Progresión Laboral Normal y Anormal - UpToDate

10/1/2018 Progresión laboral normal y anormal - UpToDate
Autores: Robert M Ehsanipoor, MD, Andrew J Satin, MD, FACOG

Editor de sección: Vincenzo Berghella, MD
Editor Adjunto: Vanessa A Barss, MD, FACOG
Divulgaciones del colaborador
Todos los temas se actualizan a medida que hay nuevas pruebas disponibles y nuestro proceso de
revisión por pares está completo.
Revisión bibliográfica actual hasta: dic. 2017. | Última actualización de este tema: 13 de octubre
de 2017.
INTRODUCCIÓN - Durante el trabajo de parto normal, las contracciones uterinas regulares y

dolorosas causan dilatación progresiva y borramiento del cuello uterino, acompañado de descenso y
eventual expulsión del feto. "Trabajo de parto anormal", "distocia" y "falta de progreso" son términos
tradicionales pero imprecisos que se han utilizado para describir un patrón de trabajo que se desvía del
observado en la mayoría de las mujeres que tienen un parto vaginal espontáneo. Estas anomalías
laborales se describen mejor como trastornos de la protracción (es decir, más lentos que el progreso
normal) o trastornos de la detención (es decir, el cese completo del progreso). - Por convención, una
fase activa anormalmente larga generalmente se describe como prolongada, mientras que una fase
latente anormalmente larga o una segunda etapa generalmente se describe como prolongada.
Este tema describirá el progreso laboral normal y discutirá el diagnóstico y el tratamiento de los
trastornos de detención y arresto. El manejo del trabajo de parto y parto normal se revisa por separado.
(Consulte "Gestión del trabajo de parto y parto normales" ).
PROGRESIÓN NORMAL DEL PARTO - Aunque determinar si el trabajo de parto progresa

