A Brief Look Back at AFP's "Dystocia in Nulliparous Women"

Dystocia in Nulliparous Women
SARA G. SHIELDS, MD, MS, University of Massachusetts, Worcester, Massachusetts, STEPHEN D. RATCLIFFE, MD, MSPH, Lancaster General Hospital Family Medicine Residency Program, Lancaster, Pennsylvania, PATRICIA FONTAINE, MD, MS, University of Minnesota, Minneapolis, Minnesota, LARRY LEEMAN, MD, MPH, University of New Mexico, Albuquerque, New Mexico
Am Fam Physician. 2007 Jun 1;75(11):1671-1678.
http://www.aafp.org/afp/2007/0601/p1671.pdf

     Labor that is prolonged or is progressing slowly is known as dystocia. Arrested labor is having contractions for two hours without cervical change. Proper management of dystocia can dramatically affect the rates of c-sections. Labor in recent years has taken a slower rate of progression that previously documented on the Friedman curve. Physicians with strict adherence to the Friedman curve may advise intervention prematurely.
     In dystocia, the four issues that need to be addressed are:
(1) assessment of adequate contractions,
(2) fetal malposition,
(3) cephalopelvic disproportion, and
(4) coexisting clinical issues.
    In the latent phase of stage 1, supportive care (observation, sedation, antihistamines, narcotics and labor augmentation) can be given, but surgical intervention should not be considered this early in the labor. Once the patient is in the active phase of stage one, amniotomy and oxytocin can be considered, which may shorten labor lengths without affecting CS rates. Amniotomy, however, is a risky procedure which may cause variable decelerations (cord compression). The use of intrauterine pressure catheters can measure contractions, but it has no effect on the duration of labor or rate of CS. It may, however, help in deciding when to give oxytocin. If the patient is in arrested labor, waiting an additional two hours has lowered the rate of CS more than 2/3's.
     In the second stage of labor, malposition is a common cause of dystocia. Occipitoposterior position is the most common position. Having the mother go into certain poses (knee-chest, lunging, pelvic rocking, side-lying, among others) may help the child fall into proper position. Manual rotation by the physician is another option. If the second stage of labor is prolonged, it is not an indication for CS.
     Dysfunctional labor can be limited by using methods including:
(1) labor support,
(2) avoiding hospital admission in the latent phase of stage one labor,
(3) avoidance of a elective induction with an unripe cervix,
(4) cautious use of an epidural.
Labor support is best done with a professional, such as a doula. It has shown to lower the incidence of epidurals. Patients unnecessarily admitted, especially in the latent phase, will be exposed to more interventions, such as oxytocin and epidurals. The use of ripening agents (misoprostol, mechanical) has lowered the labor time but has not changed the rate of CS.  The use of epidurals, although oftentimes very appropriate and acceptable (maternal request is one), has led to an increase in operative vaginal delivery. They have no relationship to incidence or CS.