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Normal and Abnormal Labor

Normal and Abnormal Labor. Christopher R. Graber, MD Salina Women’s Clinic 7 May 2010. Overview. Background Normal Labor Friedman curve Abnormal Labor (dystocia) Risk factors for dystocia Complications from dystocia Augmentation Other. Background.

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Normal and Abnormal Labor

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  1. Normal and Abnormal Labor Christopher R. Graber, MD Salina Women’s Clinic 7 May 2010

  2. Overview • Background • Normal Labor • Friedman curve • Abnormal Labor (dystocia) • Risk factors for dystocia • Complications from dystocia • Augmentation • Other

  3. Background • Labor – uterine contractions of sufficient intensity, frequency, and duration to cause cervical effacement and dilation • A retrospective diagnosis • Latent vs. active • Dystocia – slow, abnormal progression of labor • Leading indication for C/S • Responsible for 60% of all C/S

  4. Normal Labor • Contractions  dilation  delivery • First stage – dilation up to 10cm • Latent  active • Second stage – from 10cm to delivery • Third stage – del baby to del placenta • Fourth stage – until 6w postpartum • Friedman curve • Developed in 1950’s, challenged recently

  5. Normal Labor • First Stage (minimum; Friedman) • Nulliparas – 1.2 cm dilation/hr • Multiparas – 1.5 cm dilation/hr • First Stage (Alexander, 2002) • Epidural slows active phase by 1hr • Second Stage (median; Kilpatrick, 1989) • Nulliparas – 50 min • Multiparas – 20 min

  6. Abnormal Labor • Anything not normal • Power, passenger, passage • CPD, failure to progress, dystocia • Arrest of dilation vs. Arrest of descent • Protraction • Second stage arrest/prolongation • Nullip – 2h (3h w/ epidural) • Multip – 1h (2h w/ epidural)

  7. Risks for Dystocia • Maternal age • Medical complications of pregnancy • Diabetes, hypertension, PROM • Chorio, macrosomia, pelvic contractions • Second stage • Nulliparity, epidural analgesia, OP, long first stage

  8. Complications from Dystocia • Chorioamnionitis • Fetal infection and bacteremia • Pelvic floor injuries? • Pressure necrosis  fistula formation • Increased risk of operative delivery

  9. Augmentation • Consider oxytocin for protraction or arrest • Goal: 3-5 ctx in 10min, >200 Montevideo units • “2-hour rule” should likely be 4-6 hours • If second stage arrest • Continued observation (continued augmentation) • Operative vaginal delivery • Cesarean delivery • Low-dose vs. high-dose oxytocin

  10. Other • No clear role for pelvimetry in prediction of dystocia • Walking during labor doesn’t hurt or help • Continuous support during labor is encouraged • Amniotomy may enhance progress of active labor but increases risk of fever • Women with twins may have augmentation

  11. Induction and Augmentation(by me) • Bishop score to determine if cervical ripening is needed • Cervidil (dinoprostone) vs cytotec (misoprostol) • Pitocin – start at 2mu/min • Increase by 2mu every 15 minutes • Maximum 40mu/min • Tips • If reach 40 and no Δ, off for 30 min then restart 20 • Consider (re-)prostaglandin

  12. References • ACOG practice bulletin 49 • Dystocia and Augmentation of Labor • ACOG practice bulletin 10 • Induction of Labor

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