normalmente es un componente clave del cuidado intraparto, determinar el inicio del parto, medir su
progreso y evaluar los factores (poder, pasajeros, pelvis) que afectan su curso son una ciencia inexacta.
Etapas y fases : la interpretación del progreso laboral depende de la etapa y la fase. Las tres etapas y
sus fases son:
● Primera etapa : tiempo desde el inicio del parto hasta completar la dilatación cervical.
Clínicamente, a las mujeres simplemente se les pregunta el momento en que creen que comenzó el
trabajo de parto (es decir, cuando las contracciones comenzaron a ocurrir regularmente cada 3 a 5
minutos durante más de una hora) para documentar el comienzo del trabajo de parto. El momento
en que la dilatación completa se identifica por primera vez en el examen físico documenta el final
de la primera etapa. Los tiempos precisos tanto del comienzo del trabajo de parto como de la
dilatación completa son imposibles de determinar ya que el útero normal se contrae de forma
intermitente e irregular durante la gestación, las contracciones iniciales iniciales al inicio del parto
son leves e infrecuentes, los cambios cervicales iniciales son sutiles y físicos. el examen para
documentar el cambio cervical se realiza de forma intermitente.
La primera etapa consiste en una fase latente y una fase activa . La fase latente se caracteriza por
un cambio gradual en el cuello uterino y la fase activa se caracteriza por un cambio cervical rápido.
La curva de trabajo de multiparas puede mostrar un punto de inflexión entre las fases latente y
activa; este punto ocurre a unos 5 cm de dilatación [ 1 ]. En nulíparas, el punto de inflexión a
menudo no está claro y, si está presente, se produce en una dilatación cervical más avanzada, por
lo general a aproximadamente 6 cm o más. En cualquier caso, este punto de inflexión es un
hallazgo retrospectivo.
● Segunda etapa : tiempo desde la dilatación cervical completa hasta la expulsión fetal.
https://www.uptodate.com/contents/normal-and-abnormal-labor-progression?search=labor%20de%20parto&source=search_result&selectedTitle… 1/19
When pushing is delayed, some clinicians divide the second stage into a passive phase (from
complete cervical dilation to onset of active maternal expulsive efforts) and an active phase (from
beginning of active maternal expulsive efforts to expulsion of the fetus) [2].
● Third stage – Time between fetal expulsion and placental expulsion.
Criteria for normal progress — Emanuel Friedman established criteria for the normal progress of labor
in the 1950s, and these criteria were used for assessment and management of labor for decades.
However, data derived from women in labor in the 21st century suggest that changes in obstetric and
anesthesia practices and in women themselves in recent decades have resulted in changes in the
average progress of labor. Therefore, criteria for normal labor progress have been revised, although this
remains controversial.
Friedman (historic) criteria — Emanuel Friedman conducted his now classic studies defining the
spectrum of normal labor by evaluating the course of labor of 500 primigravidas admitted to the Sloane
Hospital for Women in New York in the mid-1950s [3-5]. The norms established by his data, depicted as
the "Friedman curve" (figure 1), were widely accepted as the standard for assessment of normal labor
progression for decades.
Based on these data, the transition from the latent phase to active phase appeared to occur at 3 to 4 cm
cervical dilation, and the statistical minimum rate (5th centile) of normal cervical dilation during the active
phase was 1.2 cm/hour for nulliparous women and 1.5 cm/hour for multiparous women.
A prolonged second stage for nulliparas and multiparas was defined as three hours and one hour,
respectively.
Contemporary criteria — The applicability of the Friedman curve and its established norms to
contemporary obstetric practice was challenged in the 21st century. Several studies evaluated labor
curves in thousands of contemporary women to establish contemporary criteria for normal labor
progression [6-8]. These criteria are different from, and generally slower than, those cited by Friedman.
This change has been attributed to changes in patient characteristics (eg, higher mean body mass
index), anesthesia practices (more use of neuraxial anesthesia), and obstetric practices over the past
half-century. In addition, a limitation of Friedman's findings is that his data were based on labors in only
500 women who were managed at a single institution. However, revision of the classic labor curve as
described by Friedman has not been accepted universally. For example, Friedman and Cohen argue that
the shape of the curve may have been influenced by selection biases and confounders [9,10]. The most
appropriate statistical methods remain debated.
First stage — Zhang and colleagues obtained data on normal labor patterns by evaluating
contemporary data from the Consortium on Safe Labor, which included information on 62,415 singleton
pregnancies with spontaneous onset of labor, cephalic vaginal delivery (≥88 percent spontaneous), and
normal neonatal outcome [6]. The data were collected retrospectively from the electronic medical
records at 19 medical centers in the United States. These data have been used to define normal labor
progress, as shown in the table (table 1).
The shape of the normal labor curve generated from Zhang's data (figure 2) is different from the
Friedman curve (figure 1). The Friedman curve depicts a relatively slow rate of cervical dilation until
approximately 4 cm (ie, latent phase), which is followed by an abrupt acceleration in the rate of dilation
(ie, active phase) until entering a deceleration phase at approximately 9 cm. Zhang's labor curves also
demonstrate an increase in the rate of cervical dilation as labor progresses, but the increase is more
gradual than that described by Friedman: Over 50 percent of patients did not dilate >1 cm/hour until
reaching 5 to 6 cm dilation, and a deceleration phase at the end of the first stage of labor was not
observed. Labor curves constructed from other contemporary data sets also generally differ from
Friedman's curve [7,11]. Specifically, there is no abrupt change in the rate of cervical dilation indicating a
clear transition from latent to active phase and there is no deceleration phase at the end of the first stage
of labor.
While the presence or absence of a deceleration phase at the end of the 1st stage of labor is not of major
clinical significance, defining the transition from latent to active phase (ie, transition from slower to more
rapid cervical dilation) is clinically important for diagnosing labor abnormalities. Contemporary data
suggest that the normal rate of cervical change between 3 and 6 cm dilation is much slower than
described by Friedman, who reported minimum dilation should be at least 1 cm/hour [7,12]. Many
contemporary women who go on to deliver vaginally have rates of cervical dilation <1 cm/hour before
reaching 6 cm dilation. Indeed, both nulliparas and multiparas who go on to deliver vaginally can take
more than six hours to dilate from 4 cm to 5 cm and more than three hours to dilate from 5 cm to 6 cm
(table 1) [6]. Beyond 6 cm dilation, rates of cervical dilation are more rapid in both nulliparas and
multiparas. This suggests that before 6 cm, slow cervical dilation reflects the shallow slope of the latent
phase portion of the contemporary normal labor curve, not a protracted active phase. At ≥6 cm dilation,
nearly all women should be in active labor, so slow cervical dilation beyond this point (ie, less than about
1 to 2 cm/hour) is a deviation from the slope of the contemporary normal labor curve and is abnormal if it
persists.
These contemporary observations about hourly labor progress translate into a longer normal duration of
the first stage than described by Friedman [11,13-16]. Zhang observed that the median (95th percentile)
times for the cervix to dilate from 4 to 10 cm in nulliparas and multiparas were 5.3 hours (16.4) and 3.8
hours (15.7), respectively [6]. In contrast, Friedman reported the corresponding mean (95th percentile)
durations in nulliparous and parous women were 4.6 hours (11.7) and 2.4 hours (5.2), respectively [5].
The contemporary increase in first-stage duration persists after adjustments are made for maternal and
pregnancy characteristics [13], suggesting that changes in labor practice patterns may be the primary
reason for the increase. Although epidural use has increased dramatically since the 1960s, increased
use of epidurals does not fully account for the difference. Further study is required to explain these
findings.
Second stage — Zhang observed that the median (95th percentile) duration of the second stage in
nulliparous and parous women with epidural anesthesia was 1.1 hours (3.6) and 0.4 hours (2.0),
respectively [6]. Without epidural anesthesia, the median (95th percentile) was 0.6 hours (2.8) and 0.2
hours (1.3), respectively (table 1). Thus, epidural anesthesia increased the 95th percentile for the second
stage by 0.8 hours in nulliparous women and 0.7 hours in parous women compared with no epidural
anesthesia. (See 'Neuraxial anesthesia' below.)
Diabetes, preeclampsia, fetal size, chorioamnionitis [17], duration of the first stage [18], maternal height,
and station at complete dilation may also play a role in predicting the duration of the second stage, but
standards that account for these characteristics are not available [19]. The effect of induction is
discussed below.
At full cervical dilation, fetal station is typically ≥0. In nulliparous women in the second stage, Zhang
found that the median (95th percentile) time interval for fetal descent from station +1/3 to +2/3 was 16
minutes (three hours) [11]. The median (95th percentile) time interval for fetal descent from station +2/2
to +3/3 was 7 minutes (38 minutes).
Fetal station at full cervical dilation tends to be higher in multiparous women than in nulliparous women,
and descent tends to be faster [20,21].
Normal progression in induced labors — The time to dilate 1 cm in latent phase (defined as dilation
<6 cm) is significantly longer in women undergoing induction than in those in spontaneous labor and can
take many hours [22,23]. In a retrospective study, the median (95th percentile) times for dilation in the
latent phase for nulliparous women were [22]:
● From 3 to 4 cm: Induced labor 1.4 hours (8.1 hours), spontaneous labor 0.4 hours (2.3 hours)
● From 4 to 5 cm: Induced labor 1.3 hours (6.8 hours), spontaneous labor 0.5 hours (2.7 hours)
● From 5 to 6 cm: induced labor 0.6 hours (4.3 hours), spontaneous labor 0.4 hours (2.7 hours)
The time to dilate from 6 to 10 cm was more rapid and similar in both induced and spontaneous labors
[22,23].
Because the latent phase is longer in induced labors, the duration of the first stage (defined as the time
to dilate from 4 to 10 cm) is significantly longer in induced labor than in spontaneous labor. For
nulliparas, the median (95th percentile) duration of the first stage for induced and spontaneous was 5.5
hours (16.8 hours) versus 3.8 hours (11.8 hours); for multiparas, the median (95th percentile) was 4.4
hours (16.2 hours) versus 2.4 hours (8.8 hours), in one study [22].
There is no difference in length of the second stage between induced and spontaneous labor [24].
ASSESSMENT OF LABOR PROGRESS
Digital examination — Cervical examinations to document cervical dilation, effacement, and fetal
station are usually routinely performed:
● On admission
● At two- to four-hour intervals in the first stage
● Prior to administering analgesia/anesthesia
● When the parturient feels the urge to push (to determine whether the cervix is fully dilated)
● At one- to two-hour intervals in the second stage
● If fetal heart rate abnormalities occur (to evaluate for complications such as cord prolapse or uterine
rupture or fetal descent)
More frequent examinations are warranted when there is a concern about labor progress. A limitation of
digital examination is that it is imprecise, which is not a problem when monitoring most labors, but is a
concern when the clinician is trying to determine whether cervical dilation and station are advancing
slowly or not at all. In a study that evaluated the accuracy of digital measurement of cervical dilation with
a position-tracking system, when cervical dilation was >8 cm, the mean error of digital examination was
0.75 +/- 0.73 cm; when cervical dilation was 6 to 8 cm, the mean error was 1.25 +/- 0.87 cm [25]
Partogram — Results of cervical examinations can be documented on a partogram, in addition to the

