SALWA NEYAZI ASSISTANT PROF.& CONSULTANT OBGYN KKUH DYSTOCIA.

SALWA NEYAZISALWA NEYAZIASSISTANT PROF.& CONSULTANTASSISTANT PROF.& CONSULTANT

OBGYNOBGYN

KKUHKKUH

DYSTOCIADYSTOCIA

ا الرحيم للهبسم الرحٰم�ن ا الرحيم للهبسم الرحٰم�ن

OutlineOutline Introduction: definition, significanceIntroduction: definition, significance DiagnosisDiagnosis CausesCauses Prevention & treatment of dystociaPrevention & treatment of dystocia ConclusionConclusion

INTRODUCTIONINTRODUCTION Definition:Definition:

Dystocia is difficult labor or abnormally slow Dystocia is difficult labor or abnormally slow progression of laborprogression of labor

≥ ≥ 4 hrs of 4 hrs of < < 0.5 cm/ hr dilatation in the 10.5 cm/ hr dilatation in the 1stst stage stage

≥ ≥ 1 hr with no descent in the 21 hr with no descent in the 2ndnd stage stage

It can occur in 2 formsIt can occur in 2 formsA-Primary dysfunctional labourA-Primary dysfunctional labourB-Secondary arrestB-Secondary arrest

Expressions used to describe dystociaExpressions used to describe dystocia CPD, failure to progress (lack of progressive CPD, failure to progress (lack of progressive Cx dilatation or lack of fetal descent) Cx dilatation or lack of fetal descent)

INTRODUCTIONINTRODUCTION

What is the importance of diagnosing dystocia?What is the importance of diagnosing dystocia? Dystocia is the most common indication for Dystocia is the most common indication for

1ry CS1ry CS

50-60% of CS in USA attributed to dystocia50-60% of CS in USA attributed to dystocia

There has been dramatic There has been dramatic ↑ ↑ in CS rate with in CS rate with ↑ ↑ in maternal mortality, morbidity, neonatal in maternal mortality, morbidity, neonatal morbidity & health care costsmorbidity & health care costs

Reducing Dystocia Reducing Dystocia CS rate CS rate

Diagnosis of DystociaDiagnosis of Dystocia It is generally agreed that dystocia is over It is generally agreed that dystocia is over

diagnosed diagnosed CS rate CS rate

To be able to diagnose dystocia we should be To be able to diagnose dystocia we should be able to understand labor firstable to understand labor first

WHAT IS LABOR?WHAT IS LABOR? Regular frequent uterine contractions Regular frequent uterine contractions ++ Cx changes (dilatation & effacement) Cx changes (dilatation & effacement)

or SROMor SROM

STAGES OF LABOR

FIRST STAGE

SECOND STAGE

Latent phase Active phase

Acceleration Phase Decceleration Phase

THIRD STAGE

PHASES OF LABOURPHASES OF LABOUR

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LATENT PHASELATENT PHASE ACTIVE PHASEACTIVE PHASE

ACCELRATION PHASEACCELRATION PHASE

DECELRATION PHASEDECELRATION PHASE

Duration of labourDuration of labour

Cerv

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LABOUR TIME FRAMESLABOUR TIME FRAMES

Phases/ Stages of Phases/ Stages of labourlabour

NulliparoNulliparousus

MultiparoMultiparousus

Latent Latent phasephase

Mean Mean timetime

6.4 h6.4 h 4.8 h4.8 h

Longest Longest 20.1 h 20.1 h 13.6 h13.6 h

Active Active phasephase

Mean rateMean rate 3 cm/h3 cm/h 5.7cm/h 5.7cm/h

Slowest Slowest 1.2cm/h1.2cm/h

1.5cm/h1.5cm/h

22ndnd Stage Stage Mean Mean timetime

1.1 h1.1 h 0.4 h0.4 h

Longest Longest 2.9 h2.9 h 1.1 h1.1 h

Diagnosis of DystociaDiagnosis of Dystocia Dystocia Dystocia shouldshould not be diagnosed before not be diagnosed before

the active phase of laborthe active phase of labor

--IN Primiparous women IN Primiparous women the cervix the cervix should have reached 3-4 cm should have reached 3-4 cm

& 80-100% effacement.& 80-100% effacement.

--IN Multiparous womenIN Multiparous women the cervix the cervix should have reached 4-5 cm should have reached 4-5 cm

& 70-80% effaced& 70-80% effaced

CAUSES OF DYSTOCIA

Dystocia is the consequence of 3 Dystocia is the consequence of 3 abnormalities that may exist singly or in abnormalities that may exist singly or in combinationcombination1-Abnormalities of the powers1-Abnormalities of the powers uterine contractility uterine contractility maternal expulsive forcesmaternal expulsive forces

2-Abnormalities of the passage2-Abnormalities of the passage maternal boney pelvis maternal boney pelvis the soft tissue of the reproductive tractthe soft tissue of the reproductive tract

3-Abnormalities of the passenger3-Abnormalities of the passenger presentation presentation position position development of the fetus development of the fetus size size

How to assess these factors?How to assess these factors?

