Protracted/Arrested labor

[Apoplexy__]

Can someone verify the information below? I couldn't find it all in one place, so I compiled it from a combination of UWorld, UpToDate, and Ob/Gyn case files:

1st stage, latent:
Arrested labor = N/A
Protracted labor = >20 hours in the nullipara, and >14 hours in the multipara

1st stage, active:
Arrested labor = No progress for >4 hours with adequate contractions, or >6 hours with inadequate contractions
Protracted labor = <1.2 cm/hr for nulliparous patients, or <1.5 cm/hr for multiparous patients

2nd stage:
Arrested labor = No progress for >4 hours in nullipara w/ epidural (3 hours w/o), or >3 hours in multipara (2 hours w/o)
Protracted labor = Same as arrest times, all minus 1 hour

-Management of protracted labor: Either rest or augmentation (oxytocin and possibly artificial rupture of membranes)
-Management of arrested labor: C-section

Anything wrong or missing?

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[Phloston]

Can someone verify the information below? I couldn't find it all in one place, so I compiled it from a combination of UWorld, UpToDate, and Ob/Gyn case files:

1st stage, latent:
Arrested labor = N/A
Protracted labor = >20 hours in the nullipara, and >14 hours in the multipara

1st stage, active:
Arrested labor = No progress for >4 hours with adequate contractions, or >6 hours with inadequate contractions
Protracted labor = <1.2 cm/hr for nulliparous patients, or <1.5 cm/hr for multiparous patients

2nd stage:
Arrested labor = No progress for >4 hours in nullipara w/ epidural (3 hours w/o), or >3 hours in multipara (2 hours w/o)
Protracted labor = Same as arrest times, all minus 1 hour

-Management of protracted labor: Either rest or augmentation (oxytocin and possibly artificial rupture of membranes)
-Management of arrested labor: C-section

Anything wrong or missing?

I'm glad you posted this cuz I didn't realize UpToDate had different values here compared to Case Files (that's really annoying btw). I was originally thinking lower values, but I'd definitely go with UpToDate on this one.

 

[Apoplexy__]

I'm glad you posted this cuz I didn't realize UpToDate had different values here compared to Case Files (that's really annoying btw). I was originally thinking lower values, but I'd definitely go with UpToDate on this one.

Cool. Do you think the management portion of my post is correct? Do they only ever seem to test on those steps in management?

 

[notbobtrustme]

Cool. Do you think the management portion of my post is correct? Do they only ever seem to test on those steps in management?

ya, that's exactly how it was on my ob shelf.

It was grossly obvious. Like, patient has failed pitocin twice in the past 4 hours, has made little cervical change and fetal heart tones are becoming distressed. What to do next? Or it would be, patient has progressed from 2cm dilation to 8cm dilation but has made no change in the past 4 hours, membranes were ruptured 4 hours ago. Pt is not currently on pitocin, what is the next best step?

 

[Apoplexy__]

Or it would be, patient has progressed from 2cm dilation to 8cm dilation but has made no change in the past 4 hours, membranes were ruptured 4 hours ago. Pt is not currently on pitocin, what is the next best step?

Hahaha well when you word it that way I know you're saying the answer is putting them on pitocin...But that description would fit arrest, which I would think warrants c-section.

I'm assuming you always at least try pitocin before c-section except in an emergency? (you can tell my Ob/Gyn rotation sucked)

 

[notbobtrustme]

Hahaha well when you word it that way I know you're saying the answer is putting them on pitocin...But that description would fit arrest, which I would think warrants c-section.

I'm assuming you always at least try pitocin before c-section except in an emergency? (you can tell my Ob/Gyn rotation sucked)

ya, I believe so. That's how I approached my ob/gyn shelf and I did well enough on it.

 

[Phloston]

Cool. Do you think the management portion of my post is correct? Do they only ever seem to test on those steps in management?

ya, that's exactly how it was on my ob shelf.

It was grossly obvious. Like, patient has failed pitocin twice in the past 4 hours, has made little cervical change and fetal heart tones are becoming distressed. What to do next? Or it would be, patient has progressed from 2cm dilation to 8cm dilation but has made no change in the past 4 hours, membranes were ruptured 4 hours ago. Pt is not currently on pitocin, what is the next best step?