medical record. The partogram is a graphical representation of the patient's cervical dilation over time in
comparison with the expected lower limit of normal progress. The following partogram is based on
cervical dilation at admission and shows the minimum rate of labor progress achieved by 95 percent of
nulliparous women with singleton term pregnancies and spontaneous onset of labor who had a vaginal
delivery and normal neonatal outcomes (figure 3) [6]. Right deviation from this curve suggests a
protraction or arrest disorder. Although useful for visualizing labor progress, use of partograms has not
been proven to significantly improve obstetric outcome [26].
Ultrasound — Although not widely used clinically, intrapartum transperineal ultrasound examination can
document fetal descent and rotation in the second stage when performed serially, and assess the
presence and extent of caput [27]. Ultrasound examination appears to be more objective and
reproducible than digital examination. One technique is to measure the angle between the symphysis
pubis and the leading part of the fetal skull (called the angle of progression) in the second stage (figure
4); a wide angle (variously defined but at least >90 degrees and >120 degrees in two studies [28,29]) is
highly predictive that the pregnancy will deliver vaginally.
OVERVIEW OF PROTRACTION AND ARREST DISORDERS
Prevalence — Protraction and arrest disorders are common. Reported incidences vary among studies
due to differences in the definitions used by authors as well as differences among study populations (eg,
gestational age range, personal characteristics).
About 20 percent of all labors ending in a live birth involve a protraction and/or arrest disorder [30]. The
risk is highest in nulliparous women with term pregnancies. In a prospective Danish study, for example,
37 percent of healthy term nulliparas experienced dystocia during labor [31].
Protraction or arrest of labor is the most common reason for primary cesarean delivery. In one study
including over 700 women who had unplanned cesareans, 68 percent of the cesarean deliveries were
due to lack of progress in labor [32].
When only the second stage is considered, 11.5 percent of nulliparous women with epidural anesthesia
experienced a prolonged second stage in a systematic review (two studies, n = 5350 women) [33].
Risk factors — Abnormal progress of spontaneously initiated labor may to related to uterine factors,
fetal factors, the bony pelvis, or a combination of these factors (table 2) [17]. A genetic component has
been purported to account for 28 percent of the susceptibility to protracted and difficult labor [34].
Selected risk factors for protraction and arrest are discussed below. Some risk factors are more
prominent during the first stage of labor and others primarily exert their effects in the second stage.
Hypocontractile uterine activity — Hypocontractile uterine activity is the most common risk factor
for protraction and/or arrest disorders in the first stage of labor. Uterine activity is either not sufficiently
strong or not appropriately coordinated to dilate the cervix and expel the fetus.
Diagnosis — Uterine activity can be monitored qualitatively by palpation or external

tocodynamometry. The diagnosis of hypocontractile uterine activity in this setting is subjective, based on
the perception that contractions are not strong on palpation and/or infrequent (<3 or 4 contractions/10
minutes) and/or of short duration (<50 seconds) [35,36].
Uterine activity can also be monitored quantitatively by measurement of Montevideo units (MVUs) using
an internal pressure catheter (IUPC). MVUs are calculated by subtracting the baseline uterine pressure
from the peak contraction pressure of each contraction in a 10-minute window and adding the pressures
generated by each contraction (figure 5). Uterine activity less than 200 to 250 MVUs is considered
inadequate (ie, increased likelihood of not achieving expected normal rate of cervical change and fetal
descent), based on the following seminal studies [37,38], and other data [35,39,40]:
● In a retrospective report, 91 percent of women who had spontaneous vaginal deliveries after
oxytocin induction achieved contractile activity greater than 200 MVUs and 40 percent reached 300
MVUs; 77 percent of women who had spontaneous vaginal deliveries after augmentation achieved
contractile activity greater than 200 MVUs and 8 percent reached 300 MVUs [37].
● In a study of women with spontaneous initiation of labor, uterine activity averaged about 100 MVUs
in the early first stage of labor, 175 MVUs in the advanced first stage, and 250 MVUs in the second
stage [38].
In most women, external and intrauterine devices for monitoring uterine activity perform equally well [41];
routine use of IUPCs does not improve outcome [42-44]. However, selective use of an IUPC can be
helpful for assessing uterine activity when it is difficult to monitor contractions externally, such as in
obese women. (See "Use of intrauterine pressure catheters".)
Maternal obesity — Increasing maternal body mass index (BMI) correlates with an increasing length
of the first stage of labor. In one study, for example, the median time to dilate from 4 to 10 cm in
nulliparous women with BMI <25 kg/m2 and >40 kg/m2 was 5.4 and 7.7 hours, respectively, even after
controlling for multiple confounders [45]. The authors concluded more time should be allowed for labor
progress in obese patients. Maternal obesity is not independently correlated with the length of the
second stage of labor [45,46]. (See "Obesity in pregnancy: Complications and maternal management",
section on 'Progress of labor'.)
Cephalopelvic disproportion — A disproportion in the size of the fetus relative to the maternal
pelvis can result in failure to progress in the second stage and has been termed cephalopelvic
disproportion (CPD). This is usually due to fetal malposition (eg, extended or asynclitic fetal head,
occiput posterior or transverse position [discussed below]) or malpresentation (mentum posterior, brow)
rather than a true disparity between fetal size and maternal pelvic dimensions. However, true CPD may
occur if the fetus has a large surface anomaly (eg, teratoma, conjoined twin), the maternal pelvic bone is
very small or deformed (eg, after pelvic trauma), or the fetus is extremely large (although vaginal
deliveries have been described in infants weighing 13 to 17 pounds and more).
Diagnosis — Cephalopelvic disproportion is a subjective clinical assessment based on physical

