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Dystocia in labour - Risk factors, management and outcome: A retrospective

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Dystocia in labour - risk factors, management and
outcome: a retrospective observational study in a
Swedish setting
Lotta Selin ab; Gunnar Wallin c; Marie Berg b
a
Department of Obstetrics and Gynecology, NU Hospital Group, Trollhättan,
Sweden
b
The Institute of Health and Care Sciences, Sahlgrenska Academy, Göteborg
University, Göteborg, Sweden
c
The Institute of Clinical Sciences, Department of Obstetrics and Gynecology,
Sahlgrenska University Hospital, Göteborg, Sweden

Online Publication Date: 01 January 2008

To cite this Article: Selin, Lotta, Wallin, Gunnar and Berg, Marie (2008) 'Dystocia in labour - risk factors, management and
outcome: a retrospective observational study in a Swedish setting', Acta Obstetricia et Gynecologica Scandinavica, 87:2,
216 - 221
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 Acta Obstetricia et Gynecologica. 2008; 87: 216
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ORIGINAL ARTICLE

Dystocia in labour risk factors, management and outcome: a
retrospective observational study in a Swedish setting

LOTTA SELIN1,2, GUNNAR WALLIN3 & MARIE BERG2

1
Department of Obstetrics and Gynecology, NU Hospital Group, Trollhättan, Sweden, 2The Institute of Health and Care
Sciences, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden, and 3The Institute of Clinical Sciences, Department
of Obstetrics and Gynecology, Sahlgrenska University Hospital, Göteborg, Sweden

Abstract
Background. Labour dystocia (LD) is associated with adverse maternal and child outcomes. This study investigated obstetric
risk factors, frequency of interventions and delivery outcomes for LD. Methods. A retrospective, observational, study of
1,480 deliveries was undertaken in a Swedish district hospital during 2000 and 2001. Results. LD was identified in 21% of
deliveries, 16.7% of which ended in caesarean section (CS) compared to 1.7% of deliveries without LD. Multiparity with no
previous vaginal delivery (OR6.0), epidural analgesia (EDA) at cervical dilation 55 cm (OR 4.6), primiparity (OR 
4.5), gestational age ]42 weeks (OR 3.1), birth weight 4,000 g (OR2.7) and EDA at cervical dilation 5 cm (OR 
2.0) were major independent risk factors for LD. Conclusions. In delivery management, special attention should be directed
to primiparous women and multiparous women with no previous vaginal delivery. Women given EDA, especially at cervical
dilation 55 cm are also of particular interest. Furthermore, rigorous routines for LD diagnosis and oxytocin augmentation
are important.

Key words: Labour dystocia, delivery, management, risk factor, outcome

Abbreviations: CS: caesarean section, EDA: epidural analgesia, LD: labour dystocia, MNPVD: multiparity with no
previous vaginal delivery, TOL: trial of labour

Introduction search shows divergent results (3,7). The conse-

Why is labour dystocia (LD) still a problem in
modern obstetrics, what are its major risk factors
and how do professional management and interven-
tions influence its frequency? These are important
questions, since LD has been found to be one of
the main reasons for the rapid increase in caesa-
rean section (CS) (1). In Sweden, the CS rate
has increased from 10.6% in 1990 to 17.2% in
2005 (2).
According to earlier research, primiparity, inferti-
lity treatment, labour induction, premature rupture
of membranes, hypertensive disorders, hydramniosis
(3), advanced maternal age (3,4), cephalopelvic
disproportion, occipitoposterior position (5) and
macrosomia (6) are risk factors for LD. Epidural
analgesia (EDA) increases the risk, although re-
quences of increased medicalisation, technification
and professional management of labour progress and
delivery outcomes are unknown. Despite extensive
research, there is no universal definition of LD or
prolonged labour (8).
Studies of women’s experiences indicate that
women are more satisfied with intervention leading
to shorter labour at the expense of more interference
than with expectant management (9,10), and pro-
longed labour is connected with loss of control and
inadequate trust in the body’s competence (11).
The influence of intrapartum management factors
and demographic factors on LD has been insuffi-
ciently studied. The aim of our study was to
investigate obstetric risk factors, frequency of inter-
ventions and delivery outcomes for LD.