Adequate powersAdequate powers contractions that contractions that

-last for 60 sec-last for 60 sec

-reach 20-30 mmHg of pressure-reach 20-30 mmHg of pressure

-occur every 1-2 min-occur every 1-2 min

Hypotonic contractions are responsible for 2/3 Hypotonic contractions are responsible for 2/3 of nulliparous dystociaof nulliparous dystocia

If powers are adequate If powers are adequate check Passage for check Passage for size & abnormal shape and check the size & abnormal shape and check the Passenger for size & malpresentationPassenger for size & malpresentation

PREVENTION & PREVENTION & TREATMENT OF TREATMENT OF

DYSTOCIADYSTOCIA

PREVENTION & TREATMENT OF PREVENTION & TREATMENT OF DYSTOCIADYSTOCIA

1-Admit only women inactive labor1-Admit only women inactive labor

2-Birthing companion2-Birthing companion A supportive companion A supportive companion with experience of labor with experience of labor faster progress , less faster progress , less dystocia & less CSdystocia & less CS

3-Ambulation3-Ambulation Promotes the progress of the 1Promotes the progress of the 1stst stage stage the incidence of dystocia the incidence of dystocia augmentation augmentation

operative deliveryoperative delivery pain percieved by the woman pain percieved by the woman analgesia & analgesia &

epiduralepidural Supine position Supine position antroposterior compression of the antroposterior compression of the

pelvis/ pelvis/ the size of the passage the size of the passage


4-Avoid unnecessary inductions4-Avoid unnecessary inductions

Induction is associated with increase incidence of Induction is associated with increase incidence of Dystocia DX in the latent phase of labor & Dystocia DX in the latent phase of labor & increase in obstetric interventionsincrease in obstetric interventions

Dystocia is more common with IOLDystocia is more common with IOL

5-Cervical Ripening5-Cervical Ripening

PGE2 gel is indicated for Cx ripening in pt. with PGE2 gel is indicated for Cx ripening in pt. with Bishop score Bishop score ≤ 6≤ 6 when IOL is indicated when IOL is indicated

Cx ripening with PGE2 Cx ripening with PGE2 failed induction, failed induction, in in labor duration, & labor duration, & risk of operative delivery risk of operative delivery


6-Analgesia6-Analgesia EpiduralEpidural Nitrous oxideNitrous oxide NarcoticsNarcotics

↑ ↑ pain pain

& anxiety& anxiety

↑ ↑ CatecholaminesCatecholamines

Uterine Uterine

blood flowblood flow

Uterine Uterine

ContractionContraction

strengthstrength

DystociaDystocia


Low dose epiduralLow dose epidural Minimize motor block while maintaining effective Minimize motor block while maintaining effective

sensory block (low dose bupivacaine 0.125% + sensory block (low dose bupivacaine 0.125% + narcotics) narcotics) the risk of operative deliveries the risk of operative deliveries associated with epiduralassociated with epidural

Delayed pushing in the 2Delayed pushing in the 2ndnd stage stage for 2 hrs or for 2 hrs or untill the head is visible at the perineumuntill the head is visible at the perineum

Routine oxytocin in the 2Routine oxytocin in the 2ndnd stage for women with stage for women with epidural analgesia may be helpful epidural analgesia may be helpful

Oxytocin agumentation for women with arrested Oxytocin agumentation for women with arrested progress in the 2progress in the 2ndnd stage should be considered stage should be considered provided there is no evidence of CPDprovided there is no evidence of CPD

A multicenter randomized controlled A multicenter randomized controlled trial comparing patient-controlled trial comparing patient-controlled epidural with intravenous analgesia for epidural with intravenous analgesia for pain relief in labor.pain relief in labor.Anesth Analg. 2004 Nov;99(5):1532-8; table of contents,Anesth Analg. 2004 Nov;99(5):1532-8; table of contents,HalpernHalpern SH SH, , Muir HMuir H, ,

Breen TWBreen TW, , Campbell DCCampbell DC, , Barrett JBarrett J, , ListonListon R R, , Blanchard JWBlanchard JW, Toronto, , Toronto, Canada. Canada.

ObjectivesObjectivesTo determine whether patient-controlled epidural To determine whether patient-controlled epidural

analgesia analgesia (PCEA)(PCEA) for labor affected the incidence for labor affected the incidence of CS when compared with patient-controlled IV of CS when compared with patient-controlled IV opioid analgesia opioid analgesia (PCIA)(PCIA)

MethodsMethods Multicenter randomized, controlled trialMulticenter randomized, controlled trial Healthy, term PG in 4 Canadian institutions Healthy, term PG in 4 Canadian institutions

were randomly assigned to receive PCIA with were randomly assigned to receive PCIA with fentanyl fentanyl

(n = 118) (n = 118) oror PCEA with 0.08% bupivacaine and PCEA with 0.08% bupivacaine and fentanyl 1.6 microg/mL (n = 124). fentanyl 1.6 microg/mL (n = 124).

ResultsResults

There was no difference in the incidence of CS There was no difference in the incidence of CS 10.2% (12 of 118) 10.2% (12 of 118) VSVS 9.7% (12 of 124) 9.7% (12 of 124)

No difference in the incidence of instrumental vaginal No difference in the incidence of instrumental vaginal deliverydelivery

21.2% (25 of 118) 21.2% (25 of 118) VSVS 29% (36 of 124) 29% (36 of 124)

The duration of the second stage of labor was The duration of the second stage of labor was increased in the increased in the PCEA gpPCEA gp by a median of 23 min (P = by a median of 23 min (P = 0.02)0.02)

51 Pt. (43%) in the 51 Pt. (43%) in the PCIA gpPCIA gp received epidural received epidural analgesia: analgesia:

39 (33%) because of inadequate pain relief 39 (33%) because of inadequate pain relief and and 12 (10%) to facilitate operative delivery12 (10%) to facilitate operative delivery

ResultsResults

Patients in the Patients in the PCIA gpPCIA gp required more antiemetic required more antiemetic therapy therapy

(17% (17% VS VS 6.4%; P = 0.01) 6.4%; P = 0.01) and and had more sedation (39% had more sedation (39% VSVS 5%; P < 0.001) 5%; P < 0.001)

Maternal mean pain and satisfaction with Maternal mean pain and satisfaction with analgesia scores were better in the analgesia scores were better in the PCEA gpPCEA gp (P < (P < 0.001 and P = 0.02, respectively)0.001 and P = 0.02, respectively)

More neonates in the More neonates in the PCIA gpPCIA gp required active required active

resuscitation resuscitation (52% (52% VSVS 31%; P = 0.001) and naloxone (17% 31%; P = 0.001) and naloxone (17% VSVS

3%; P < 0.001).3%; P < 0.001).

