Dystocia refers to a lack of progress in labor for any reason.  Dysfunctional labor refers to long, difficult, or abnormal labor.

This may be caused by:

• Hormones and neurotransmitters released in response to stress (e.g., catecholamines) and/or anxiety

• Ineffective uterine contractions or maternal bearing-down efforts (the powers)

• Fetal causes, including abnormalities of presentation, position, or development (the passenger)

• Alterations in the pelvic structure, including abnormalities of the maternal bony pelvis or soft-tissue abnormalities of the reproductive tract (the passage)

There are six abnormal labor patterns:

1. Prolonged latent phase: Extended time in the latent phase of labor without cervical dilation, due to hypotonic uterine contractions and treated by augmentation of labor

2. Protracted active-phase dilation: Extended time in the active phase of labor without cervical dilation due to hypotonic uterine contractions and treated by augmentation of labor

3. Arrest of dilation: No change in cervical dilation in the active phase of labor with documented adequate strength of labor (usually counting Montevideo Units with an IUPC).  Delivery would be by cesarean section.

4. Protracted descent: Slow progression with pushing in the second stage of labor through the pelvic outlet due to CPD.  May necessitate vacuum or forceps assistance.  

5. Arrest of descent: Progression begins with pushing in the second stage of labor, but then stops through the pelvic outlet due to CPD.  Delivery would be by cesarean section. 

6. Failure of descent:  No descent in the pelvic outlet at all with pushing during second stage.  Delviery would be by cesarean section.  

Secondary powers are often compromised in these situations. Large amounts of analgesic medications are given. Anesthesia may also block the bearing-down reflex. Exhaustion reduces the effectiveness of the bearing-down efforts as well.

These abnormal labor patterns may result from:

• Ineffective uterine contractions

• Pelvic contractures

• CPD (cephalopelvic disproportion)

• Abnormal fetal presentation or position

• Early use of analgesics

• Nerve block analgesia or anesthesia

• Anxiety and stress

Also, maternal position can work against the forces of gravity and decrease the strength and efficiency of the contractions. The functional relationship between the uterine contractions, the fetus, and the mother’s pelvis are altered by the maternal position. The position can provide a mechanical advantage or disadvantage to the mechanisms of labor.  Risk assessment is a continual process that involves:

• The woman’s history of past labor or labors

• Observing physical and psychologic responses to current labor

• Factors that might contribute to dysfunctional labor should be identified

• Status of labor in terms of the characteristics of uterine contractions and progress of cervical effacement and dilation

• Fetal well-being in terms of FHR (fetal heart rate) and pattern, presentation, station, and position; and status of the amniotic membranes

Common problems that might be identified in women experiencing dysfunctional labor include the following:

• Potential injury to mother or fetus related to interventions implemented for dystocia

• Anxiety related to a loss of control

• Decreased ability to cope related to an inadequate support system, exhaustion secondary to a prolonged labor process, and pain

• Potential for impaired self-concept as a parent related to separation from the infant associated with emergency cesarean birth and emotional responses to a traumatic childbirth experience

Precipitous labor is labor that lasts less than three hours from the onset of contractions to the time of birth.  Precipitous labor may result from hypertonic uterine contractions.  

Maternal complications:

• • Uterine rupture

  • Lacerations of the birth canal

  • Amniotic fluid embolus (AFE) (anaphylactoid syndrome of pregnancy)

  • Postpartum hemorrhage

Fetal complications:

• • Hypoxia

  • Fetal injury, especially to the head (intracranial) related to rapid descent in the pelvis

External Cephalic Version (ECV) may be attempted for a fetus in a breech or transverse lie (i.e., shoulder) presentation at or after 36 to 37 weeks of gestation if membranes are intact and CPD and placenta previa are not present. Cesarean birth may be necessary.

Before ECV is attempted, ultrasound scanning is done for the following reasons:

• To confirm the breech presentation

• To detect multiple gestation, oligohydramnios, or fetal abnormalities

• To measure fetal dimensions

An NST is performed to confirm fetal well-being. A tocolytic agent such as terbutaline often is given to relax the uterus.  During an attempted ECV, the nurse continuously monitors the FHR and pattern, checks the maternal vital signs, assesses the woman’s level of comfort because the procedure can be painful (epidural anesthesia is often administered). 

