Abnormal Labor

What is Abnormal Labor?

Normal childbirth is defined by regular contractions of the uterus that result in the cervix gradually thinning and widening. If this pattern deviates from the norm, it’s referred to as abnormal labor. It’s important to understand the usual progression of labor in order to identify and manage instances where it’s not proceeding as it should.

Childbirth consists of three stages. The first stage starts with contractions that change the cervix and ends when the cervix is fully dilated. This stage is further divided into two phases: latent and active. The second stage of labor begins with the cervix being fully dilated and ends with the baby’s delivery. The third stage spans from the delivery of the baby to the delivery of the placenta. Abnormal labor can occur during any of these stages and can consist of prolonged labor, delayed labor, or a total halt in labor progression.

Each stage of labor has specific timeframes, which are useful for assessing labor progress. Ideally, the person giving birth is checked every two hours, with or without an internal examination, to determine how the labor is progressing.

Here’s a summary of the stages and timeframes of labor:

The first stage: from 0 cm to 10 cm dilation of the cervix;

The latent phase: from 0 cm to 5 cm dilation;
The active phase: from 6 cm dilation to complete dilation of the cervix.

The second stage: involving uterine contractions and the person’s efforts to push, which result in the baby moving down and being delivered;
The third stage: the period between the baby’s delivery and the delivery of the placenta.

The following guidelines are for full-term pregnancies with a single baby and show the time that 95% of people will take to complete each stage or phase of labor. If these guidelines are not met, the labor could be classified as abnormal:

First Stage Prolongation, Delay, and Halt

Latent Phase Prolongation

In those giving birth for the first time: the latent phase lasts more than 20 hours;
In those who have given birth before: the latent phase lasts more than 14 hours;
Because the latent phase can vary and progress slowly, it does not on its own indicate a need for cesarean delivery.

Active Phase Delay and Halt (once 6 cm cervical dilation is reached)

No further dilation of the cervix after 4 hours of adequate contractions, with ruptured waters;
No further dilation of the cervix after 6 hours of inadequate contractions, with ruptured waters, even after administering a drug called oxytocin to stimulate contractions.

Second Stage Delay and Halt

For those giving birth for the first time: a second stage lasting more than 3 hours without an epidural, or over 4 hours with an epidural;
For those who’ve given birth before: a second stage lasting more than 2 hours without an epidural, or over 3 hours with an epidural;
Longer durations may be tolerated provided the person giving birth and the baby are doing well, and progress is being made.

Third Stage Abnormality

The placenta is not delivered within 30 minutes of the baby’s delivery.

What Causes Abnormal Labor?

The process of labor can be broken down into three parts: the power, the passage, and the passenger. The ‘power’ refers to the muscle contractions of the uterus and the mother’s efforts to push the baby out. The ‘passage’ is the mother’s pelvis, and the ‘passenger’ is the baby. Sometimes, complications can occur with one or more of these parts, leading to abnormal labor.

Problems can arise if the baby is too big, in an unusual position, or the mother’s pelvis is too small. For these reasons, doctors need to monitor the size and position of the baby as it moves along with the power of the mother’s contractions. If there’s a problem, it may be necessary to have a cesarean delivery.

In rare cases, a complication called a ‘Bandl ring’ can occur. This is a constriction or tightening in the uterus that may interfere with the labor process. It’s unclear why this happens, but suggestions include prolonged labor or labor problems (known as labor dystocia).

There are several risk factors that can contribute to abnormal labor. Some are related to the mother, such as being of an older age, having a condition where the amniotic sac gets infected (chorioamnionitis), or having high blood pressure. Others relate to things like the size and position of the baby or poor heart rate.

Finally, there’s always a chance that a long labor or other problems can lead to the need for a cesarean delivery. This is why it’s so important for pregnant women to get regular check-ups and ensure they are in good health for the entirety of the pregnancy.

Risk Factors and Frequency for Abnormal Labor

In women, the shape of the pelvis varies a lot. The baby must fit tightly in this pelvis during birth, unlike in other animals like monkeys. Around 20% of all labors have complications, often requiring a cesarean section, which is an operation to deliver the baby.

Difficulties during labor can sometimes lead to injury or even death for the mother or baby. Because of this, more attention is being given to ways of reducing the need for cesarean sections in safer ways. Medical guidelines have been created to manage labor stages more conservatively.