examination and course of labor. Antepartum, the clinician is generally unable to predict maternal pelvis-
fetal size/position discordance leading to arrest of labor requiring cesarean delivery. Clinical and
radiologic assessments of the maternal pelvis and fetal size (ie, pelvimetry) are inexact and poorly
predict the course and outcome of labor [47,48]. Radiographic pelvimetry is not recommended [48].
Ultrasound evaluation of fetal position is accurate, but common malpositions such as occiput posterior
(OP) usually rotate intrapartum.
Non-occiput anterior position — The length of the second stage appears to correlate with the
degree of rotation away from occiput anterior (OA). Among nulliparous women under neuraxial
anesthesia who began pushing at full dilation, the mean duration of the second stage for OA, occiput
transverse (OT), and OP positions was 2.2, 2.5, and 3.0 hours, respectively, and the cesarean delivery
rates were 3.4, 6.9, and 15.2 percent, respectively [49]. Many fetuses actually enter labor in either OP or
OT position and then undergo spontaneous rotation of the fetal head during labor. Protraction and arrest
disorders associated with malposition occur when rotation to OA does not occur or is slow to occur
during labor. (See "Occiput posterior position" and "Occiput transverse position".)
Bandl's ring — An hourglass constriction ring of the uterus, called Bandl's ring, has been estimated
to occur in 1 in 5000 live births and is associated with obstructed labor in the second stage [50-52]. The
constriction forms between the upper contractile portion of the uterus and the lower uterine segment. It is
not clear if it is the cause or the result of the associated labor abnormality. It may also occur between
delivery of the first and second twin.
Diagnosis — Diagnosis is typically made at cesarean delivery. At the time of laparotomy, a

