with normally formed fetus, Arrest of Descent, CPD, Cepahalopelvic Disproportion, Fetopelvic disproportion, Cephalopelvic disproportion, CPD - Cephalopelvic disproportion, Cephalopelvic disproportion (disorder), Disproportion between fetal head and pelvis, Disproportion between fetus and pelvis (disorder), Disproportion of mixed maternal AND fetal origin with normally formed fetus, cephalopelvic; disproportion, disproportion; cephalopelvic, Cephalopelvic disproportion, NOS, Disproportion between fetal head and pelvis, NOS, Fetopelvic disproportion, NOS, Foetopelvic disproportion, NOS, Cephalopelvic disproportion (disorder) [Ambiguous], Cephalopelvic disproportion [ambiguous] (disorder), Cephalopelvic disproportion NOS, Disproportion of mixed maternal and fetal origin, with normally formed fetus, Disproportion, Cephalopelvic
Czech cefalopelvická disproporce, Kefalopelvický nepoměr, Fetopelvický nepoměr, Fetopelvická disproporce
Finnish Sikiön ja lantion välinen epäsuhta
French Disproportion foeto-pelvienne, Disproportion foetopelvienne, Disproportion céphalo-pelvienne, Disproportion céphalopelvienne
Polish Niewspółmierność porodowa
Hungarian Cephalo-pelvikus téraránytalanság, Foetopelvikus discrepantia, Foetopelvikus aránytalanság
Norwegian Fetopelvint misforhold, Trangt bekken, Fetopelvin disproporsjon