CONCLUSIONSCONCLUSIONS

PCEA does not result in an increased incidence PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA.of obstetrical intervention compared with PCIA.

PCEA provides superior analgesia compared PCEA provides superior analgesia compared with PCIA.with PCIA.

PCEA provides less maternal and neonatal PCEA provides less maternal and neonatal sedation compared with PCIA.sedation compared with PCIA.


7-Time limits for the 27-Time limits for the 2ndnd stage of stage of laborlabor

Traditionally 2hrs in nulliparaTraditionally 2hrs in nullipara No absolute time limit should be set No absolute time limit should be set

for the 2for the 2ndnd stage when epidural stage when epidural blockade is present, if good progress blockade is present, if good progress is maintained & in the absence of is maintained & in the absence of fetal compromisefetal compromise

TREATMENT OF DYSTOCIA


8-ACTIVE MANAGEMENT OF LABOR8-ACTIVE MANAGEMENT OF LABORPRINCIPLES OF ACTIVE MANAGEMENTPRINCIPLES OF ACTIVE MANAGEMENT Accurate diagnosis of laborAccurate diagnosis of labor Continuous assessment of the progress of laborContinuous assessment of the progress of labor One to one nursing careOne to one nursing care Early amniotomyEarly amniotomy OxytocinOxytocinBenefits of active managementBenefits of active management Significant reduction in dystocia instrumental Significant reduction in dystocia instrumental

deliveries & CS ratedeliveries & CS rate No increase in birth asphyxia or perinatal No increase in birth asphyxia or perinatal

mortalitymortality

9-INSTRUMENTAL DELIVERIES9-INSTRUMENTAL DELIVERIES10-CS10-CS

ActiveActive ControlControl

Labour Labour >12 hrs>12 hrs

7%7% 20%20%

ForcepsForceps 19.4%19.4% 29%29%

CSCS 4.3%4.3% 13%13%

ACTIVE MANAGEMENT OF LABOR ACTIVE MANAGEMENT OF LABOR

A randomised controlled trial and A randomised controlled trial and meta-analysis of active meta-analysis of active management of labor.management of labor.

BJOG. 2000 Jul;107(7):909-15.BJOG. 2000 Jul;107(7):909-15. Links, Links, Sadler LCSadler LC, , Davison TDavison T, , McCowanMcCowan LM LM., ., New Zealand.New Zealand.

MethodsMethods Randomised controlled trial.Randomised controlled trial. PG in spontaneous labor at term with singleton PG in spontaneous labor at term with singleton

pregnancy and ceph presentationpregnancy and ceph presentation Randomly assigned to Randomly assigned to active management (n = 320) or routine care active management (n = 320) or routine care

(n = 331). (n = 331). Active management included: Active management included: early amniotomy, 2-hr vaginal assessments, and early amniotomy, 2-hr vaginal assessments, and

early use of high dose oxytocin for slow progress early use of high dose oxytocin for slow progress in labor. in labor.

Maternal satisfaction with labor care was Maternal satisfaction with labor care was assessed by questionnaire at six weeks assessed by questionnaire at six weeks postpartum. postpartum.

RESULTS:RESULTS: Active management of labor did not reduce the Active management of labor did not reduce the

rate of CS 30/320 (9.4%), compared with 32/331 rate of CS 30/320 (9.4%), compared with 32/331 (9.7%) for routine care, (9.7%) for routine care,

Active management of labor shortened the length of Active management of labor shortened the length of first stage of labor (median 240 min vs 290 min; P first stage of labor (median 240 min vs 290 min; P = 0.02),= 0.02),

Reduced the RR of prolonged labor (>12 hrs)Reduced the RR of prolonged labor (>12 hrs) (RR 0.39; 95% CI 0.22, 0.71).(RR 0.39; 95% CI 0.22, 0.71). There were no differences between gp in the rates There were no differences between gp in the rates

of NICU admission, neonatal acidosis, low Apgar of NICU admission, neonatal acidosis, low Apgar scores, or PPH scores, or PPH

Satisfaction with labor care was high (77%) and did Satisfaction with labor care was high (77%) and did not differ between gps not differ between gps

CONCLUSIONS:CONCLUSIONS: Active management of labor reduced the duration of Active management of labor reduced the duration of

the first stage of labor without affecting the rate of the first stage of labor without affecting the rate of CS, maternal satisfaction, or other maternal or CS, maternal satisfaction, or other maternal or newborn morbidity.newborn morbidity.

Aggressive or expectant management of Aggressive or expectant management of labour: a randomised clinical triallabour: a randomised clinical trial

BJOG. 2003 May;110(5):457-61.BJOG. 2003 May;110(5):457-61. PattinsonPattinson RC RC, , HowarthHowarth GR GR, , MdluliMdluli W W, , Macdonald APMacdonald AP, , MakinMakin JD JD, , Funk MFunk M. University of Pretoria, South Africa.. University of Pretoria, South Africa.

METHODS: METHODS: Randomised trial. Randomised trial. PG in active labour, at term, with singleton pregnancy PG in active labour, at term, with singleton pregnancy

and ceph presentation.and ceph presentation. Randomised to either aggressive (n = 344) or Randomised to either aggressive (n = 344) or

expectant (n = 350) management protocols. expectant (n = 350) management protocols. Aggressive management entailed using a single line Aggressive management entailed using a single line

partogram, a vaginal examination every two hours and partogram, a vaginal examination every two hours and use of an oxytocin infusion if the line was crossed.use of an oxytocin infusion if the line was crossed.

