LABOR & DYSTOCIA LABOR & DYSTOCIA

DEFINITION OF THE ACTIVE PHASE OF LABOR MANAGEMENT OF DIFFERENT ABNORMAL PATTERNS OF LABOR

A. Cervical dilatation of 6 cm is designated as the beginning of the The other Friedman’s Criteria for the indications for a Cesarean Section
“TRUE” active phase. Before the 6 cm threshold, standards for still hold:
progress in the active phase of labor may not be applied.
A. Prolonged Latent Phase
B. A cesarean section for active phase arrest (in cervical dilatation) 1. Defined as:
must be reserved for women with > 6 cm of dilation with ruptured Multipara: > 14 hours
membranes with NO progress in cervical dilatation. Nullipara: > 20 hours

1. for > 4 hours with adequate uterine contractions (> 200 MVU)
OR
2. at least 6 hours inadequate contractions despite oxytocin
administration
C. 4-5 cm cervical dilatation is designated as the “EARLY” active phase
1. Arrest disorders are NOT applicable as indications for a
cesarean section during this period.
2. In the presence of a protraction, reassess the 3 Ps (passage,
passenger, power) and manage expectantly or augment with
oxytocin if needed.
3. If a cesarean section is decided upon, there should be an
explanation as to the indications in the operative record.
e.g. CPD (include findings on pelvimetry, position of the head,
etc.) or fetal and/or maternal indication/s.
2. Note that the latent phase is at 1-4 cm cervical dilatation
3. Do NOT admit patients (in latent phase), if low risk. False labor
must be ruled out.
a. The management of low risk patient in the latent phase of
labor is expectant/observation/rest.
b. The more active interventions like oxytocin administration
and even caesarean section only for those with
morbidities occurring in the latent phase (e.g.
fetal/maternal problems, PROM)
4. Prolonged Latent Phase of labor as an indication for Cesarean
Section delivery should NOT apply to those with low risk
(uncomplicated) latent phase of labor, but may be an indication
among those with co-morbidities/complications in this phase of
labor.

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 LABOR & DYSTOCIA LABOR & DYSTOCIA

MANAGEMENT OF DIFFERENT ABNORMAL PATTERNS OF LABOR MANAGEMENT OF DIFFERENT ABNORMAL PATTERNS OF LABOR

Example: B. Prolonged Deceleration Phase

A 35-year-old G3P1 (0111), 40-41 weeks AOG with GDM, controlled, 1. Defined as:
EFW = 3.5 kg, (+) moderate-strong uterine contractions (250 MVU), IE Multipara: > 1 hour
= 2-3 cm, 70% effaced, station -2, (+) BOW Nullipara: > 3 hours

Sedation was given, but uterine contractions persisted with same 2. Note that Deceleration Phase is at 8-9 cm (cervical dilatation)
character.
C. Prolonged Second Stage of Labor
On the 10th hour of labor, amniotomy was done which revealed clear 1. Defined as:
amniotic fluid. Multipara: > 1 hour
Nullipara: > 2 hours
IE done after 6 hours from amniotomy (16th hour of labor) showed
similar findings as that of admission, (-) BOW IF on epidural anesthesia with pushing,
Multipara: > 2 hour
Is Cesarean Section indicated? If so, what is the indication and explanation? Nullipara: > 3 hours

 Yes, a cesarean section may be indicated. D. Descent Disorders in the Pelvic Division

 Indication: Prolonged Latent Phase 1. Failure of Descent

 Explanation: Already 16 hours in latent phase, in a woman with
spontaneous onset of labor complicated by DM, big baby (?)
and prolonged pregnancy with full trial of labor with
amniotomy, still remained to be in latent phase (> 14 hours in a 2.
multiparous patient)
- Fetal head does NOT go beyond Station 0 during the pelvic
division of labor in the deceleration phase or the second
stage of labor
Arrest of Descent
- Fetal head goes beyond Station 0 but stays there for > 1
hour in the deceleration phase or the second stage of
labor

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 LABOR & DYSTOCIA
MANAGEMENT OF DIFFERENT ABNORMAL PATTERNS OF LABOR
RATIONALE FOR STATION 0
 It has its basis on the Cardinal Movements of Labor, which
commence/happen during the Pelvic division of labor (Deceleration
phase and the 2nd stage of labor).
 Engagement is followed by Descent
 Engagement is when the BPD has passed through the pelvic inlet and
the leading bony portion of the head is at Station 0, after which
Descent follows.
 Therefore, the fetal head must reach Station 0 (engagement),
before descent occurs.
Failure of the head to go down beyond Station 0 means there is
FAILURE OF DESCENT after engagement, more so if the station is
higher (NO engagement).
 If the head reached beyond Station 0 (e.g. at +1 or lower) but did not
descend further after more than 1 hour, this means that there was
engagement followed by initial descent but arrested at that station
(e.g. at Station 1). Therefore, this is ARREST OF DESCENT.
LABOR & DYSTOCIA
MANAGEMENT OF DIFFERENT ABNORMAL PATTERNS OF LABOR
3. A descent disorder is NOT an indication for a cesarean section
and must be correlated with the abnormality of the
Deceleration Phase or Second Stage of Labor.
A CESAREAN SECTION is indicated only if the criterion for
Prolonged Deceleration or Second Stage of Labor is satisfied.
Case No. 1: G1P0, 9cm at Station -1 for > 3 hours
Indication for CS:
Prolonged deceleration phase with failure of descent secondary to inlet
contraction.
Explanation:
Prolonged deceleration phase: primigravid at 9 cm dilatation for more
than 3 hours
Failure of descent: fetal head failed to reach Station 0 during the pelvic
division (deceleration phase); absent of engagement, failure of descent
Inlet Contraction: Station -1, therefore there was no engagement and the
BPD was not able to pass through the pelvic inlet due to contraction