transverse thickened muscular band can be observed separating the upper and lower segment of the
uterus. However, case reports have described predelivery diagnosis using ultrasound [53,54]. Findings
included thinning of the lower uterine segment, a thick upper uterine segment, and a prominent ring
compressing the fetus unaffected by contractions.
Neuraxial anesthesia — The potential impact of neuraxial anesthesia on uterine activity and fetal
malposition has received a lot of attention as a possible source of increasing rates of protracted labor,
arrest, and cesarean delivery. Randomized trials have not shown a major impact on the incidence of
protraction and arrest disorders. In a 2011 systematic review of randomized trials, use of neuraxial labor
anesthesia did not increase the duration of the first stage of labor compared with non-neuraxial
anesthesia or no analgesia (weighted mean difference [WMD] 18.5 minutes; 95% CI -12.9 to 49.9) or
increase the risk of cesarean delivery (relative risk [RR] 1.10, 95% CI 0.97-1.25) [55]. There were small
but statistically significant increases in the duration of the second stage of labor (WMD 13.7 minutes;
95% CI 6.7-20.7) and use of oxytocin (RR 1.19, 95% CI 1.03-1.39). Women receiving neuraxial
anesthesia were more likely to undergo operative vaginal delivery (RR 1.42, 95% CI 1.28-1.57). (See
"Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the
progress and outcome of labor'.)
FIRST STAGE PROTRACTION AND ARREST
Diagnosis — The diagnosis of protraction and arrest disorders is based on deviation from the
contemporary norms described above and are defined according to the phase of the first stage in which
they occur.
Protraction — The diagnosis of a protracted active phase is made in women at ≥6 cm dilation who
are dilating less than about 1 to 2 cm/hour, which reflects the 95th centile in contemporary women (table
1).
Women with cervical dilation <6 cm are considered to be in latent phase. The same table (table 1)
serves as a guide for diagnosing a prolonged latent phase [6]. According to the table, it may take six to
seven hours to progress from 4 to 5 cm and three to four hours to progress from 5 to 6 cm during a
normal latent phase, regardless of parity.
Arrest — We agree with the criteria for arrest proposed by a workshop convened by the United
States National Institute of Child Health and Human Development (NICHD), Society for Maternal-Fetal
Medicine (SMFM), and American College of Obstetricians and Gynecologists (ACOG) and based on
contemporary data [56]. Active phase arrest is diagnosed at cervical dilation ≥6 cm in a patient with
ruptured membranes and [6]:
● No cervical change for ≥4 hours despite adequate contractions (usually defined as >200 Montevideo
units [MVU])
● No cervical change for ≥6 hours with inadequate contractions
Given the slowness of the latent phase, latent phase arrest is not considered a clinical diagnosis.
Management
Prolonged latent phase — Management of labor abnormalities before 6 cm dilation (ie, latent phase)
is reviewed separately. (See "Latent phase of labor", section on 'Management'.)
Dilation ≤1 cm over two hours in active phase — For patients (nulliparous or multiparous) in the
active phase (cervix ≥6 cm) who dilate ≤1 cm over two hours, we administer oxytocin (if not already
started) and proceed with amniotomy (if not already ruptured) if there has been adequate fetal descent to
a safe fetal station (eg, -2 or lower) for amniotomy. Oxytocin administration for women with slow progress
is reasonable even in the absence of documented hypocontractile uterine activity [57].
If the head is high and not well applied to the cervix, we begin oxytocin but delay performing amniotomy.
If oxytocin alone for four to six hours does not result in adequate progress, we consider performing an
amniotomy at that time, regardless of fetal head position. A controlled amniotomy is performed if the
head is still high and not well applied to the cervix. (See "Umbilical cord prolapse", section on 'Minimizing
risk from obstetric maneuvers'.)
In a 2013 meta-analysis of randomized trials, our approach: early intervention with oxytocin and
amniotomy, reduced the time to delivery by approximately 1.5 hours [58]. Maternal satisfaction is also
improved [59,60].
Alternatively, expectant management can be considered. Although meta-analyses have shown that the
mean duration of labor can be shortened by these interventions [58,61], cesarean delivery and
instrumental delivery rates were not affected.
Oxytocin augmentation — Oxytocin is the only medication approved by the US Food and Drug
Administration for labor stimulation in the active phase. It is typically dosed to effect, as predicting a
women's response to a particular dose is not possible [62]. We titrate the dose to obtain an adequate
uterine contraction pattern and do not generally exceed a dose of 30 milliunits/minute, but others have
used cutoffs of 20 or 40 milliunits/minute.
After four hours of adequate uterine contractions (usually defined as >200 MVU if an internal pressure
catheter is in place), or six hours without adequate uterine contractions and no cervical change in the
active phase of labor, we proceed with cesarean delivery. If labor is progressing, either slowly or
normally, we continue oxytocin at the dosage required to maintain an adequate uterine contraction
pattern.
Dosing regimen — Numerous oxytocin dosing protocols that vary in initial dose, incremental
dose increase, and time interval between dose increases have been studied (table 3). (See "Induction of
labor with oxytocin", section on 'Dose titration and maintenance'.)
The decision to use a high- versus a low-dose oxytocin regimen poses a risk-benefit dilemma: Higher-
dose regimens are associated with shorter labor and fewer cesareans but more tachysystole (>5
contractions in 10 minutes, averaged over a 30-minute window). The value placed on each of these
outcomes and the ability to respond to tachysystole may vary among labor and delivery units. Therefore,
either a high- or low-dose oxytocin regimen is acceptable and should depend on local factors. We use a
high-dose regimen and do not alter our management based on parity [42,63,64], with one important
exception: We do not use a high-dose regimen in women who have had a previous cesarean delivery
because of risk of rupture [63].
Low-dose regimens were developed, in part, to avoid uterine tachysystole and are based upon the
observation that it takes 40 to 60 minutes to reach steady-state oxytocin levels in maternal serum [65]. A
2010 systematic review of randomized trials of high- versus low-dose oxytocin for augmentation of
women in spontaneous labor (10 trials, n = 5423 women) found that high-dose oxytocin [66]:
● Increased the frequency of tachysystole (relative risk [RR] 1.91, 95% CI 1.49-2.45)
● Decreased the cesarean delivery rate (RR 0.85, 95% CI 0.75-0.97) and increased the rate of
spontaneous vaginal delivery (RR 1.07, 95% CI 1.02-1.12)
● Decreased the total duration of labor (mean difference -1.54 hours, 95% CI -2.44 to -0.64 hours)
● Resulted in similar maternal and neonatal morbidities
A 2013 systematic review had fewer trials because it excluded those involving augmentation as part of
an active management of labor protocol, but came to similar conclusions [67].
Ineffective and less well studied approaches
● Misoprostol – Oxytocin with or without amniotomy is the best approach for treatment of a protraction
disorder, based on extensive experience and data attesting to safety and efficacy. The body of
evidence does not support using any alternative pharmacologic approach. Misoprostol is typically
used for cervical ripening and labor induction; there are limited data on its safety and efficacy for
treatment of protraction disorders [68,69]. However, low-dose titrated misoprostol may be a
reasonable alternative in low-resource settings where safe oxytocin infusion is not feasible.
● Ambulation may improve the comfort of the parturient and is not harmful, but there is no convincing
evidence that this intervention prevents or treats protraction or arrest disorders [70].
Active phase arrest — Women with labor arrest in the active phase of the first stage are managed
by cesarean delivery. The key issue is using appropriate criteria for diagnosing labor arrest. Some
unnecessary cesareans will be performed in arrest is diagnosed too soon, and maternal complications
(eg, uterine rupture) are likely to increase if arrest is diagnosed too late. We use the criteria described
above, proposed by a workshop convened by the NICHD, SMFM, and ACOG and based on
contemporary data criteria. (See 'Arrest' above.)
These criteria were based on the following studies. These studies showed that oxytocin augmentation for
at least four hours, rather than the historical standard of two hours, before diagnosing arrest is safe for
mother and fetus and increases the chances of achieving a vaginal delivery. They also show that vaginal
delivery is often possible despite levels of uterine activity and rates of cervical dilation below the range
historically considered necessary for success.
● A prospective study including 542 women in spontaneous labor at term with active phase labor
arrest (defined as cervix ≥4 cm dilated and ≤1 cm of cervical progress in four hours) evaluated a
protocol whereby oxytocin augmentation was initiated and cesarean delivery was not performed for
labor arrest until (1) the woman experienced at least four hours uterine contractions >200 MVUs or
(2) the woman experienced a minimum of six hours of oxytocin augmentation if this contraction
pattern could not be achieved [42]. Only 12 percent of women did not achieve the target 200 MVUs.
The authors found that 91 percent of multiparas and 74 percent of nulliparas who had not
progressed (≤1 cm additional dilation) by the traditional two hours of oxytocin administration and
thus would have undergone cesarean delivery at that time went on to achieve a vaginal delivery.
Indeed, waiting at least four hours before performing a cesarean for labor arrest allowed 88 percent
of multiparas and 56 percent of nulliparas to achieve a vaginal delivery.
● The same investigators subsequently used a standardized protocol to manage 501 consecutive,
term, spontaneously laboring women with slow labor progress [43]. The protocol involved
administration of oxytocin to achieve at least 200 MVUs for four hours before considering cesarean
delivery.
In this study, 80 percent of nulliparous women and 95 percent of multiparous women had a vaginal
delivery, whether or not they were able to achieve and/or maintain the MVU goal. Mean (5th
percentile) rates of cervical dilation in nulliparas and multiparas were 1.4 cm/hour (0.5) and 1.8
cm/hour (0.5), respectively.
Prevention of first stage labor abnormalities — There is no strong evidence that any intervention will
prevent first stage protraction and arrest disorders.
Amniotomy is the most common intervention that has been proposed for shortening the duration of labor.
Routine amniotomy alone versus intention to preserve the membranes (no amniotomy) did not clearly
shorten the first or second stage in a meta-analysis of randomized trials [71]. However, in another meta-
analysis, the combination of early amniotomy and early oxytocin administration versus routine care for
women in spontaneous labor shortened the first stage (mean difference -1.57 hours, 95% CI -2.15 to
-1.00), and possibly resulted in a small decrease in cesarean delivery (RR 0.87, 95% CI 0.77-0.99) [58].
The potential small benefits of the combined intervention are not sufficiently compelling to warrant a
recommendation for a change in routine management of spontaneous labor. (See "Management of
normal labor and delivery", section on 'Amniotomy'.)
Avoiding or delaying neuraxial anesthesia to potentially reduce the risk of labor abnormalities is not
recommended. ACOG has stated that the decision to place a neuraxial anesthetic should depend upon
the patient's wishes with consideration of factors, such as parity, also taken into account [72]. In
particular, concern about future labor progress should not be a reason to require a woman to reach an
arbitrary cervical dilation, such as 4 to 5 cm, before fulfilling her request to receive neuraxial anesthesia.
PROLONGED SECOND STAGE
Diagnosis — The appropriate duration and maximum length of time allowed for the second stage of
labor is not clearly defined. Parity, regional anesthesia, and delayed pushing in addition to other clinical
considerations all significantly impact the length of the second stage.
We follow the 2014 Obstetric Care Consensus statement of recommendations for safe prevention of
primary cesarean delivery by the American College of Obstetricians and Gynecologists and the Society
for Maternal-Fetal Medicine [73]. These recommendations are used as a pragmatic approach for
diagnosis of a prolonged second stage and are supported by the data from Zhang et al (table 1), which
we believe is the best guide for establishing the normal duration for the second stage of labor (median
and 95th centile). The following is a summary of the statement/recommendations [73]:
● For nulliparous women, allow three hours of pushing, and for multiparous women, allow two hours of
pushing prior to diagnosing arrest of labor, when maternal and fetal conditions permit
● Longer durations may be appropriate on an individual basis (eg, epidural anesthesia, fetal
malposition) as long as progress is being documented
● A specific absolute maximum length of time that should be allowed in the second stage of labor has
not been identified
Based on these recommendation and those of a 2012 workshop (National Institute of Child Health and
Human Development workshop Preventing the First Cesarean Delivery) [56], many obstetric providers
allow an extra hour of pushing for women with an epidural, and good outcomes have been reported [74].
Of note, this statement does not provide specific criteria for the upper limit of the second stage; it merely
states that arrest should not be diagnosed before passage of a specific minimum period of time. It should
also be noted that the use of these criteria has been challenged by some experts, who believe that the
safety of extending the second stage to these lengths, particularly in nulliparous women with an epidural,
has not been established [9,75].
Assessing progressive, but small, degrees of descent and rotation by physical examination is
challenging. Additional physical findings can support the diagnosis of arrest due to cephalopelvic
disproportion. The soft bones and open sutures of the fetal skull (figure 6) allow it to change in shape (ie,
molding) and thus adapt to the maternal pelvis during descent. Some overlap of the parietal and occipital
bones at the lambdoid sutures and overlap of the parietal and frontal bones at the coronal sutures is
common in normal labor [47]. However, lack of descent with severe molding, especially overlap of the
parietal bones at the sagittal suture, is suggestive of cephalopelvic disproportion. Likewise, lack of
descent with malposition or malpresentation is suggestive of cephalopelvic disproportion.
Management
Candidates for oxytocin augmentation — After 60 to 90 minutes of pushing, we begin oxytocin