Correspondence: Lotta Selin, Department of Obstetrics and Gynecology, NU Hospital Group, 46186 Trollhättan, Sweden. E-mail: lotta.selin@vgregion.se

(Received 23 June 2007; accepted 30 November 2007)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2008 Taylor & Francis
DOI: 10.1080/00016340701837744
 Dystocia in labour
risk factors, management and outcome 217
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Material and methods women included in the study population. Statistical

associations between categorical variables were
This is an observational study, approved by the
tested using the x2-test. The two-tailed Fisher exact
regional Ethics Committee, in which 2,000 electro-
test was used if the expected cell frequencies were
nic antenatal and delivery records from the NU
too small. The two-sample t-test was used to
Hospital Group (2000
2001) were retrospectively
analyse normally distributed continuous variables.
examined. There were 5,702 deliveries during the
A p value B0.05 was considered statistically
study period. Inclusion criteria were primiparity and
significant. The multiple linear logistic regression
multiparity, singleton gestation, pregnancy ]37
method was used to predict the probability of an
weeks and cephalic presentation. As LD only occurs
individual having LD for a combination of selected
during the active phase of labour, all women under-
explanatory variables. The variables were entered in
going elective CS and acute CS during the latent
the model forward stepwise. Unadjusted and ad-
phase were excluded. The charts were randomly
justed odds ratios (OR) were reported together with
chosen from sequences in the register of deliveries. 95% confidence intervals (CI). Dummy variables
Among these, 520 were excluded due to missing were created to analyse covariates with more than 2
partograms or cervical dilation ]7 cm on admission categories. The category ‘multipara’ was used as the
to the delivery ward. reference level for the parity variable. Primiparas
Progress of labour was retrospectively followed by and MNPVD, respectively, were compared with this
partogram, from the active phase until delivery. The reference level.
active phase of labour was confirmed if (1) the cervix
was effaced, (2) the cervix was dilated ]4 cm, and
(3) there were regular painful uterine contractions. Results
In cases in which a partogram had been started at Of the study population (n 1,480 women), 21%
cervical dilation 5
6 cm, onset of labour was noted had LD (Figure 1). The estimated prevalence of LD
in the partogram 1
2 h previously (presumably at for all women meeting the inclusion criteria (n 
cervical dilation 4 cm). LD was diagnosed based on 2,000) was 16
20%. Table I shows the descriptive
the cervical dilation rate according to the parto- statistics for the study population and the excluded
gram’s alert and action line. The action line was group. Primiparas and multiparas were equally
placed 2 h to the right of the alert line and LD was distributed in the study population, while multiparas
diagnosed if the cervical dilation rate crossed the were predominant in the excluded group (68.7
action line. A second stage lasting more than 2 h was versus 29.6%).
also classified as LD. The frequency of LD in primiparas and MNPVD
The following variables were included in the was 33.6 and 37.5%, respectively, compared to 7.6%
analysis: maternal age, parity, multiparity with no in other multiparas. Bivariate analyses of demo-
previous vaginal delivery (MNPVD), gestational age, graphic and clinical characteristics in pregnancies
high-risk pregnancy, e.g. diabetes prior to pregnancy
and gestational diabetes, essential hypertension,
pregnancy-induced hypertension, pre-eclampsia
and obstetric and medical complications requiring
bed rest. Additional variables were induction of
labour, EDA (administered at cervical dilation 55
cm and at cervical dilation 5 cm), interval from
onset of established labour to amniotomy, mode of
delivery, postpartum haemorrhage ( 1,000 ml),
perineal trauma (third- and fourth-degree lacera-
tions), retained placenta, abnormal vertex presenta-
tion, birth weight, Apgar score and umbilical cord
arterial pH.
Statistical analysis was performed using the SPSS
statistical package version 12.0 (SPSS, Chicago, IL,
USA). LD prevalence for all the women meeting
the inclusion criteria (n 2,000) was estimated with
2 assumptions: one over-rating and one under-
rating LD prevalence among the 520 excluded
women. Further analyses were made only on Figure 1. Flow chart of the selection procedure.
 218 L. Selin et al.
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Table I. Descriptive statistics for the study population and
excluded parturients.
Included
(n 1,480)*
Maternal age (years), mean9SD 29.195.0
Parity
Primipara 717 (48.5)
Multipara 723 (48.9)
MNPVD$ 40 (2.8)
High-risk pregnancy 168 (11.4)
Gestational age ]42 weeks 91 (6.1)
Induction of labour 182 (12.3)
*Data shown as numbers and percentages unless otherwise stated.
$Multipara with no previous vaginal delivery.
%Missing partogram or cervical dilation ]7 cm on admission to
the delivery ward.
with and without LD are presented in Table II.
Significant associations were found between LD and
maternal age, parity, gestational age ]42 weeks,
birth weight 4,000 g and abnormal vertex pre-
sentation. The frequency of primiparity, MNPVD,
gestational age ]42 weeks and birth weight 4,000
g in the LD group was almost double that in the
non-LD group. Deliveries in abnormal vertex pre-
sentations were increased 3-fold in the LD group
(Table II). Among deliveries resulting in a birth
weight 4,000 g, 30.6% were affected with LD
compared with 17.4% of deliveries with a birth
weight 54,000 g (pB0.001). Women in the non-
LD group were older. However, further analysis of
the primiparas showed that mean maternal age in the
LD group was 27.9, compared to 26.8 in the non-
LD group (p B0.01). No significant difference in age
related to LD or non-LD was found, either in the
MNPVD or in the other multiparas.
EDA was administered to 41% of the women,
57.3% primiparas and 24.4% multiparas. EDA was
administered more frequently (65 versus 34.5%) and
more often at an early stage (37.3 versus 14.9%) in
the LD group than in the non LD-group. LD
affected 33.4% of the women who were given EDA
Excluded% compared to 12.5% of women who were not
(n520)*
administered EDA. Oxytocin was administered
29.894.7 frequently in both groups. The frequency of induc-
tion of labour was quite similar in the two groups
154 (29.6) (Table III). Notably, 40.2% of women with sponta-
357 (68.7)
neous onset of labour and without LD were given
9 (1.7)
oxytocin during delivery. LD affected 39% of
52 (10.0) primiparas whose labour had been induced com-
40 (7.7)
39 (7.5)
pared with 32.7% of primiparas with spontaneous
onset (p 0.25). In the case of multiparas, 9.1% of
induced deliveries were affected by LD compared
with 7.4% in the spontaneous onset group (p 
0.65).
The multiple linear logistic regression model in-
cluded the following variables: maternal age, parity,
MNPVD, gestational age, induction of labour, EDA,
interval from onset of established labour to accom-
plished amniotomy, abnormal vertex presentation
and birth weight. The variables that emerged sig-
nificant in the model are presented in Table IV.
The frequency of operative deliveries, i.e. instru-
mental vaginal delivery or CS, was high among
women with LD (Table V). Intrapartum CS was
16.7% compared with 1.7% in the non-LD group.
MNPVD gave birth spontaneously in 75%. The
adjusted OR for CS in women with LD was 6.3. The
unadjusted frequency of postpartum haemorrhage
and perineal trauma was significantly increased in
women with LD, but no significant difference could
be seen between the 2 groups after controlling for
parity, birth weight and EDA. Furthermore, no
significant difference was found in the proportion
of infants with a 5-min Apgar score B7 or umbilical
cord arterial pH B7.10, between the LD and non-
LD groups.