Expectant management entailed using a two line Expectant management entailed using a two line partogram, with the alert line and a parallel action partogram, with the alert line and a parallel action line four hours to the right, with a vaginal examination line four hours to the right, with a vaginal examination every four hours. If the action line was reached, every four hours. If the action line was reached, oxytocin was started. The women were reassessed oxytocin was started. The women were reassessed every two hours thereafter. Analgesia was prescribed every two hours thereafter. Analgesia was prescribed on request. on request.

RESULTS:RESULTS: The gps were similar with respect to maternal The gps were similar with respect to maternal

age, Cx dilation at trial entry, and infants BWt.age, Cx dilation at trial entry, and infants BWt. Significantly fewer women managed Significantly fewer women managed

aggressively had CSs (16.0%) than those aggressively had CSs (16.0%) than those managed expectantly (23.4%) managed expectantly (23.4%)

(RR 0.68, 95% CI 0.50, 0.93) (RR 0.68, 95% CI 0.50, 0.93) Significantly more oxytocin was used in the Significantly more oxytocin was used in the

aggressive management gp aggressive management gp There was no difference with respect to the There was no difference with respect to the

use of analgesia or episiotomy or in neonatal use of analgesia or episiotomy or in neonatal outcome with respect to the Apgar score at 1 outcome with respect to the Apgar score at 1 or 10 minutes.or 10 minutes.

CONCLUSIONS:CONCLUSIONS: Aggressive management of labor reduces the Aggressive management of labor reduces the

CS rate in nulliparous women but requires CS rate in nulliparous women but requires more intensive nursing.more intensive nursing.

The continuing effectiveness of active The continuing effectiveness of active management of first labor, despite a management of first labor, despite a doubling in overall nulliparous doubling in overall nulliparous cesarean delivery.cesarean delivery.Am J Obstet Gynecol. 2004Am J Obstet Gynecol. 2004 Sep;191(3):891-5, Sep;191(3):891-5, Foley MEFoley ME, , AlarabAlarab M M

, , Daly LDaly L, , Keane DKeane D, , RathRath A A, , O'herlihyO'herlihy C C, Dublin, Ireland. , Dublin, Ireland.

MethodsMethods This was a retrospective analysis of annually This was a retrospective analysis of annually

collated institutional data on CS and perinatal collated institutional data on CS and perinatal outcomeoutcome

PG Spontaneous labor cephalic PG Spontaneous labor cephalic From 1989 to 2000From 1989 to 2000 81,855 women were delivered , of whom 81,855 women were delivered , of whom

34,201 women (42%) were nulliparous34,201 women (42%) were nulliparous

RESULTS:RESULTS: The overall NP(nulliparous) CS rate increased from 8.1% The overall NP(nulliparous) CS rate increased from 8.1%

to 16.6%to 16.6%

CS rate among NP, although showing a significant upward CS rate among NP, although showing a significant upward trend between 1989 and 2000 (2.4%-4.8%; P = .001), trend between 1989 and 2000 (2.4%-4.8%; P = .001),

was stable, averaging 5% for the last 8 years (P = .705)was stable, averaging 5% for the last 8 years (P = .705)

The peripartum death rate in this gp fell significantly (P The peripartum death rate in this gp fell significantly (P = .024). = .024).

Comparing results for 1989 with results for 2000Comparing results for 1989 with results for 2000 NP women in spontaneous labor accounted for 14% of the NP women in spontaneous labor accounted for 14% of the

overall increase in CS (dystocia, 5%), compared with 51% overall increase in CS (dystocia, 5%), compared with 51% for NP women with induced labor. for NP women with induced labor.

The perinatal mortality rate in term infants was The perinatal mortality rate in term infants was unchanged.unchanged.

CONCLUSION:CONCLUSION:

Active management of spontaneous first Active management of spontaneous first labors remains an effective protocol for labors remains an effective protocol for the promotion of vaginal delivery the promotion of vaginal delivery

Active management of labor has a low Active management of labor has a low peripartum mortality ratesperipartum mortality rates

Factors other than dystocia in Factors other than dystocia in spontaneous labor account for the spontaneous labor account for the progressive increase in the nulliparous CS progressive increase in the nulliparous CS rate. rate.

A-Continuous assessment A-Continuous assessment

of progress of laborof progress of labor

THE PARTOGRAMTHE PARTOGRAM

It permits the progress of It permits the progress of

labor to be seen at a glancelabor to be seen at a glance

It is a useful guidline for It is a useful guidline for

clinical decision makingclinical decision making

Role of partogram in preventing Role of partogram in preventing prolonged labourprolonged labour..

J Pak Med Assoc. 2007 Aug;57(8):408-11. J Pak Med Assoc. 2007 Aug;57(8):408-11. JavedJaved I I, , BhuttaBhutta S S, , ShoaibShoaib T T, Karachi., Karachi.

METHOD: METHOD: A case controlled, prospective studyA case controlled, prospective study 1000 women in labor 11000 women in labor 1stst/7—30/12, 2002. /7—30/12, 2002. 500 women were studied before and after the 500 women were studied before and after the

introduction of partogram. introduction of partogram. Duration of labour, mode of delivery, number Duration of labour, mode of delivery, number

of cases augmented and neonatal outcome of cases augmented and neonatal outcome were notedwere noted

Primigravida Multigravida

Before-Before-PartogramPartogram

After-After-PartogramPartogram

Before-Before-PartogramPartogram

After-After-PartogramPartogram

Labor <12 hrsLabor <12 hrs

80.8%80.8%91.6% 91.6% delivered delivered within 12 hours within 12 hours

88.4% 88.4% delivered delivered within 12 hours within 12 hours

94.4% 94.4% delivered delivered within 12 hourswithin 12 hours

18.4% had 18.4% had labour shorter labour shorter than 24 hoursthan 24 hours

(8.4%) (8.4%) delivered delivered within 24 within 24 hours.hours.