augmentation if descent is minimal (ie, <1 cm) or absent and uterine contractions are less frequent than
every 3 minutes. In the second stage, we are more concerned about a possible physical issue (eg,
malposition or malpresentation, macrosomia, small maternal pelvis) slowing descent than
hypocontractile uterine activity, which is the prominent concern in the first stage. (See 'Hypocontractile
uterine activity' above and 'Oxytocin augmentation' above.)
Timing of operative delivery — In the absence of epidural anesthesia, we allow nulliparous women
to push for at least three hours and multiparous women to push for at least two hours prior to considering
operative intervention. We avoid operative delivery (vacuum, forceps, cesarean) in the second stage as
long as the fetus continues to descend and/or rotate to a more favorable position for vaginal delivery, and
the fetal heart rate pattern is not concerning. Prompt operative intervention is indicated for fetuses with
category III fetal heart rate tracings, regardless of labor progress. (See "Management of intrapartum
category I, II, and III fetal heart rate tracings".)
https://www.uptodate.com/contents/normal-and-abnormal-labor-progression?search=labor%20de%20parto&source=search_result&selectedTitl… 10/19
In women who have epidural anesthesia, we allow an additional hour of pushing on a case-by-case
basis before considering operative intervention for a prolonged second stage. Extending the duration of
the second stage to four hours in nulliparous women and three hours in multiparous women with epidural
anesthesia may increase the chance of achieving a vaginal delivery. In a randomized trial of 78
nulliparous women with epidural anesthesia who had not delivered three hours after reaching full cervical
dilation, intention to extend labor by at least one hour resulted in a lower cesarean rate compared with
expediting delivery by an operative method (19.5 versus 43.2 percent, relative risk [RR] 0.45, 95% CI
0.22-0.93) [74]. However, the trial was underpowered to detect small but clinically important differences
in the frequency of adverse outcomes between groups or provide a precise estimate of cesarean rate.
Importantly, the durations of the second stage for each group were not significantly different, in part
because 14 percent of the cohort crossed-over from their assigned group.
Whether to extend the duration of the second stage beyond four hours in nulliparous women and beyond
three hours in multiparous women with epidural anesthesia (or beyond three hours in nulliparous women
and beyond two hours in multiparous women without epidural anesthesia) is controversial, as a
prolonged second stage has potential clinical challenges and consequences [17,76,77]:
● If a cesarean delivery is necessary, a prolonged second stage may result in the fetal head trapped
deep in the pelvis, which increases the difficulty of delivering the fetus. Reverse breech extraction
may reduce the risk of a difficult delivery or injury to the uterine vessels (see "Management of deeply
engaged and floating fetal presentations at cesarean delivery", section on 'Reverse breech
extraction ("pull method")').
A prolonged second stage may also further thin the lower uterine segment, increasing the risk of
extension of the hysterotomy into the uterine vessels at cesarean.
● Prolonging the second stage appears to increase the risk for postpartum hemorrhage and maternal
infection.
● Prolonging the second stage may worsen neonatal outcome. (See 'Maternal and newborn outcomes
associated with abnormal labors' below.)
The importance of clinical experience and judgment regarding management of the second stage of labor
must be emphasized, particularly when the duration of the second stage approaches or exceeds two to
three hours. This can be a challenging clinical scenario where the risks of both maternal and neonatal
morbidity are increased. We only allow labor to continue if our judgment suggests safe vaginal delivery is
achievable. Numerous clinical factors need to be considered. Examples of these factors and how they
may favor expectant management is illustrated below:
● Obstetric history – A previous vaginal delivery
● Medical/surgical history – No comorbidities likely to impact labor
● Clinical pelvimetry – Pelvis deemed adequate for vaginal delivery based on physical examination
● Maternal height and weight – Gravida is not short and/or obese
● Fetal position – Occiput anterior, minimal caput and molding
● Maternal temperature – Absence of temperature ≥38.0°C (102.2°F) (presumptive chorioamnionitis)
● Estimated fetal weight – Appropriate for gestational age
● Effectiveness of maternal pushing – Effective pushing, mother is not exhausted
● Fetal heart tracing – Category I tracing
● Woman's desire to proceed with labor
If the woman has not been pushing or not effectively pushing, then we factor that into consideration and
are more likely to have her continue to push. If the fetal station is still high, the estimated fetal weight is
>4000 to 4500 g, chorioamnionitis is suspected, or significant decelerations are present, we generally
proceed with cesarean delivery. When the fetal heart rate tracing is reassuring and maternal pushing is
resulting in progressive descent, we discuss with the patient the options of an operative vaginal (if she is
an appropriate candidate (see "Operative vaginal delivery", section on 'Prerequisites')) or cesarean
delivery versus continued pushing. In our experience, unless delivery occurs or appears to be imminent
within the next 30 to 45 minutes, we proceed with an operative delivery.
Ineffective management interventions
● Turning down the epidural – A dense motor block may impair a woman's ability to push, but there
is no strong evidence that turning down the neuraxial anesthetic in women with a prolonged second
stage is beneficial. In a meta-analysis including five trials in which patients with epidurals were
randomly assigned to discontinuation late in labor or continuation until birth, early discontinuation did
not clearly reduce instrumental delivery (23 versus 28 percent, RR 0.84, 95% CI 0.61-1.15) or other
adverse delivery outcomes [78]. (See "Adverse effects of neuraxial analgesia and anesthesia for
obstetrics", section on 'Effects on the progress and outcome of labor'.)
● Changing maternal position – There is no strong evidence that a change in maternal position (eg,
upright posture, lateral, or hands and knees position instead of supine) is useful for treatment of a
prolonged second stage [79-81]. Women should be encouraged to labor and give birth in the
position they find most comfortable.
● Fundal pressure – Manual fundal pressure does not significantly shorten the duration of the second
stage, although available data are low quality [82].
Prevention of prolonged second stage — There is no strong evidence that any intervention will
prevent a prolonged second stage of labor. The following interventions have been studied.
● Delayed pushing – In a 2017 meta-analysis of trials of pushing/bearing methods in women with

