Abnormal Labor (Dystocia)

Asheber Gaym M.D.

January 2009
 Outline

• Definition of abnormal labor (dystocia)

• Discuss classifications of abnormal labor patterns
• Outline etiologies of abnormal labor
• Discuss the diagnosis of abnormal labor
• Describe management options of abnormal labor
patterns

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 Definition of Abnormal labor

• An abnormal labor is any labor in which the pattern

of labor progress is significantly different from
accepted and recognized patterns of labor progress
in terms of cervical changes, decent of fetal
presenting part or profile of uterine contractions
• Dystocia ( difficult labor) is often used
interchangeably to denote an abnormal labor pattern

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Classifications of abnormal labor patterns – Four
major groups
• Prolongation disorders
• Protraction disorders
• Arrest Disorders
• Precipitate labor

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 Prolongation Disorders

• Only one prolongation disorder recognized

• Prolonged latent phase of labor
– Definition – A latent phase lasting more than 14
hours in a multigravida and 20 hours in a
primigravida
– Challenge in diagnosis is often due to the problem
in diagnosing the exact time of onset of labor

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 Protraction Disorders

• Two protraction disorders

• Protracted cervical dilatation
– A cervical dilatation less than 1.2 cms in the multigravida
and 1.5 cms in the primigravida during active labor
• Protracted descent
– Descent of the fetal presentation less than 1 cms per hour
in the multigravida and 2 cms per hour in the primigravida

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 Arrest Disorders

• Three arrest disorders

• Secondary Arrest of Cervical Dilatation
– No cervical dilatation for 2 or more hours in the active
phase of labor
• Arrest of descent
– No descent for more than 2 hours
• Failure of descent
– No descent of fetal presentation for more than 3 hours

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 Precipitate labor

• Two precipitate labor disorders

• Precipitated dilatation

• Precipitated descent

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Etiologies of abnormal labor – related to one of
the four P’s of labor determinants
• Abnormalities of the powers
– Primary power – uterine contraction
– Secondary power – maternal expulsive efforts
• Abnormalities of the passages
– Contraction of the bony pelvis –inlet, midpelvic , outlet
– Soft tissue dystocia – tumor previa, vaginal septa etc
• Abnormalities of the passenger
• Psychological factors
– Often due to stress of labor affecting autonomic nervous
system
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 Abnormalities of the powers – Etiologies

• Primary uterine inertia – abnormal uterine contraction frequencies,

duration and intensity that is due to inherent myometrial
dysfunction
– Mainly affects primigravid labors without other additional factors
• Secondary uterine inertia – causes
– Prolonged labor
– Malpresentations/ malpositions
– Epidural analgesia
– Uterine myomata
– Dehydration and electrolyte imbalances
– Fetopelvic disproportion
– Abruptio placentae with couvaliare uterus

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Abnormalities of the passenger (fetus) leading to
dystocia
• Fetal macrosomia
• Multifetal gestation
• Congenital anomalies – e.g. hydrocephalus
• Malpresentations/malpositions

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 Diagnosis of abnormal labor patterns - Steps

• Document following parameters against time

– Uterine contraction profile
– Cervical dilatation/effacement
– Descent of fetal presentation
• Compare against normal patterns for respective parity,
identify any deviations and then classify into
respective abnormal patterns
• Look for specific etiology responsible for the
abnormal labor patterns by carefully assessing the
four determinants of labor progress (P’s of labor)
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Evaluation for causes of abnormal labor patterns
– Assessment of the four P’s of labor
• Assessment of powers of labor – three ways
– Palpation of uterine contractions
– External tocodynamometer
– Intrauterine pressure catheter monitoring
– Maternal exhaustion, vital signs, blood glucose and evidence of dehydration
• Assessment of the passenger
– Size, number, presentation, position and anomalies of the fetus by Leopold's
palpations and ultrasonography
• Assessment of the passages
– Bony pelvis – clinical pelvimetry
– Soft tissue dystocia – vaginal exam
• Assessment of maternal emotional status and pain control

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 Management of abnormal labor – depends on
specific etiology diagnosed
• Power abnormalities
– Uterine inertia – Augmentation
– Secondary powers failure – Instrumental assistance
• Passenger abnormalities
– Often caesarean deliveries required
– Destructive deliveries in cases of fetal deaths
• Abnormalities of the passages
– Often Caesarean delivery
– Episiotomy for perineal level obstruction
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