After the procedure is completed, the nurse continues to:

• Monitor maternal vital signs.

• Monitor uterine activity.

• Assess for vaginal bleeding until the woman’s condition is determined to be stable.

• Rh negative women should receive Rh immune globulin because the manipulation can cause fetomaternal bleeding.

Internal Version

Internal version is the fetus being turned by the obstetric health care provider. The provider inserts a hand into the uterus and changes the presentation to cephalic (head) or podalic (foot). Internal version is only rarely used, most often in twin gestations to assist with the birth of the second fetus.  

Whether cesarean birth is planned (scheduled) or unplanned, the loss of experiencing a vaginal birth is challenging for couples. The purpose is to preserve the well-being of the mother and her fetus.

Indications

There are few absolute indications that exist for cesarean birth. Most are performed for conditions that might pose a threat to both the mother and the fetus if vaginal birth occurred.

• Elective Cesarean Birth:  Elective cesarean birth, sometimes referred to as cesarean on maternal request, is the primary cesarean birth without medical or obstetric indication.

• Scheduled Cesarean Birth:  Cesarean birth is scheduled or planned if any of the following occur:

  • • Labor and vaginal birth are contraindicated (e.g., complete placenta previa, active genital herpes, positive HIV status with a high viral load).

    • Birth is necessary but labor is not inducible (e.g., hypertensive states that cause a poor intrauterine environment that threatens the fetus).

    • This course of action has been chosen by the obstetric health care provider and the woman (e.g., a repeat cesarean birth).

• Unplanned Cesarean Birth:  The woman may approach the procedure tired and discouraged after an ineffective and difficult labor.

• Forced Cesarean Birth:  The woman’s refusal to undergo cesarean birth when indicated for fetal reasons is often described as a maternal-fetal conflict. Health care providers must decide if it is ethical to get a court order for the surgery.

Possible Complications 

Possible maternal complications related to cesarean birth include:

• Anesthesia events (problems with intubation, drug reactions, aspiration pneumonia)

• Hemorrhage

• Bowel or bladder injury

• Amniotic fluid embolism

• Air embolism

• Atelectasis

• Endomyometritis

• Urinary tract infection

• Abdominal wound hematoma formation

• Dehiscence

• Infection

• Necrotizing fasciitis

• Thromboembolic disease

• Bowel dysfunction

Significant dangers to the infant include:

• Fetus may be born prematurely

• Fetal asphyxia

• Fetal injuries (e.g., injuries caused by scalpel lacerations) can also occur during the surgery

• More likely to require resuscitation efforts and develop respiratory complications

Anesthesia

Spinal, epidural, and general anesthetics are used for cesarean births. Epidural blocks are popular because women want to be awake for and aware of the birth experience. The choice of anesthetic depends on several factors, including:

• Mother’s medical history or present condition

• Time, especially if there is an obstetrical or fetal emergency

• The woman herself is a factor

Labor After Having a Cesarean Section

Trial of labor after cesarean section (TOLAC) is the term used for woman who want to try to have a vaginal delivery after a previous cesarean section.  It requres observance of a woman and her fetus for a reasonable period (e.g., four to six hours) of spontaneous active labor to assess the safety of vaginal birth for the mother and infant.  Induction of labor is done very cautiously and cervical ripening is not recommended.  When attempted, it is successful about 75% of the time, but there is an increased risk for uterine rupture.  Women choose to have a vaginal delivery because their postpartum recovery is much easier than after abdominal surgery.  

Vaginal Birth After Cesarean (VBAC)

A woman who has had a cesarean birth with a low transverse uterine incision may subsequently become pregnant, experience no contraindications to labor and vaginal birth during the pregnancy, and choose to attempt a vaginal birth after cesarean (VBAC).

VBAC is contraindicated for women at high risk for uterine rupture.  It should not be attempted by women with:

• A previous classical or T-shaped uterine incision

• Extensive transfundal uterine surgery

• Previous uterine rupture

• Medical or obstetric complications that prevent vaginal birth

Women with the following characteristics are less likely to have a successful VBAC:

• Recurrent indication (e.g., labor dystocia) for initial cesarean birth

• Increased maternal age

• Non-Caucasian race or ethnicity

• Gestational age at or beyond 40 weeks

• Maternal obesity (BMI > 30)

• Estimated fetal weight greater than 4000 g

• Labor induction