After the baby is born, the third stage of labor ends with the delivery of the placenta, the organ that provides nourishment to the baby during pregnancy. Problems during this third stage can lead to heavy bleeding after childbirth, which requires blood transfusions and can sometimes result in maternal injury or death. This heavy bleeding affects about 5% of all deliveries.

The average length of the third stage of labor is 5 to 6 minutes with active management.
90% of the third stages take less than 10 minutes.
If the third stage lasts more than 18 minutes, there’s a higher chance of heavy bleeding after childbirth.
If it lasts over 30 minutes, the risk increases significantly.

Signs and Symptoms of Abnormal Labor

Childbirth starts when a woman begins to experience regular contractions, leading to a thinning and opening of the cervix, which is an important part of getting ready for birth. Doctors need to know when contractions started and how often they are happening. One of the key parts of a physical exam during labor is examining the stomach to estimate the size of the baby and to see how the baby is positioned. Doctors use regular monitoring to see how often contractions occur, and sometimes use a special device to measure the actual strength of the contractions. Checking the baby’s heart rate regularly helps doctors make sure the baby is doing well during labor.

Throughout labor, doctors will periodically perform vaginal examinations to assess the shape and size of the pelvis, check how much the cervix has thinned and opened and to evaluate the baby’s position, level, and how far down it is. These examinations are essential in understanding if labor is progressing normally or if there are any concerns.

Testing for Abnormal Labor

Keeping track of labor progress is an important part of childbirth care. To monitor the mother’s uterine activity, doctors may use hand palpation, external measurement tools, or an internal pressure monitoring device. When using an external measurement tool, doctors aim to track 3 to 5 contractions every 10 minutes, each lasting 30 to 40 seconds.

In cases where the mother’s water has broken, doctors often use an internal pressure monitoring device to measure the strength of uterine contractions. This involves the insertion of a tube through the cervix into the uterus, leading to a direct pressure reading within the uterus. Contracting intensity is measured in Montevideo units (MVUs), which add up the total contraction pressures over a 10-minute period, aiming for 200-250 MVUs. Although not perfect, this system is currently the best available.

Another innovative technique for monitoring uterine contractions involves the use of electrodes placed on the abdomen to record electrical signals generated by the muscle contractions. However, this method is not yet part of standard clinical practice.

Moreover, checking the baby’s position is also a significant aspect of childbirth care. Research shows that unfavorable positions such as the “occiput posterior” can result in a longer second stage of labor and an increased need for a cesarean section. Trials have shown that manually turning the baby from this position to a more favorable one can help shorten the second part of labor. Interestingly, manual rotation is often easier and safer than using instruments or changing the mother’s position during labor.

Treatment Options for Abnormal Labor

When labor doesn’t progress normally, it can lead to negative outcomes for both the mother and the baby. That’s why it’s so important to actively manage the process. Most labor units have a protocol for giving a drug called oxytocin to help with weak contractions. This plan includes knowing what dose to give, when to increase the dose, and how to monitor the mother and the baby for any problems. If labor continues to be slow, the use of forceps or vacuum could help speed up the delivery. Sometimes, a C-section is needed if labor doesn’t move along fast enough. For a delayed third stage of labor, sometimes the placenta needs to be manually removed.

When it comes to the first stage of labor, it can be drawn out for hours or even days. Whether or not a woman is admitted to the hospital depends on several things, like how her cervix is doing, how she’s feeling emotionally, any complications, her pain level, and how close she lives to the hospital. More medical interventions are often needed if she’s admitted during the first stage of labor. So, decisions have to be made about whether to check her into the hospital or to continue managing labor outside of the hospital.

If labor is too slow, medical professionals may want to help her rest. They might give her morphine to help with this, alongside other drugs if needed. Additionally, oxytocin and a procedure called an amniotomy can help get labor moving again.

If a woman is in the active stage of the first stage of labor, oxytocin can be given, and an amniotomy can be done. If labor hasn’t shown any progress after certain checkpoints, a C-section might be the best option. If labor is slowly moving along, oxytocin is usually continued.

In the second stage of labor, if there’s little or no progress after a certain amount of time, then oxytocin is typically started. Depending on whether a woman is having her first child or has given birth before, there are different durations of time that she can push before other methods are considered. If the baby keeps moving and there’s no problem with their heartbeat, any other methods should be delayed. If needed, the baby can be rotated manually to a more favorable position for vaginal delivery. More pushing time can be given if the woman is under epidural anesthesia.

