Labor Dystocia in Nulliparous Women.

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Improving management of first and second stages of labour in low- and middle-income countries.

Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations.

Outcomes associated with introduction of a shoulder dystocia protocol.

The objective of this study was to assess outcomes that are associated with the implementation of a shoulder dystocia protocol that is focused on team response. We identified women who had a shoulder dystocia during 3 time periods: 6 months before (period A), 6 months during (period B), and 6 months after (period C) the institution of a shoulder dystocia protocol. Documentation and health outcomes were compared among the time periods. During the study period, 254 women (77, 100, and 77 in periods A, B, and C, respectively) had a shoulder dystocia. There were no differences among study periods in patient characteristics. However, complete and consistent documentation increased (14% to 50% to 92%; P < .001), and brachial plexus palsy that was diagnosed at delivery (10.1% to 4.0% to 2.6%; P = .03) and at neonatal discharge (7.6% to 3.0% to 1.3%; P = .04) declined.

[Twin dystocia: about one case of compaction]. / Dystocie gémellaire: à propos d'un cas de compaction.

We report a case of twin dystocia during the evacuation of full-term fetus both in cephalic presentation. A low-outlet forceps for second-phase arrest was performed for the first twin but the head remained stuck to maternal perineum, mimicking a shoulder dystocia. Digital examination found a twin compaction, that is the presence of the second twin's fetal head at the level of the first twin's chest. The discrepancy between fetal weights and the use of forceps could favor this rare complication. Various maneuvers were described previously attempted to solve the problem. Forcing back the second head may help to achieve delivery of the first twin.

[Management of shoulder dystocia]. / Conduite à tenir en cas de dystocie des épaules.

OBJECTIVE: The objective of this review is to propose recommendations on the management of shoulder dystocia. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the foreign obstetrical societies or colleges have been consulted. RESULTS: In case of shoulder dystocia, if the obstetrician is not present at delivery, he should be systematically informed as quickly as possible (professional consensus). A third person should also be called for help in order to realize McRoberts maneuver (professional consensus). The patient has to be properly installed in gynecological position (professional consensus). It is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts maneuver, with or without a suprapubic pressure, is simple to perform, effective and associated with low morbidity, thus, it is recommended in the first line (grade C). Regarding the maneuvers of the second line, the available data do not suggest the superiority of one maneuver in relation to another (grade C). We proposed an algorithm; however, management should be adapted to the experience of the operator. If the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). Routine episiotomy is not recommended in shoulder dystocia (professional consensus). Other second intention maneuvers are described. It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver McRoberts (professional consensus). CONCLUSION: All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation.

Diagnostic criteria and the management of dystocia.

Cephalopelvic disproportion has been identified as making an important contribution to the rising cesarean birth rate. O'Driscoll and colleagues in Dublin, Ireland, have suggested replacement of cephalopelvic disproportion by the term dystocia for failure of labor to progress and have defined two major subcategories: (1) true cephalopelvic disproportion, and (2) inefficient uterine action. A chart audit of reported indications for cesarean birth in a family practice residency population was done, and patients were classified using the O'Driscoll et al diagnostic criteria for dystocia. When reclassified, the percentage of cesarean births in this population for true cephalopelvic disproportion did not differ significantly from that reported from Dublin (6.1 as compared with 8.8), while the percentage done for inefficient uterine action was significantly greater (35.4 as compared with 4.2). This finding suggests there is a set of labors amenable to a management strategy that could result in a decrease in the cesarean birth rates if efficient uterine action is assured with adequate use of oxytocin.

When is primary cesarean appropriate: maternal and obstetrical indications.

To describe appropriate maternal and obstetrical indications for primary cesarean delivery. The list of potential indications is long. Among all maternal and obstetrical indications, labor dystocia is the most common; multifetal pregnancy and malpresentation are not infrequent. Maternal indications, including human immunodeficiency virus (with high viral load) and herpes simplex virus (with active lesions), are rare. Preeclampsia alone typically is not an appropriate indication for cesarean delivery. Although the need for a cesarean is absolute for some conditions, such as complete placenta previa or placenta accreta, minimum criteria for a cesarean are variable and subjective for many indications, including dystocia. The subjective diagnosis of labor dystocia provides the best opportunity to prevent the first cesarean.

Dystocia in nulliparous women.

Dystocia is common in nulliparous women and is responsible for more than 50 percent of primary cesarean deliveries. Because cesarean delivery rates continue to rise, physicians providing maternity care should be skilled in the diagnosis, management, and prevention of dystocia. If labor is not progressing, inadequate uterine contractions, fetal malposition, or cephalopelvic disproportion may be the cause. Before resorting to operative delivery for arrested labor, physicians should ensure that the patient has had adequate uterine contractions for four hours, using oxytocin infusion for augmentation as needed. For nulliparous women, high-dose oxytocin-infusion protocols for labor augmentation decrease the time to delivery compared with low-dose protocols without causing adverse outcomes. The second stage of labor can be permitted to continue for longer than traditional time limits if fetal monitoring is reassuring and there is progress in descent. Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously.

An early labor assessment program: a randomized, controlled trial.

BACKGROUND: Approximately 31 percent of cesarean deliveries in the United States and Canada are performed for dystocia. The aim of this study was to determine the effectiveness of early labor assessment to reduce cesarean birth rates for low-risk nulliparous women. METHODS: Two hundred and nine low-risk nulliparous women were randomly allocated to either the early labor assessment group or the direct admission to hospital group. Women in the early labor assessment group were evaluated and, if found to be in false or latent labor, were encouraged to go home or walk before admission to the labor unit. Those in the direct admission group were admitted to the labor unit without an assessment. Data were collected and analyzed about method of delivery, duration of labor, intrapartum interventions, and neonatal well-being. Women completed an evaluation of their experience in the early postpartum period. RESULTS: Significant decreases occurred in duration of labor, use of epidural analgesia for pain, and use of oxytocin to augment labor in the early labor assessment group. These women evaluated their labor and birth experience more positively than women in the direct admission group. No significant differences were found in the frequency of cesarean section or instrumental vaginal delivery for the two groups. CONCLUSIONS: Early labor assessment has the potential to reduce the number of women receiving oxytocin for augmentation, the rate of epidural analgesia for pain relief, and the duration of the active and second stages of labor, and to improve women's evaluations of their labor and birth experiences.

Revisão histórica da literatura sobre partograma / Literature historical review on labor diagram

Trata-se de uma revisão de literatura que oferece subsídios para utilização do partograma no acompanhamento do trabalho de parto. O objetivo foi analisar o estado do conhecimento sobre partograma, de 1975 a 2005 em língua portuguesa e inglesa. Foram analisadas 20 publicações nacionais e internacionais e apresentadas em forma de quadro sinóptico, objetivos, tipo de estudo, tamanho da amostra e principais resultados. Os artigos focalizam a construção do partograma com as linhas de alerta e ação e os benefícios do partograma na assistência, destacando o diagnóstico oportuno das distocias.