Table II. Demographic and clinical characteristics in pregnancies with and without LD.

LD (n311)* Non-LD (n1,169)* p-Value

Maternal age (years), mean9SD 28.494.6 29.295.1 0.015

Parity
Primipara 241 (77.5) 476 (40.7)
Multipara 55 (17.7) 668 (57.2) B0.001
MNPVD$ 15 (4.8) 25 (2.1)

High-risk pregnancy 43 (13.8) 125 (10.7) 0.131

Gestational age ]42 weeks 33 (10.6) 58 (5.0) B0.001
Birth weight (g), mean9SD 38599501 36759500 B0.001
Birth weight 4,000 g 122 (39.4) 277 (23.7) B0.001
Abnormal vertex presentation 31 (10.0) 46 (3.9) B0.001

*Data shown as numbers and percentages unless otherwise stated.

$Multipara with no previous vaginal delivery.
 Dystocia in labour
risk factors, management and outcome 219
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Table III. Characteristics of management of labour for women with and without LD.

LD (n311)* Non-LD (n 1,169)* p-Value

Induction of labour 47 (15.1) 135 (11.5) 0.098

Epidural analgesia (EDA)
No EDA 109 (35.0) 766 (65.5)
EDA at cervical dilation 55 cm 116 (37.3) 174 (14.9) B0.001
EDA at cervical dilation 5 cm 86 (27.7) 229 (19.6)
Oxytocin
No oxytocin 15 (4.8) 596 (51.0)
Oxytocin augmentation, spontaneous onset 249 (8.1) 470 (40.2) B0.001
Oxytocin augmentation, induction$ 47 (15.1) 103 (8.8)
Amniotomy (h)%, mean9SD 2.6193.3 1.6691.8 B0.001

*Data shown as numbers and percentages unless otherwise stated.