epidural anesthesia, delayed pushing decreased the duration of pushing by a mean of 19 minutes
but increased the duration of the second stage by a mean of 56 minutes compared with immediate
pushing [83]. Delayed pushing was also associated with a small increase in spontaneous vaginal
delivery (for nulliparas: 76 versus 71 percent, RR 1.07, 95% CI 1.02-1.11; 12 studies, 3114 women).
Although the frequency of low umbilical cord blood pH was increased (4.5 versus 2.0 percent, RR
2.24, 95% CI 1.37-3.68), no differences were observed in rates of admission to neonatal intensive
care or five-minute Apgar score less than 7.
● Maternal position and technique do not appear to affect the length of the second stage. (See
"Management of normal labor and delivery", section on 'Pushing position and technique'.)
● Role of exercise:
• Pelvic floor muscle exercises – Training the muscles of the pelvic floor may prevent some cases
of prolonged second stage. One trial randomly assigned 301 healthy nulliparous women to an
antepartum pelvic floor muscle training program or usual care from 20 to 36 weeks of gestation
[84]. Women in the intervention group trained with a physiotherapist for one hour/week and
were encouraged to perform 8 to 12 intensive pelvic floor muscle contractions twice daily.
Women in the exercise group were less likely to have a second stage over 60 minutes than
controls (21 versus 34 percent), but the overall duration of the second stage was similar for
both groups (40 and 45 minutes, respectively), as was the rate of instrumental delivery (15 and
17 percent, respectively).
• Exercise – Exercise during pregnancy improves fitness, but does not affect the length of labor.
In two trials, women randomly assigned to participation in an aerobic exercise program during
pregnancy had the same overall duration of labor as women who received standard prenatal
care [85,86]. Although the smaller trial (n = 91 women) observed a reduction in primary
cesarean delivery in the exercise group [85], the larger trial (n = 855 women) found no
difference in labor outcomes [86].
In addition, it should be noted that women who are not able to push because of a spinal cord
injury tend to have a normal, or even short, second stage [87].
MATERNAL AND NEWBORN OUTCOMES ASSOCIATED WITH ABNORMAL LABORS — For the
mother, first and second stage protraction disorders have been associated with increased risks for
operative vaginal delivery, third-/fourth-degree perineal lacerations, cesarean delivery, urinary retention,
postpartum hemorrhage, and chorioamnionitis in observational studies [2,31,88-95]. A prolonged second
stage has also been associated with pelvic floor injury, but this is likely related to instrumental
intervention rather than the specific length of the second stage [17,77,91,92,96,97].
For the neonate, a protracted first stage of labor has been associated with increased risks for admission
to the neonatal intensive care unit and five-minute Apgar score <7, but no increased risk for serious
morbidity or mortality. In contrast, in many but not all studies, a prolonged second stage has been
associated with a small absolute increase in serious neonatal morbidity (seizures, hypoxic-ischemic
encephalopathy) and mortality [10,75,90,92,94,98]. In one such study, the rate of birth asphyxia-related
complications progressively increased with duration of second stage: from 0.42 percent for second stage
<1 hour to 1.29 percent when ≥4 hours (adjusted RR 2.46, 95% CI 1.66-3.66) [98].
However, a prolonged second stage itself may not be the causal factor for these adverse outcomes;
factors such as persistent malposition or macrosomia may both prolong the second stage and increase
maternal and/or neonatal morbidity. It remains unclear whether performing a cesarean delivery late in the
second stage of labor would reduce the risk of adverse outcomes compared with continued labor. As
discussed above, a small randomized trial of nulliparous women with a prolonged second stage found no
difference in the rates of maternal and neonatal complications when labor was extended for at least one
hour versus expedited operative delivery, but the trial was underpowered to detect small differences in
these outcomes [74].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: Labor".)
SUMMARY AND RECOMMENDATIONS
● The Friedman curve (figure 1) and the norms established from Friedman's data historically had been
widely accepted as the standard for assessment of normal labor progression. However, Zhang and
others have proposed a contemporary curve (figure 2) and norms (table 1) that are different and
slower from those cited by Friedman. (See 'Friedman (historic) criteria' above and 'Contemporary
criteria' above.)
● Labor abnormalities may be related to hypocontractile uterine activity, neuraxial anesthesia, obesity,
and/or absolute or relative obstruction due to factors such as fetal size/position, Bandl’s ring, or a
small maternal bony pelvis. (See 'Risk factors' above.)
● The normal duration of the latent phase tends to be longer in induced labors than spontaneous
labors, but the active phase and second stage have similar durations whether labor is spontaneous
or induced. (See 'Normal progression in induced labors' above.)
First stage
● The diagnosis of a protracted active phase is made in women at ≥6 cm dilation who are dilating less
than about 1 to 2 cm/hour, which reflects the 95th centile. Slow cervical dilation before 6 cm reflects
the shallow slope of the latent phase portion of the normal labor curve. (See 'First stage' above and
'Protraction' above.)
● The diagnosis of active phase arrest is made in women at ≥6 cm cervical dilation with ruptured
membranes and either no cervical change for ≥4 hours despite adequate contractions or no cervical
change for ≥6 hours with inadequate contractions. (See 'Arrest' above.)
● For women (nulliparous or multiparous) in the active phase who dilate ≤1 cm over two hours, we
administer oxytocin and proceed with amniotomy if there has been adequate fetal descent, except
when the head is high and not well applied to the cervix. In these cases, we begin oxytocin but delay
performing amniotomy. If oxytocin alone for four to six hours does not result in adequate progress,
we consider performing an amniotomy at that time. A controlled amniotomy is performed if the head
is still high and not well applied to the cervix. (See 'Dilation ≤1 cm over two hours in active phase'
above.)
● We use a high-dose oxytocin regimen (table 3) regardless of parity, except in women who have had
a previous cesarean delivery. (See 'Dosing regimen' above.)
● In pregnancies with reassuring maternal and fetal status, if there has been no cervical change after
four hours of adequate (>200 Montevideo units) uterine contractions or six hours without adequate
uterine contractions in the active phase, we proceed with cesarean delivery. If labor is progressing,
either slowly or normally, we continue oxytocin at the dosage required to maintain an adequate
uterine contraction pattern. (See 'Oxytocin augmentation' above.)
Second stage
● Parity, regional anesthesia, delayed pushing, and other clinical factors significantly impact the length
of the second stage. A pragmatic approach is to diagnose a prolonged second stage when a
nulliparous woman without epidural anesthesia has pushed for three hours or a multiparous women
without epidural anesthesia has pushed for two hours; an additional hour is added for women with
epidural anesthesia. (See 'Diagnosis' above.)
● For women in the second stage with minimal (ie, <1 cm) or absent descent after 60 to 90 minutes of
pushing and uterine contractions less frequent than every 3 minutes, we begin oxytocin
augmentation. In the second stage, we are more concerned about a possible physical issue (eg,
malposition or malpresentation, macrosomia, small maternal pelvis) slowing descent than
hypocontractile uterine activity. (See 'Candidates for oxytocin augmentation' above.)
● In the absence of epidural anesthesia, we allow nulliparous women to push for at least three hours
and multiparous women to push for at least two hours prior to considering operative intervention. We
avoid operative delivery (vacuum, forceps, cesarean) in the second stage as long as the fetus
continues to descend and/or rotate to a more favorable position for vaginal delivery, and the fetal
heart rate pattern is not concerning. In women who have epidural anesthesia, we allow an additional
hour of pushing on a case-by-case basis before considering operative intervention for a prolonged
second stage. Prompt operative intervention is indicated for fetuses with category III fetal heart rate
tracings, regardless of labor progress. (See 'Timing of operative delivery' above.)
● Whether to extend the duration of the second stage beyond four hours in nulliparous women and
beyond three hours in multiparous women with epidural anesthesia (or beyond three hours in
nulliparous women and beyond two hours in multiparous women without epidural anesthesia) is
controversial as a prolonged second stage has potential clinical challenges and adverse
consequences. We only allow labor to continue if our judgement suggests safe vaginal delivery is
achievable. (See 'Timing of operative delivery' above and 'Maternal and newborn outcomes
associated with abnormal labors' above.)
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10/1/2018 Progresión laboral normal y anormal - UpToDate