11.6%) within 11.6%) within 24 hours 24 hours

5.6% delivered 5.6% delivered within 24 hours within 24 hours

0.8% had 0.8% had labour longer labour longer than 24 hours. than 24 hours.

Normal vaginal Normal vaginal delivery in delivery in 88%, 88%,

5.6% operative 5.6% operative vaginal delivery vaginal delivery

6.4% 6.4% caesarean caesarean section. section.

CONCLUSIONCONCLUSION

In primiparas introduction of partogram showed In primiparas introduction of partogram showed significant impact on duration of labour (p < significant impact on duration of labour (p < 0.001) as well as on mode of delivery (p < 0.01)0.001) as well as on mode of delivery (p < 0.01)

In multipara the partogram showed significant In multipara the partogram showed significant

reduction in duration of labour (p < 0.01). Results reduction in duration of labour (p < 0.01). Results also showed significant reduction in number of also showed significant reduction in number of augmented labour (p < 0.001) and vaginal augmented labour (p < 0.001) and vaginal examinations (p < 0.001)examinations (p < 0.001)

By using partogram, frequency of prolonged and By using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced.morbidity and mortality was reduced.

A randomized controlled trial of a A randomized controlled trial of a bedside partogram in the active bedside partogram in the active

management of primiparous labour.management of primiparous labour.

J Obstet Gynaecol Can. 2007 Jan;29(1):27-34. J Obstet Gynaecol Can. 2007 Jan;29(1):27-34. WindrimWindrim R R, , Seaward PGSeaward PG, , HodnettHodnett E E, , AkouryAkoury H H, , Kingdom JKingdom J, , SalenieksSalenieks ME ME, , FallahFallah S S, , Ryan GRyan G, , Toronto, ON, Canada.Toronto, ON, Canada.

OBJECTIVE: OBJECTIVE: To evaluate the effect of partogram use on the To evaluate the effect of partogram use on the

CS and obstetric intervention rates. CS and obstetric intervention rates.

METHODS:METHODS: A randomized controlled trial A randomized controlled trial 1932 PG with uncomplicated pregnancies at 1932 PG with uncomplicated pregnancies at

term. term. Randomly assigned to : Randomly assigned to : --the standard gpthe standard gp, or , or the partogram gpthe partogram gp

RESULTS:RESULTS: No significant difference between the gps in No significant difference between the gps in

rates of rates of CS (partogram 24%, standard notes 25%)CS (partogram 24%, standard notes 25%) rates of other interventionsrates of other interventions amniotomyamniotomy oxytocin use oxytocin use the mean cervical dilatation in laborthe mean cervical dilatation in labor

CONCLUSION:CONCLUSION: The use of a partogram without a mandatory The use of a partogram without a mandatory

management of labor protocol had no effect on management of labor protocol had no effect on rates of CS or other intrapartum interventions rates of CS or other intrapartum interventions in healthy PG at term.in healthy PG at term.

Dystocia increases with advancing Dystocia increases with advancing maternal age.maternal age.

Am J Obstet Gynecol. 2006 Sep;195(3):760-3, Am J Obstet Gynecol. 2006 Sep;195(3):760-3, TreacyTreacy A A, , Robson MRobson M, , O'HerlihyO'Herlihy C C, Dublin, Ireland., Dublin, Ireland.

STUDY DESIGN:STUDY DESIGN: Information was collected prospectively and Information was collected prospectively and

retrieved retrospectively for a 5-year period on a retrieved retrospectively for a 5-year period on a consecutive series of PG in spontaneous term labor consecutive series of PG in spontaneous term labor with singleton cephalic presentations.with singleton cephalic presentations.

All women were managed according to an All women were managed according to an established Active Management protocol.established Active Management protocol.

Indices for dystocia:Indices for dystocia:1.1. need for oxytocin augmentationneed for oxytocin augmentation2.2. prolonged labor (> 12 hr)prolonged labor (> 12 hr)3.3. instrumental deliveryinstrumental delivery4.4. cesarean section cesarean section were compared between 5 maternal age categories were compared between 5 maternal age categories

(< 20 years, 20-24, 25-29, 30-34, and > or = 35 (< 20 years, 20-24, 25-29, 30-34, and > or = 35 years). years).

RESULTS: RESULTS: 10,737 consecutive PG in spontaneous term labor10,737 consecutive PG in spontaneous term labor All of the examined indices for dystocia increased All of the examined indices for dystocia increased

significantly and progressively with increasing significantly and progressively with increasing maternal age: maternal age:

1.1. the incidences of oxytocin augmentation the incidences of oxytocin augmentation 2.2. prolonged laborprolonged labor3.3. instrumental delivery instrumental delivery 4.4. intrapartum CS including cesareans for dystocia intrapartum CS including cesareans for dystocia Mean gestational age and BWt were similar in Mean gestational age and BWt were similar in

each age categoryeach age category

CONCLUSION: CONCLUSION: All 4 indices of dystocia examined were increased All 4 indices of dystocia examined were increased

progressively with maternal age, progressively with maternal age, Oxytocin augmentation proved a generally Oxytocin augmentation proved a generally

effective intervention in all age categories.effective intervention in all age categories.

