Abnormal labor is any interference with the normal progression of labor resulting in the delivery of a normal healthy baby. Normal labor is the gradual progression starting with uterine contractions, full cervical dilatation and gradual descent of the baby through the birth canal. Labor is divided into three stages: First stage, second stage and third stage. The first stage of labor starts with uterine contractions and finishes when the cervix is fully dilated; the second stage of labor is the period of time between the full cervical dilatation and the delivery of the infant; and the third stage of labor is the period of time between the delivery of the baby and the delivery of the placenta. All three stages can range from normal to degrees of abnormalities which, if left untreated, can result in tragic consequences to the mother and baby.
o Prolonged latent phase o Protracted cervical dilatation o Arrest of cervical dilatation o Prolonged deceleration phase
o Protracted descent o Arrest of descent
o Retained placenta o Postpartum hemorrhage
The first stage of labor can be further subdivided into a latent phase of labor and an active phase of labor. The latent phase start with the onset of uterine contractions with minimal or no cervical dilatation at all. The active phase of labor begins with the upswing of cervical dilatation that culminates in full dilatation absent an abnormality such as a protracted cervical dilatation or an arrest of cervical dilatation.
A prolonged latent phase defined as more than 20 hours in a nulliparous woman (first delivery) and more than 14 hours in a multiparous woman (previously delivered a child or children) before entering the active phase of dilatation is not a very serious problem. Sometimes, the prolongation of the latent phase can be due to excessive narcotic analgesia or sedation; correction of this excess is sufficient to resolve the problem. Prolonged latent phase is generally treated with therapeutic rest (morphine is the drug of choice) to allow the pregnant woman gain some sleep. Approximately 85% of women given a therapeutic rest for a prolonged latent phase will wake up in active labor and proceed to delivery. Approximately 10% will wake up and have no more uterine contractions and be discharged with a retrospective diagnosis of false labor. Only 5% of women will wake up following a therapeutic rest and continue with ineffectual uterine contractility.
A protracted active phase of labor has serious clinical implications because the mother and infant are at risk. In approximately one third (1/3) of woman experiencing a protracted disorder the cause can be attributed to cephalopelvic disproportion (the dimensions of the baby’s head are larger than the dimensions of the mother’s pelvis). Vaginal delivery in a woman with cephalopelvic disproportion is associated with an increased occurrence of morbidity and mortality. Neurologic and developmental problems are common in particular when operative vaginal delivery is attempted (forceps). If vaginal delivery is attempted, it should be spontaneous and whenever possible free from analgesic and/or anesthetic drugs.
Abnormalities of the first stage of labor (protraction disorder and arrest of dilatation) require close fetal heart rate monitoring. If progress is slow but continuous (protracted cervical dilatation) observation and fetal monitoring is essential. Progress no matter how slow it is can be acceptable if such progress is not made at the expense of the baby’s descent as a result of unusual head molding and fetal heart rate remains within normal range. When fetal head deformation occurs, there is no real progress of labor and the risk of intracranial damage to the infant increases dramatically. Arrest of cervical dilatation that results from cephalopelvic disproportion requires that a cesarean section be performed sooner rather than later to prevent additional trauma to the fetus without any appreciable gain.
A prolonged deceleration phase is the last portion of the active phase of the first stage of labor. It is considered to be abnormal if it last more than three (3) hours in a nulliparous woman or more than one (1) hour in a multiparous woman. A prolongation of the deceleration phase is caused by the same factors causing an arrest of dilatation; namely cephalopelvic disproportion. The treatment is similar: accomplishing immediate delivery by cesarean section. Active fetal descent of the presenting part should begin at the latest during the deceleration phase. Failure of descent to begin at this time points to a serious problem, namely cephalopelvic disproportion.
Abnormalities of the second stage of labor (protraction disorder and arrest of descent) mainly relate to the progressive descent of the presenting part. Arrest of dilatation is diagnosed by the failure to document descent of the presenting part in two successive vaginal examinations one hour apart from each other. True descent occurs when the presenting part is lower in the birth canal not accompanied by excessive molding or caput. It is essential to rule out cephalopelvic disproportion before allowing labor to continue. When protracted descent is slow and continuous, cephalopelvic disproportion must be ruled out before allowing labor to continue. Close fetal monitoring must be continuous and operative vaginal delivery by forceps avoided. Perinatal morbidity (long term neurologic and developmental problems) and mortality (fetal death) are greater in deliveries following a protracted disorder of labor.
Abnormalities of the third stage of labor (retained placenta, postpartum hemorrhage) are related to difficulties associated with the uterus and placenta. In the majority of deliveries (80%) the placenta is expulsed within 10 minutes following the delivery of the baby. A third stage that lasts more than 30 minutes can be due to multiple pregnancies, overdistended uterus, uterine atony or uterine defects. Rarely, a placenta accrete may require emergency surgery. Uterine atony (failure of the uterus to contract) can cause severe and life threatening postpartum hemorrhage. Factors that increase the risk for postpartum hemorrhage include: multiple gestation, hydramnios, large baby (macrosomia), precipitate or prolonged labor. Precautionary measures and immediate treatment must be instituted in the event of a postpartum hemorrhage to minimize maternal morbidity and mortality.
Labor abnormalities are usually described as failure to progress or slow labor. A medical provider (physician or nurse midwife) should be able to recognize a labor abnormality and take the necessary steps to manage these disorders without exposing the fetus or the mother to increased risk of morbidity and/or mortality. A mismanaged labor can result in serious long term problems and life- long complications for the fetus (cerebral palsy, developmental delay, Erb’s palsy) and the mother (uterine rupture, postpartum hemorrhage).
Medical providers (physician, nurse midwife) are responsible for the diagnosis and management of complications that arise during the three stages of labor. If you believe that you, your child or your loved one have been misdiagnosed, are victims of a mismanaged labor or wrongly treated and suspect your child’s complications may be the result of a medical provider’s error that was diagnosable, avoidable and/or preventable, you may have a valid cause of action. The injury may be the result of a medical provider's mistake in handling your condition and the result of medical negligence. Dr. Borten has over 35 years of experience as an obstetrician and gynecologic surgeon to fully evaluate the merits of your potential case. Allow the Boston area medical malpractice attorneys at Gorovitz & Borten help you assert your rights and get the compensation you deserve.
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