Autores: Robert M Ehsanipoor, MD, Andrew J Satin, MD, FACOG

Divulgaciones del colaborador

INTRODUCCIÓN - Durante el trabajo de parto normal, las contracciones uterinas regulares y

PROGRESIÓN NORMAL DEL PARTO - Aunque determinar si el trabajo de parto progresa

● Third stage – Time between fetal expulsion and placental expulsion.

ASSESSMENT OF LABOR PROGRESS

● At two- to four-hour intervals in the first stage

● Prior to administering analgesia/anesthesia

● At one- to two-hour intervals in the second stage

Partogram — Results of cervical examinations can be documented on a partogram, in addition to the

OVERVIEW OF PROTRACTION AND ARREST DISORDERS

Diagnosis — Uterine activity can be monitored qualitatively by palpation or external

Diagnosis — Cephalopelvic disproportion is a subjective clinical assessment based on physical

Diagnosis — Diagnosis is typically made at cesarean delivery. At the time of laparotomy, a

FIRST STAGE PROTRACTION AND ARREST

● No cervical change for ≥6 hours with inadequate contractions

● Resulted in similar maternal and neonatal morbidities

Ineffective and less well studied approaches

PROLONGED SECOND STAGE

Candidates for oxytocin augmentation — After 60 to 90 minutes of pushing, we begin oxytocin

● Obstetric history – A previous vaginal delivery

● Medical/surgical history – No comorbidities likely to impact labor

● Maternal height and weight – Gravida is not short and/or obese

● Fetal position – Occiput anterior, minimal caput and molding

● Maternal temperature – Absence of temperature ≥38.0°C (102.2°F) (presumptive chorioamnionitis)

● Estimated fetal weight – Appropriate for gestational age

● Effectiveness of maternal pushing – Effective pushing, mother is not exhausted

● Fetal heart tracing – Category I tracing

● Woman's desire to proceed with labor

Ineffective management interventions

● Delayed pushing – In a 2017 meta-analysis of trials of pushing/bearing methods in women with

SUMMARY AND RECOMMENDATIONS

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Tema 4464 versión 73.0

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