$Induction method can be prostaglandin, amniotomy or oxytocin.
%Time given in intervals of 0.5 h, from established labour (cervical dilation 4 cm) to amniotomy.

Discussion MNPVD was found to be the main independent

risk factor for LD; 75% of this group managed to
Based on multivariable analysis, our study shows
give birth vaginally, a higher success rate than in two
that MNPVD, EDA at cervical dilation 55 cm,
other studies: 60.9% (12) and 65% (13), respec-
primiparity, gestational age ]42 weeks, birth weight
tively. Nevertheless, it is difficult to compare our
4,000 g, EDA at cervical dilation 5 cm and
results with the results of these studies, as there is no
interval from established labour to amniotomy were
independent risk factors for LD. information on how many women with a previous
The main reason for initiating this study was the CS were permitted trial of labour (TOL) (12,13). It
constantly increasing CS rate during the last decades is well known that an increasing number of women
in Sweden, as well as in other countries. Our results with a previous CS undergo a repeat CS, especially
show a strong relationship between LD and opera- since the risk of uterine rupture has attracted
tive delivery. Just over half (61.4%) of the LD group considerable attention. A study by Landon et al.
succeeded in a spontaneous vaginal delivery com- (12) reported that women offered TOL after a
pared to 93.6% in the non-LD group. previous CS decreased from 60.7 to 38.4% during
the 4-year study period.
Table IV. Multivariate logistic regression analysis of risk factors As previously reported, primiparas in our study
associated with LD*. were at increased risk of LD compared to multiparas
(3,10). Birth weight 4,000 g also increased the risk
OR (CI) p-Value of LD.
Parity Fetal macrosomia is a well known risk factor for
Primipara 4.5 (2.8
7.1) B0.001 LD (3,6), and the relationship between postdate
Multipara 1 (Reference) pregnancy and fetal macrosomia is also well known
MNPVD$ 6.0 (2.2
16.2) B0.001 (14). This study shows that these two variables are
EDA independent risk factors for LD. Increased frequency
No EDA 1 (Reference) of LD in older women, both primiparas and multi-
EDA at cervical dilation 55 cm 4.6 (2.8
7.7) B0.001
EDA at cervical dilation 5 cm 2.0 (1.3
2.0) 0.003
paras, has been reported (4). In our study, primi-
paras with LD were an average of 1 year older than
Gestational age ]42 weeks
No 1 (Reference)
those without LD. No such significant difference was
Yes 3.1 (1.5
6.3) 0.002 found among multiparas. After controlling for con-
Birth weight 4,000 g founders, age did not remain an independent risk
No 1 (Reference) factor.
Yes 2.7 (1.8
4.2) B0.001 In contrast to other studies (3), induction of
Amniotomy (h)%, mean9SD 1.3 (1.2
1.4) B0.001 labour was not shown to be a risk factor for LD,
including primiparas, presumably because we only
*Data presented as OR (odds ratio), 95% CI (confidence interval)
included women in the active phase.
and p-values.
$Multipara with no previous vaginal delivery. Our results indicate that both EDA and amnio-
%Time given in intervals of 0.5 hours, from established labour tomy independently influence the frequency of LD.
(cervical dilation 4 cm) to amniotomy. EDA is a common pain relief method, not least
 220 L. Selin et al.
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Table V. LD and outcome.
LD (n 311)*
Mode of delivery
Spontaneous vaginal delivery 191 (61.4)
Operative vaginal delivery 68 (21.9)
Caesarean section 52 (16.7)
Postpartum haemorrhage 1,000 ml 29 (9.3)
Retained placenta 7 (2.7)
Perineal trauma’ 20 (7.7)
5-min Apgar score B7 2 (0.6)
Umbilical cord arterial pH B7.10 3 (1.1)
*Data presented as numbers and percentages.
$Data presented as OR (odds ratio), 95% CI (confidence interval).
%Controlled for parity, birth weight and EDA.
’Third- and fourth-degree lacerations.
among primiparas. The Swedish National Birth
Register reported administration of EDA to 43% of
primiparas and 15.2% of multiparas (total: 27.7%)
in 2004. EDA is considered the most potent pain
relief method, albeit associated with a number of
side effects, foremost among them being LD. The
method is also associated with increased use of
oxytocin and an increase in instrumental vaginal
deliveries, but not with increased CS (15,16). In this
