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Failure to ProgressAka: Labor Dystocia, Cephalopelvic Disproportion, CPD

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  1. See Also
    1. First Stage of Labor
    2. Labor Dystocia Management
    3. Labor Dystocia Prevention
  2. Epidemiology
    1. Labor dystocia is responsible for 50% of Cesereans
      1. Primary Ceserean rate: 20% in U.S.
  3. Criteria for active phase delay or arrest
    1. Background
      1. Based on Friedman Curve
      2. Assumes Active Phase of Labor
        1. Cervix dilated to 4 cm and
        2. Frequent contractions
    2. Protracted labor (slow rate of dilation and descent)
      1. Nulliparous women
        1. Fetal Descent: <1 cm/hour
        2. Cervical Dilation: <1 cm/hour
      2. Multiparous women
        1. Cervical Dilation: <1.5 cm/hour
        2. Fetal Descent: <2 cm/hour
    3. Arrest of Labor (complete cessation of progress)
      1. Active labor without change in descent for 1 hour
      2. Active labor without change in dilation for 2 hours
        1. Pause for 2 hours in dilation is common <7 cm
          1. Zhang (2002) Am J Obstet Gynecol 187:824
        2. Consider extending c-section indication to 4 hours
          1. Would decrease cesarean rate from 26 to 8%
          2. Rouse (2001) Obstet Gynecol 98:550
  4. Risk factors for failure to progress
    1. Obesity in nulliparous women
      1. Increased risk of ceserean delivery
      2. Decreased cervical dilation risk
      3. Increased labor duration
      4. Nuthalapaty (2004) Obstet Gynecol 103:452
  5. Etiologies for failure to progress
    1. Consider Macrosomia
      1. Gestational Diabetes
      2. Excess weight gain
      3. Older patient
      4. Multiparous
    2. Consider Cephalopelvic Disproportion (CPD)
      1. Pelvic Inlet AP <10 cm
      2. Midpelvis Interspinous <9 cm
      3. Outlet intertuberosity <8 cm
    3. Consider Fetal Malpresentation
      1. Occiput Posterior (consider manual rotation)
  6. Evaluation
    1. Confirm that patient is in Active Phase of Labor
      1. Cervix at least 4 cm dilated and
      2. Regular contractions
    2. Confirm cervical dilatation
      1. No anterior lip if "complete"
      2. Check cervix q1-2 hours if membranes intact
      3. Assess for fetal malposition (e.g. Occiput Posterior)
    3. Confirm Fetal Presentation
      1. Digital cervical exam
      2. Consider Ultrasound if unsure of Fetal Presentation
    4. Empty bladder (consider catheterization)
    5. Evaluate maternal hydration status
    6. Evaluate for adequate pushing or Powers
      1. Consider IUPC to document adequate contractions
      2. Adequate contractions: 200-300 montevideo Units
        1. Cumulative contraction amplitudes for 10 minutes
    7. Consider graphing labor curve (partograph)
  7. Management
    1. See Active Management of Labor
  8. Prevention
    1. See Prevention of Labor Dystocia
  9. References
    1. Shields (2000) ALSO, F:1-14

Dystocia (C0013418)

Definition (MSH)Slow or difficult OBSTETRIC LABOR or CHILDBIRTH.
ConceptsDisease or Syndrome (T047)
ICD9660.9, 661.9
MSHD004420
EnglishABNORMAL LABOR, Difficult labor, Difficult labour, Dysfunctional labor, Dysfunctional labour, Dystocia, Dystocias, LABOR ABNORMAL, LABOR DIFFICULTY, Labor problem, Labour problem, Unspecified abnormality of labor
Spanishdistocia, parto anormal, parto dificil, parto disfuncional, parto distocico, problema en el parto
Parent Conceptspregnancy and puerperal disorders (C0549597), Abnormal delivery (C0549629), Abnormality of forces of labor NOS unspecified (C0473462), Obstetric Labor Complications (C0022865), Dystocia (C0013418), Labor finding (C0566640), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesCST, DXP, ICD9CM, MSH, MTH, MTHICD9, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Cephalopelvic Disproportion (C0085988)

Definition (MSH)A condition in which the HEAD of the FETUS is larger than the mother's PELVIS through which the fetal head must pass during a vaginal delivery.
ConceptsFinding (T033)
ICD9653.4, 653.4
MSHD052178
EnglishCephalo-pelvic disp., Cephalo-pelvic disproportion, Cephalopelvic Disproportion, CPD - Cephalopelvic disproportion, Disproportion between fetal head and pelvis, Disproportion between fetus and pelvis, Fetopelvic disproportion, Foetopelvic disproportion
Spanishdesproporcion cefalopelvica, desproporcion entre la pelvis y la cabeza fetal, desproporcion fetopelvica, distocia osea
Parent ConceptsFetopelvic disproportion; obstruction (C0810046), Disproportion in pregnancy, labor, and delivery (C0156964), Obstetric Labor Complications (C0022865), Cephalopelvic Disproportion (C0085988), Fetal disproportion (C0269718), Disorder of pelvic size and disproportion (C0404992), Ambiguous concept (C1274012)
SourcesCCS, ICD9CM, MSH, MTHICD9, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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