LABOR & DYSTOCIA

MANAGEMENT OF DIFFERENT ABNORMAL PATTERNS OF LABOR

Case No. 2: G1P0, fully dilated at Station +1 for more than 2 hours
Indication for CS:
Prolonged 2nd stage with arrest of descent secondary to midpelvic
contraction

Explanation:
Primary Diagnosis – Prolonged 2nd Stage: primigravid fully dilated for more
than 2 hours

Secondary Diagnosis – Arrest of Descent: Station +1 for more than 1 hour

(>2 hours)

Midpelvic Contraction: Station +1, therefore, there was engagement and

the BPD was able to pass through the pelvic inlet, there was initial

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 LABOR & DYSTOCIA
INDUCTION OF LABOR
- artificial stimulation of uterine contractions before the
spontaneous onset of labor, with or without ruptured
membranes

WHEN should induction of labor be done?

When the RISK of continuing the pregnancy EXCEEDS the RISK (for the
mother and/or the fetus) of the attempt for the mother to undergo labor
and ultimately achieve vaginal delivery

INDICATIONS for Induction of Labor

1. Maternal medical conditions when prolongation of pregnancy may
compromise the mother (e.g. HDP, DM, Cardiac dx, etc.)
2. Fetal conditions (e.g. IUGR, IUFD, Oligo, etc)
3. ROM in the absence of labor,
+/-chorioamnionitis
4. Pregnancies > 41 weeks (properly documented by 1st trimester sonar
aging)

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What PREREQUISITIES should be fulfilled prior to induction of labor?

1. The cervix should be adequately “primed” and “ripe” prior to

stimulating uterine contractions by oxytocin. The “ripeness” of the
cervix is the most important factor which determines the success of
the labor induction to achieve vaginal delivery.

2. At present, there is still NO universally accepted nor defined

threshold for “favorable or unfavorable” cervix for induction.

3. Investigators of the Consortium on Safe Labor reported that with a

ripe cervix, elective induction resulted in vaginal delivery in 97% of
multiparas and 76% of nulliparas.

 Bishop Score of > 9 was associated with high likelihood of a

successful induction.

 Bishop Score of < 4 was unfavorable and is an indication for

cervical ripening prior to oxytocin administration

4. What about with a Bishop Score of 5-8

 One may start induction with oxytocin without cervical priming,

but the chance of success to achieve vaginal birth may not be as
high compared to a score of >9

***Note: This information may be included during patient/family

counselling prior to starting oxytocin administration

BISHOP SCORE
- used to determine favorability/ripening of cervix in vaginal
examination
- simple and has the most predictive value

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What constitutes PATIENT PREPARATION ASSESSMENT prior to induction

of labor?
A. Review of the following:
1. Inidication/s and absence of contraindication/s
2. Established AOG
3. OB and Medical history

B. Assessment of the following:

1. Fetal presentation LABOR & DYSTOCIA
2. EFW
3. Cervical ripeness FAILURE OF INDUCTION OF LABOR
4. Fetal well-being (BPS – full or modified)  until the present time, there is NO universal definition of “failed
induction of labor”
C. Family Conference
The Obstetrician must explain the following:  in general and practical terms, definition of failed induction of labor
1. Expectations includes three parameters as follows:
2. Possible outcomes 1. stayed in the Latent Phase and did NOT reach Active Phase (> 4
3. Potential risks and benefits of the procedure cm)
2. membranes must be ruptured
3. adequate uterine contractions
CERVICAL RIPENING METHODS
1. Mechanical Methods  Summary of Failed Induction
- Balloon catheters The definition of Failure of Induction of Labor encompasses the
- Hygroscopic dilators following conditions:
1. There must be a compelling indication/s for induction of labor
2. Pharmacological Agents 2. The cervix must be ripe (Bischop Score of at least 5 and most
- Prostaglandins favorably if the score is > 9), prior to administration of oxytocin
to stimulate uterine contractions.
What induction (oxytocin) protocol should be used?
- Low or High dose OXYTOCIN protocol A Bishop Score of < 4needs cervical priming prior to induction of labor.

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 LABOR & DYSTOCIA

3. A failed induction should NOT be diagnosed until after at least

12 hours of oxytocin with ruptured membrane, with good
uterine contractions (>200 MVU) and failure to reach the active
phase or more than 4 cm cervical dilatation

During induction of labor, maternal and fetal conditions should be closely

monitored.

Onset of persistence of maternal and/or fetal non-reassuring condition/s

should necessitate active intervention such as a Cesarean delivery.

When will a FAILED INDUCTION OF LABOR be called in the presence of an

INTACT membrane (e.g. due to technical difficulty in doing an amniotomy
OR due to other safety issues such like presence of GBS infection or
colonization?

1. Presently, the length of time of induction of labor is still unclear and

being debated.

2. Thus, the concensus suggests the attending birth attendant to

exercise his/her clinical judgement on how long (whether 12, 15, 18
or 24 hours) he/she will push the induction, until clear
recommendation is at hand.

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