study, 41% of women had EDA, 57.3% of primi-
paras and 24.4% of multiparas. LD occurred more
frequently among women with EDA (33.4 versus
12.5%). The multiple linear logistic regression
model demonstrated that early-stage EDA (cervical
dilation 55 cm) increased the risk more than EDA
administered later (cervical dilation 5 cm). Earlier
research (7) showed that LD is diagnosed early
during labour, well before EDA has been adminis-
tered. LD is probably partly due to the effect of
EDA, but women choosing EDA also differ from
women who do not, both from obstetric and other
perspectives.
We found that amniotomy in the LD group was
performed an average of almost 1 h (54 min) later
than in the non-LD group. This supports a review
(17) concluding that amniotomy is associated with a
reduction in labour duration of 1
2 h.
Augmentation of labour using oxytocin is com-
mon at present (18). However, there is a major
variation in administration and dose (19), indicating
that administration can correspond to the lack of
good routines for augmentation rather than to a real
need (18,19). There is apparently no unequivocal
definition of the onset of the active phase of labour;
furthermore, the definition of LD is also obscure.
According to The Swedish National Board of Health
and Welfare (8), the partogram is mostly used in
Sweden, but the action line is seldom identified. The
Non-LD (n 1,169)* Unadjusted OR (95% CI)$ Adjusted OR% (95% CI)
1,094 (93.6)
55 (4.7) 5.7 (3.9
8.3) 3.5 (2.3
5.4)
20 (1.7) 11.5 (6.8
19.7) 6.3 (3.5
11.2)
59 (5.0) 1.9 (1.2
3.1) 1.5 (0.9
2.4)
24 (2.1) NS
32 (2.8) 2.9 (1.6
5.2) 1.6 (0.8
3.0)
6 (0.5) NS
17 (1.7) NS
Board concludes that assessment of progress and
diagnosis of LD is probably mostly based on
individual judgment, taking several factors into
consideration (8). In our study, labour was augmen-
ted with oxytocin in 40.2% of the women with
spontaneous onset and no diagnosed LD, indicating
that the diagnosis of LD and indications for the
administration of oxytocin were probably often
neglected.
Women with LD suffered postpartum hemorrhage
and third- and fourth-degree perineal lacerations
significantly more often; however, this was not
verified after multivariate analysis standardising for
parity, EDA and birth weight. Other research yields
contradictory findings; Sheiner et al. (3) did not find
an association between increased postpartum he-
morrhage and first-stage LD, while Janni et al. (20)
found an association, but for LD in the second stage.
Feinstein et al. (21) reported an increased risk of
third- and fourth-degree lacerations in cases of
prolonged second stage.
In our study, the occurrence of LD did not
increase the risk of Apgar score B7 at 5 min or of
umbilical cord arterial pH B7.10, which supports
other findings (20,22). However, Feinstein et al.
(21) found a significantly higher prevalence of LD in
cases of Apgar B7 at both 1- and 5-min (study
population of 93,266 births), but they did not
discuss the clinical implications of this finding.
Unfortunately, our study did not yield any in-
formation about the women’s BMI, childbirth ex-
perience, food intake or degree of fatigue, nor of any
relationship between these factors and LD. In order
to obtain a more holistic view of factors influencing
LD, these are important parameters that should be
included in future research, in which the presence of
a supporting person/doula in the labour room should
also be registered.
 Dystocia in labour
risk factors, management and outcome
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Conclusions
Increased knowledge of risk factors and maternal
and neonatal outcome in relation to LD may
contribute to improved care of women in labour.
MNPVD was shown to be a major risk factor for LD
in this study. As there is relationship between LD
and CS, it is important to prevent CS in primiparas,
and to devote special attention to these women as
well as to MNPVD. Women given EDA, especially at
cervical dilation 55 cm are also of particular
interest.
Acknowledgements
The authors express their gratitude to the Fyrbodal
R&D Council and to the Department of Obstetrics
and Gynecology, NU Hospital Group, especially
Anne Hofling, for supporting and participating in
the study.
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