PHILPOTT’S CERVICOGRAPHPHILPOTT’S CERVICOGRAPH

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Alert lineAlert lineAction lineAction line

Cervicograph should not be used until active Cervicograph should not be used until active

labour has been established 3-4 cm dilatationlabour has been established 3-4 cm dilatation

Partogram action line study: a Partogram action line study: a randomised trialrandomised trial

Br J Obstet Gynaecol. 1998Br J Obstet Gynaecol. 1998 Sep;105(9):976-80. Sep;105(9):976-80. Lavender TLavender T, , AlfirevicAlfirevic Z Z, , WalkinshawWalkinshaw S S..

Liverpool Women's Hospital, UK.Liverpool Women's Hospital, UK.MethodsMethods Prospective randomized clinical trial. Prospective randomized clinical trial. 928 PG / uncomplicated pregnancies / in 928 PG / uncomplicated pregnancies / in

spontaneous labor at term.spontaneous labor at term. The women were randomized to have The women were randomized to have

their progress of labor recorded on a their progress of labor recorded on a partogram with an action line 2, 3 or 4 partogram with an action line 2, 3 or 4 hours to the right of the alert line. hours to the right of the alert line.

Prolonged labor was managed according Prolonged labor was managed according to the standard ward protocol.. to the standard ward protocol..

RESULTSRESULTS C S rate was lowest when labor was managed using C S rate was lowest when labor was managed using

a partogram with a 4-hr action line. a partogram with a 4-hr action line. The difference between the 3- and 4-hr partograms The difference between the 3- and 4-hr partograms

was statistically significant (OR 1 8, 95% CI 1.1-3.2), was statistically significant (OR 1 8, 95% CI 1.1-3.2), The difference between 2 and 4 hr was not (OR 1.4, The difference between 2 and 4 hr was not (OR 1.4,

95% CI 0.8-2.4).95% CI 0.8-2.4). The women in the 2-hr arm were more satisfied with The women in the 2-hr arm were more satisfied with

their labor their labor when compared to the women in the 3-hr (P < 00001) when compared to the women in the 3-hr (P < 00001)

and 4-hr (P <00001) arm. and 4-hr (P <00001) arm.

CONCLUSIONCONCLUSION Women prefer active management of labor. Women prefer active management of labor. Partograms which favor earlier intervention are Partograms which favor earlier intervention are

associated with higher C S rate. associated with higher C S rate. As the evidence on which to base the choice of As the evidence on which to base the choice of

partograms remains inconclusive further research is partograms remains inconclusive further research is required.required.

Effect of different partogram action Effect of different partogram action lines on birth outcomes: a randomized lines on birth outcomes: a randomized

controlled trial.controlled trial.

Obstet Gynecol. 2006 Aug;108(2):295-302.Obstet Gynecol. 2006 Aug;108(2):295-302. Lavender TLavender T, , AlfirevicAlfirevic Z Z, , WalkinshawWalkinshaw S S..United Kingdom. United Kingdom.

OBJECTIVE:OBJECTIVE: WHO recommends partograms with a 4-hr WHO recommends partograms with a 4-hr

action line, others recommend earlier action line, others recommend earlier intervention. intervention.

This study assessed the effect of different This study assessed the effect of different action line positioning on birth outcomes. action line positioning on birth outcomes.

METHODS:METHODS: A randomized trial of PG / uncomplicated A randomized trial of PG / uncomplicated

pregnancies, /in spontaneous labor at termpregnancies, /in spontaneous labor at term Women were assigned to have their labors Women were assigned to have their labors

recorded on a partogram with an action line 2 recorded on a partogram with an action line 2 or 4 hours to the right of the alert line.or 4 hours to the right of the alert line.

RESULTS:RESULTS: 3,000 women were randomly assigned to groups; 3,000 women were randomly assigned to groups; Questionnaires were completed by 1,929 (65%) Questionnaires were completed by 1,929 (65%)

women.women. There were no differences in C S rate There were no differences in C S rate 136/1,490 compared with 135/1,485 136/1,490 compared with 135/1,485

(RR 1, 95% CI 0.80-1.26) (RR 1, 95% CI 0.80-1.26) There were no differences in women dissatisfied There were no differences in women dissatisfied

with labor experience with labor experience 72/962 compared with 81/96772/962 compared with 81/967 (RR 0.89, 95% CI 0.66-1.21).(RR 0.89, 95% CI 0.66-1.21). More women in the 2-hr arm had labors that More women in the 2-hr arm had labors that

crossed the action line crossed the action line 854/1,490 compared with 673/1,485854/1,490 compared with 673/1,485 ( RR 1.27, 95% CI 1.18-1.37)( RR 1.27, 95% CI 1.18-1.37) Those women received more intervention Those women received more intervention 772/1,490 compared with 624/1,485772/1,490 compared with 624/1,485( RR 1.23, 95% CI 1.14-1.33)( RR 1.23, 95% CI 1.14-1.33)

CONCLUSION:CONCLUSION:

The 2-hr partogram The 2-hr partogram the need for the need for intervention without improving intervention without improving maternal or neonatal outcomesmaternal or neonatal outcomes

(compared with the 4-hour partogram, (compared with the 4-hour partogram, advocated by the WHO) advocated by the WHO)

8-ACTIVE MANAGEMENT OF 8-ACTIVE MANAGEMENT OF LABORLABOR

B-AmniotomyB-AmniotomyRoutine early use of amniotomy after 3 cm dilatation Routine early use of amniotomy after 3 cm dilatation Shortens the average length of laborShortens the average length of labor

Does not Does not the incidence of CS the incidence of CS

Amniotomy should be considered once the Dx of Amniotomy should be considered once the Dx of dystocia has been made prior to oxytocin dystocia has been made prior to oxytocin agumentationagumentation

Further studies are required to assess the effect of Further studies are required to assess the effect of amniotomy for the Rx of dystociaamniotomy for the Rx of dystocia

