Christopher R. Graber, MD Salina Women’s Clinic 7 May 2010.
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Transcript of Christopher R. Graber, MD Salina Women’s Clinic 7 May 2010.
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Christopher R. Graber, MDSalina Women’s Clinic
7 May 2010
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OverviewBackgroundNormal Labor
Friedman curveAbnormal Labor (dystocia)
Risk factors for dystociaComplications from dystocia
AugmentationOther
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BackgroundLabor – uterine contractions of sufficient
intensity, frequency, and duration to cause cervical effacement and dilationA retrospective diagnosisLatent vs. active
Dystocia – slow, abnormal progression of laborLeading indication for C/SResponsible for 60% of all C/S
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Normal LaborContractions dilation deliveryFirst stage – dilation up to 10cm
Latent activeSecond stage – from 10cm to deliveryThird stage – del baby to del placentaFourth stage – until 6w postpartumFriedman curve
Developed in 1950’s, challenged recently
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Normal LaborFirst Stage (minimum; Friedman)
Nulliparas – 1.2 cm dilation/hrMultiparas – 1.5 cm dilation/hr
First Stage (Alexander, 2002)Epidural slows active phase by 1hr
Second Stage (median; Kilpatrick, 1989)Nulliparas – 50 minMultiparas – 20 min
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Abnormal LaborAnything not normalPower, passenger, passage
CPD, failure to progress, dystociaArrest of dilation vs. Arrest of descent
Protraction Second stage arrest/prolongation
Nullip – 2h (3h w/ epidural)Multip – 1h (2h w/ epidural)
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Risks for DystociaMaternal ageMedical complications of pregnancy
Diabetes, hypertension, PROMChorio, macrosomia, pelvic contractions
Second stageNulliparity, epidural analgesia, OP, long first
stage
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Complications from DystociaChorioamnionitisFetal infection and bacteremiaPelvic floor injuries?
Pressure necrosis fistula formationIncreased risk of operative delivery
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AugmentationConsider oxytocin for protraction or arrestGoal: 3-5 ctx in 10min, >200 Montevideo
units“2-hour rule” should likely be 4-6 hours
If second stage arrestContinued observation (continued
augmentation)Operative vaginal deliveryCesarean delivery
Low-dose vs. high-dose oxytocin
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OtherNo clear role for pelvimetry in prediction of
dystociaWalking during labor doesn’t hurt or helpContinuous support during labor is
encouragedAmniotomy may enhance progress of active
labor but increases risk of feverWomen with twins may have augmentation
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Induction and Augmentation(by me)Bishop score to determine if cervical ripening
is neededCervidil (dinoprostone) vs cytotec (misoprostol)
Pitocin – start at 2mu/minIncrease by 2mu every 15 minutesMaximum 40mu/min
TipsIf reach 40 and no Δ, off for 30 min then
restart 20Consider (re-)prostaglandin
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ReferencesACOG practice bulletin 49
Dystocia and Augmentation of LaborACOG practice bulletin 10
Induction of Labor
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