For a prolonged second stage of labor, surgical delivery options can be used.

Stomach pain
Bandl ring (a complication of labor)
Braxton Hicks contractions (also known as practice contractions)
Cervical stenosis (a condition where the cervix narrows)
Chorioamnionitis (infection of the membrane surrounding the fetus)
Placental abruption (when the placenta detaches from the uterus too early)
Premature rupture of membranes (water breaking too early)
Prodromal labor (slow, painful labor over a prolonged period)
Uterine Mullerian anomaly (a congenital irregularity in the structure of the uterus)
Uterine rupture (a serious condition where the uterus tears during childbirth)

What to expect with Abnormal Labor

The outlook for abnormal labour can differ based on the stage. If the first stage (latent phase) is taking longer than usual, certain interventions like breaking the water (amniotomy) and using the contraction-inducing hormone oxytocin can help, with labour progressing normally from there on. These same methods can be used if issues arise during the active phase of the first stage of labour. An interesting study showed that breaking the water within an hour of the cervical balloon catheter being expelled resulted in labour happening over two times faster in full-term patients undergoing mechanical cervical ripening.

If the first stage of labour takes too long, it can lead to issues for both mother and baby. For the mother, these may include a fever due to uterine infection (endometritis), difficulty with the baby’s shoulders during delivery (shoulder dystocia), heavy bleeding and need for a blood transfusion. If the second stage of labour isn’t proceeding as normal, oxytocin can be used again. A slow or stalled second stage of labour is linked to more severe tearing, cesarean delivery, and a longer hospital stay. For the baby, abnormal labour may increase the likelihood of being admitted to the neonatal intensive care unit, having a low Apgar score (a measure of infant health), and needing assistance with breathing.

In some cases, performing a vaginal delivery using instruments can speed up abnormal labour. When abnormal labour is observed in the first and second stages, a cesarean delivery may be required, depending on certain criteria. Nowadays, effective methods are in place to prevent injury, blood loss and infection, leading to a generally positive outlook when a cesarean delivery is needed.

Possible Complications When Diagnosed with Abnormal Labor

About 20% of childbirths might have complications such as extended or stopped labor. These types of labor complications can lead to a variety of problems for both the mother and the baby. These complications can include increased chances of infection, the need for surgical birth, low health scores for the baby five minutes after birth, extended hospital stays for the mother and baby, severe tears in the mother’s perineal area, higher than usual blood loss, and the need for the baby to be admitted to the neonatal intensive care unit (NICU).

When there are complications during labor, the main solution usually is a cesarean delivery. With the growing rate of cesarean surgeries in the United States, there is also a surge in complications linked to the placenta. Cases like placenta accreta and placenta previa, which involve the placenta attaching in abnormal locations, have increased. There’s also a rise in pregnancies growing in cesarean scars. These complications have led to an increase in health problems and death rates in mothers as they account for a large number of these instances.

Key Points:

20% of childbirths may have labor complications
Labor complications can cause infections, need for surgical birth, and extended hospital stays
Babies may be admitted to NICU
Mother may suffer severe perineal tears and heavy blood loss
Labor complications often lead to cesarean deliveries
Increased rate of cesarean surgeries is linked with complications, including abnormal placenta attachment
Complexities like placenta accreta and placenta previa have been on the rise
These problems can lead to an increase in health problems and death rates in mothers

Preventing Abnormal Labor

It’s very important for pregnant patients to be well-informed and reassured about what to expect during labor. This helps to avoid health issues for both the mother and the baby that could occur from long, difficult, or stalled labor. Pregnant women should be educated about possible measures taken during labor to avoid complications. This might include using a medication like oxytocin to stimulate labor, breaking the amniotic sac, or manually adjusting the baby’s position when needed. Patients are advised to take an active role in their prenatal care and childbirth, understanding that labor can be unpredictable, with the main goal being the health and safety of both mother and baby.

Staying physically active during pregnancy with regular exercise is beneficial to both the mother and the baby. In fact, one study showed that women who regularly walked in the later stages of pregnancy might be less likely to need labor stimulation and less likely to have a surgical birth or assisted vaginal birth. It’s also important to manage weight gain during pregnancy as gaining too much weight can lead to health issues like gestational diabetes and a bigger baby, which could increase risks during labor.