8-ACTIVE MANAGEMENT OF 8-ACTIVE MANAGEMENT OF LABORLABOR

C-OXYTOCINC-OXYTOCIN Oxytocin has been the mainstay for the treatment of Oxytocin has been the mainstay for the treatment of

dystociadystocia

Standard dose Standard dose 1-2mIU/min 1-2mIU/min by 1-2 mIU every 30 by 1-2 mIU every 30 minmin

High dose regimens High dose regimens 2-6mIU/min2-6mIU/min

2-3 hrs are needed to achieve therapeutic 2-3 hrs are needed to achieve therapeutic concentrationconcentration

Given the high frequency of uterine dysfunction in Given the high frequency of uterine dysfunction in association with delayed progress of laborassociation with delayed progress of labor Oxytocin Oxytocin should be implemented prior to any consideration of should be implemented prior to any consideration of operative delivery for the Rx of dystociaoperative delivery for the Rx of dystocia

High- versus low-dose oxytocin for High- versus low-dose oxytocin for augmentation or induction of labor.augmentation or induction of labor.

Ann Pharmacother. 2005 Jan;39(1):95-101. Epub 2004 Nov 30, Ann Pharmacother. 2005 Jan;39(1):95-101. Epub 2004 Nov 30, PatkaPatka JH JH, , LodolceLodolce AE AE, , Johnston AKJohnston AK, Atlanta,USA, Atlanta,USA

DATA SOURCES: DATA SOURCES: Clinical trials comparing high-versus low-dose oxytocin for Clinical trials comparing high-versus low-dose oxytocin for

augmentation or induction of labor, were accessed through augmentation or induction of labor, were accessed through MEDLINE (1966-November 2003). MEDLINE (1966-November 2003).

DATA SYNTHESIS:DATA SYNTHESIS:Relevant studies comparing high-dose (2-6 mU/min) and low-dose Relevant studies comparing high-dose (2-6 mU/min) and low-dose

(1-2 mU/min) therapy for labor augmentation and induction (1-2 mU/min) therapy for labor augmentation and induction were evaluatedwere evaluated

CONCLUSIONS:CONCLUSIONS: High-dose oxytocin decreases the time from admission to High-dose oxytocin decreases the time from admission to

vaginal delivery, vaginal delivery, High-dose oxytocin does not appear to decrease the incidence High-dose oxytocin does not appear to decrease the incidence

of cesarean sections when compared with low-dose therapy.of cesarean sections when compared with low-dose therapy.

High and low dose oxytocin in High and low dose oxytocin in augmentation of labor.augmentation of labor.

Int J Gynaecol Obstet. 2004 Oct;87(1):6-8, Int J Gynaecol Obstet. 2004 Oct;87(1):6-8, Jamal AJamal A, Kalantari R, Tehran, , Kalantari R, Tehran, Iran.Iran.

METHOD:METHOD: 200 pregnant women requiring augmentation of 200 pregnant women requiring augmentation of

labor were randomly assigned to receive oxytocin labor were randomly assigned to receive oxytocin by either by either a low dosea low dose protocol protocol (1.5 microm/min (1.5 microm/min initially, increased by 1.5 microm/min every 30 initially, increased by 1.5 microm/min every 30 min) min) or a high dose protocolor a high dose protocol (4.5 microm/min (4.5 microm/min initially, increased by 4.5 microm/min every 30 initially, increased by 4.5 microm/min every 30 min)min)

RESULTS: RESULTS: High dose of oxytocin was associated with a High dose of oxytocin was associated with a

significant shortening of labor 4 (1.10-10) vs. 6 (1-significant shortening of labor 4 (1.10-10) vs. 6 (1-10) h, p<0.0001 10) h, p<0.0001

There was no significant difference in CS rate, There was no significant difference in CS rate, neonatal or maternal outcome.neonatal or maternal outcome.

Low-dose versus high-dose oxytocin Low-dose versus high-dose oxytocin augmentation of labor--a randomized augmentation of labor--a randomized

trial.trial. Am J Obstet Gynecol. 1995 Dec;173(6):1874-8, Xenakis EM, Am J Obstet Gynecol. 1995 Dec;173(6):1874-8, Xenakis EM,

Langer O, Piper JM, Conway D, Berkus MD, San Antonio , USA.Langer O, Piper JM, Conway D, Berkus MD, San Antonio , USA. 310 term pregnancies requiring augmentation of 310 term pregnancies requiring augmentation of

labor labor Randomized to receive either a low-dose or high-Randomized to receive either a low-dose or high-

dose oxytocin augmentation regimen. dose oxytocin augmentation regimen. Maternal demographics, labor-delivery data, and Maternal demographics, labor-delivery data, and

neonatal outcome were compared.neonatal outcome were compared. RESULTSRESULTS The high-dose oxytocin group had a significantly The high-dose oxytocin group had a significantly

lower cesarean section rate, regardless of parity lower cesarean section rate, regardless of parity (10.4% vs 25.7%, p < 0.001)(10.4% vs 25.7%, p < 0.001)

There was no differences in maternal There was no differences in maternal complications and neonatal outcomes.complications and neonatal outcomes.

The time needed to correct the labor abnormality The time needed to correct the labor abnormality was also significantly decreased (1.24 +/- 1.4 hours was also significantly decreased (1.24 +/- 1.4 hours vs 3.12 +/- 1.6 hours, p < 0.001) in the high-dose vs 3.12 +/- 1.6 hours, p < 0.001) in the high-dose groupgroup

CONCLUSIONS: CONCLUSIONS:

The use of high-dose oxytocin regimen The use of high-dose oxytocin regimen benefits benefits both nulliparous and both nulliparous and multiparousmultiparous women requiring labor women requiring labor augmentation by augmentation by significantly loweringsignificantly lowering

the time necessary to correct the labor the time necessary to correct the labor abnormality abnormality

the need for cesarean section.the need for cesarean section.