Deciding when to start labor medically can play a part in making the labor process go as smoothly as possible. It also helps to have someone reliable for support during labor, and to ensure good nutrition and hydration. Experiencing labor complications can be very scary, but through a teamwork approach to identifying and treating these complications, the best possible outcomes can be achieved for both the mother and the baby.

Frequently asked questions

Abnormal labor refers to deviations from the usual progression of childbirth, such as prolonged labor, delayed labor, or a total halt in labor progression. It can occur during any stage of labor and may require intervention or medical management.

Around 20% of all labors have complications, often requiring a cesarean section.

Signs and symptoms of abnormal labor may include: - Lack of progress in cervical dilation and effacement - Irregular or weak contractions that do not increase in intensity or frequency - Prolonged labor, lasting more than 20 hours for first-time mothers or more than 14 hours for mothers who have given birth before - Fetal distress, indicated by an abnormal heart rate pattern or meconium-stained amniotic fluid - Maternal exhaustion or inability to cope with the pain of labor - Failure of the baby to descend into the birth canal - Abnormal positioning of the baby, such as a breech or transverse position - Excessive bleeding or other signs of placental abruption or uterine rupture - Infection or fever in the mother - Maternal health conditions, such as preeclampsia or gestational diabetes, that can complicate labor It is important for healthcare providers to closely monitor labor and recognize these signs and symptoms of abnormal labor in order to take appropriate action and ensure the safety of both the mother and baby.

Abnormal labor can occur due to various factors such as the baby being too big, in an unusual position, or the mother's pelvis being too small. Other risk factors include maternal age, infection of the amniotic sac, high blood pressure, and poor heart rate of the baby. Complications during labor, such as prolonged labor or labor dystocia, can also contribute to abnormal labor.

The doctor needs to rule out the following conditions when diagnosing Abnormal Labor: 1. Stomach pain 2. Bandl ring (a complication of labor) 3. Braxton Hicks contractions (also known as practice contractions) 4. Cervical stenosis (a condition where the cervix narrows) 5. Chorioamnionitis (infection of the membrane surrounding the fetus) 6. Placental abruption (when the placenta detaches from the uterus too early) 7. Premature rupture of membranes (water breaking too early) 8. Prodromal labor (slow, painful labor over a prolonged period) 9. Uterine Mullerian anomaly (a congenital irregularity in the structure of the uterus) 10. Uterine rupture (a serious condition where the uterus tears during childbirth)

The text does not mention any specific tests for diagnosing abnormal labor. However, it does mention various interventions and procedures that may be used to manage and assist with labor progression, such as: - Hand palpation - External measurement tools to track contractions - Internal pressure monitoring device to measure uterine contractions - Electrodes placed on the abdomen to record electrical signals generated by muscle contractions (not yet part of standard clinical practice) - Checking the baby's position manually or using instruments - Giving oxytocin to help with weak contractions - Using forceps or vacuum to speed up delivery - Performing a C-section if labor does not progress fast enough - Manually removing the placenta in case of a delayed third stage of labor - Giving morphine or other drugs to help the woman rest during slow labor - Performing an amniotomy to help get labor moving again These interventions and procedures are not necessarily tests, but rather interventions and procedures used to manage and assist with abnormal labor.

Abnormal labor is treated through various medical interventions. In the first stage of labor, if it is too slow, medical professionals may administer morphine to help the woman rest. Oxytocin and an amniotomy can also be used to get labor moving again. In the second stage of labor, if there is little or no progress after a certain amount of time, oxytocin is typically started. Depending on the circumstances, other methods such as manual rotation of the baby or surgical delivery options may be considered. Ultimately, the treatment for abnormal labor depends on the specific situation and the needs of the mother and baby.

The side effects when treating abnormal labor can include the following: - Increased chances of infection - Need for surgical birth (C-section) - Extended hospital stays for both the mother and the baby - Severe tears in the mother's perineal area - Higher than usual blood loss - Need for the baby to be admitted to the neonatal intensive care unit (NICU) These complications can have negative impacts on both the mother and the baby, and may require additional medical interventions and care.

The prognosis for abnormal labor can vary depending on the stage. Interventions such as breaking the water and using oxytocin can help if issues arise during the first stage of labor. If the first stage takes too long, it can lead to complications for both the mother and baby. In cases of abnormal labor in the first and second stages, a cesarean delivery may be required. However, effective methods are in place to prevent injury, blood loss, and infection, leading to a generally positive outlook when a cesarean delivery is needed.

An obstetrician or a gynecologist.

Pregnancy Women's Health