Effectiveness and safety of high dose Effectiveness and safety of high dose oxytocin for augmentation of labour in oxytocin for augmentation of labour in

nulliparous women.nulliparous women.

Cent Afr J Med. 2001 Nov-Dec;47(11-12):247-50, Majoko F, Avondale, Cent Afr J Med. 2001 Nov-Dec;47(11-12):247-50, Majoko F, Avondale, Harare, ZimbabweHarare, Zimbabwe

Methods Methods An open randomised controlled clinical trial.An open randomised controlled clinical trial. 258 nulliparous women, with spontaneous onset of labour, 258 nulliparous women, with spontaneous onset of labour,

who required augmentation.who required augmentation. Women were randomly allocated to either low dose (Women were randomly allocated to either low dose (starting starting

at 4 mIU/minat 4 mIU/min) or high dose () or high dose (starting at 10 mIU/minstarting at 10 mIU/min) oxytocin ) oxytocin gp. gp.

RESULTS:RESULTS: 258 women, 133 randomized to the low and 125 to the high 258 women, 133 randomized to the low and 125 to the high

oxytocin dose gps. oxytocin dose gps. The groups were comparable for maternal and gestational The groups were comparable for maternal and gestational

age, & Cx dilatationage, & Cx dilatation The mean augmentation to delivery interval was shorter in the The mean augmentation to delivery interval was shorter in the

high dose gp, 218 VS 326 minutes (p < 0.001).high dose gp, 218 VS 326 minutes (p < 0.001). There was no difference in the mode of delivery and fetal There was no difference in the mode of delivery and fetal

outcome in terms of BWT , 5 min Apgar score, admission to outcome in terms of BWT , 5 min Apgar score, admission to NICU and perinatal death. NICU and perinatal death.

Approaches which are not Approaches which are not advocated for the Rx or prevention advocated for the Rx or prevention of dystociaof dystocia IOL for fetal macrosomiaIOL for fetal macrosomia Routine IU pressure catheter with Routine IU pressure catheter with

oxytocin agumentationoxytocin agumentation Termination of epidural at the end of Termination of epidural at the end of

the 1the 1stst stage of labor stage of labor


Dystocia has been widely over Dx Dystocia has been widely over Dx CS rate CS rate

The diagnosis of dystocia is currently The diagnosis of dystocia is currently a leading indication for CS the a leading indication for CS the United StatesUnited States

Dystocia should Dystocia should notnot be Dx before the be Dx before the active phase of laboractive phase of labor

Cause of dystocia ---3 PCause of dystocia ---3 P


Prevention of dystociaPrevention of dystocia1-Admit only women inactive labor/accurate Dx of 1-Admit only women inactive labor/accurate Dx of

laborlabor

2-Birthing companion2-Birthing companion

3-Ambulation3-Ambulation

4-Avoid unnecessary inductions4-Avoid unnecessary inductions

5-Cervical Ripening5-Cervical Ripening

6-Analgesia6-Analgesia

7- No absolute time limit should be set for the 27- No absolute time limit should be set for the 2ndnd stage when epidural blockade is presentstage when epidural blockade is present


Treatment of DystociaTreatment of Dystocia Efforts to identify abnormal labor and Efforts to identify abnormal labor and

correct abnormal contraction patterns, correct abnormal contraction patterns, fetal malposition, and inadequate fetal malposition, and inadequate expulsive efforts may help eliminate expulsive efforts may help eliminate many CS without compromising the many CS without compromising the outcome for either mother or fetusoutcome for either mother or fetus

A-Active management of laborA-Active management of labor

B-Instrumental deliveriesB-Instrumental deliveries

C-CSC-CS

CONCLUSIONSCONCLUSIONS Active management of laborActive management of labor1.1. Accurate diagnosis of laborAccurate diagnosis of labor2.2. Continuous assessment of the progress of laborContinuous assessment of the progress of labor3.3. One to one nursing careOne to one nursing care4.4. Early amniotomyEarly amniotomy5.5. OxytocinOxytocin High dose of oxytocin is associated with a High dose of oxytocin is associated with a

significant shortening of labor , but there is no significant shortening of labor , but there is no significant difference in CS rate, neonatal or significant difference in CS rate, neonatal or maternal outcomematernal outcome

CS for dystocia should not be performed in the CS for dystocia should not be performed in the latent phase of labor or in the active phase of latent phase of labor or in the active phase of labor unless adequate uterine activity has been labor unless adequate uterine activity has been achieved.achieved.

CONCLUSIONSCONCLUSIONS CS in the 2CS in the 2ndnd of labor may be reduced if, after of labor may be reduced if, after

reevaluation of the fetus and pelvis, there is reevaluation of the fetus and pelvis, there is potential for correction of uterine forces with potential for correction of uterine forces with oxytocin, correction of malposition, operative oxytocin, correction of malposition, operative vaginal delivery, or safe continued observation.vaginal delivery, or safe continued observation.

Use of either a low-dose or high-dose oxytocin Use of either a low-dose or high-dose oxytocin regimen is appropriate for augmentation of labor. regimen is appropriate for augmentation of labor.

Regardless of the regimen used, oxytocin should be Regardless of the regimen used, oxytocin should be administered by trained personnel capable of administered by trained personnel capable of responding to complications.responding to complications.

A physician who has privileges to perform A physician who has privileges to perform cesarean delivery should be readily available.cesarean delivery should be readily available.

ACOG technical bulletin. Dystocia and the augmentation of labor.ACOG technical bulletin. Dystocia and the augmentation of labor.

THANK YOU

SALWA NEYAZI ASSISTANT PROF.& CONSULTANT OBGYN KKUH DYSTOCIA.

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