The management seems right. Would agree with notbobtrustme that they'd probably make the diagnosis obvious if it showed up on the exam.

 

[Apoplexy__]

Great. Thanks guys.

 

[Akr]

Can someone verify the information below? I couldn't find it all in one place, so I compiled it from a combination of UWorld, UpToDate, and Ob/Gyn case files:

1st stage, latent (= from beginning of maternal perception of regular contractions):
Arrested labor = N/A
Protracted labor = >20 hours in the nullipara, and >14 hours in the multipara

1st stage, active (=from beginning of accelerated cervical dilation, or at least 6cm):
Arrested labor = No progress for >4 hours with adequate contractions, or >6 hours with inadequate contractions
Protracted labor = <1.2 cm/hr for nulliparous patients, or <1.5 cm/hr for multiparous patients

2nd stage (= from complete dilation until delivery):
Arrested labor = No progress for >4 hours in nullipara w/ epidural (3 hours w/o), or >3 hours in multipara (2 hours w/o)
Protracted labor = Same as arrest times, all minus 1 hour

-Management of protracted labor: Either rest or augmentation (oxytocin and possibly artificial rupture of membranes)
-Management of arrested labor: C-section

Anything wrong or missing?

Looks like an excellent summary. Just a few comments, from ACOG's obstetric care consensus statement (March 2014). It seems even fundamental stuff like this gets hotly debated at Ob/Gyn departmental journal clubs, etc... Anyway, ACOG basically said that normal labor can take longer than what we think and that we can safely augment with pitocin for longer than we think... and that we're probably doing way too many Cesareans...

-Cesarean for active 1st stage arrest ONLY if she's been augmented at least 6h with pitocin & still has inadequate ctx (or, with adequate ctx >4h has still not progressed). To give a fair chance of vaginal delivery, the time clocks start when at least 6cm AND membranes ruptured.

-No specific maximum time limit of 2nd stage (i.e. no correlation between 2nd stage duration & neonatal outcomes) BUT after 2-4h of pushing (as you defined above), you can consider intervention depending on the situation - rotating the occiput, or using vacuum/forceps, or cesarean.

I also added the definitions as you see, because sometimes even those vary by publication.

Keep in mind that these are only concerning women without prior sections, and with reassuring maternal/fetal status. TOLAC/VBAC and fetal distress will come with their own issues & recommendations.

And, I don't know how far they would go with this on the NBME... When I took the shelf & CK last year, it seemed like they avoided questions about "new" guidelines where there was enough lack of consensus (e.g. I had 0 questions on anything cervical cancer -related)

There's a lot of gray areas here but I hope that's not too confusing!

 

[lordman]

does USMLE go that deep in OBGYN?! @kirbymiester

 

[Apoplexy__]

does USMLE go that deep in OBGYN?! @kirbymiester

Unfortunately, I don't know for sure, but I know that I got about 3/100 questions on my Ob/Gyn NBME shelf on the content within this thread. UWorld also goes into almost as much detail as this, and by knowing these definitions you can get a better idea of the labor status when they throw all those metrics at you (even if knowing the exact consequence of those metrics isn't absolutely necessary).

 

[lordman]

@kirbymiester Just had a related question in Kaplan Qbank. Active phase but the cervical has been 6 cm for 3 hours with epidural. The dx was arrested labor. According to your post, it should be prolonged labor. Kaplan explained it as no change of cervical dilation for > 2 = arrest!

 

[Apoplexy__]

@kirbymiester Just had a related question in Kaplan Qbank. Active phase but the cervical has been 6 cm for 3 hours with epidural. The dx was arrested labor. According to your post, it should be prolonged labor. Kaplan explained it as no change of cervical dilation for > 2 = arrest!

Thanks for letting me know!

UWorld (QID 3116) gives my times for arrest of active labor, and includes an example of 8 cm for 3 hours being protracted. UpToDate also gives what I put for arrest of active labor.

I think the discrepancy is because the ACOG did a recent study revising the definition. I believe UpToDate says the original definition was merely failure of progression at 4 cm or more, with sufficient contractions (defined as 200 montevideo units for 2 hours).

 

[CaliAtenza]

Thanks for letting me know!

UWorld (QID 3116) gives my times for arrest of active labor, and includes an example of 8 cm for 3 hours being protracted. UpToDate also gives what I put for arrest of active labor.

I think the discrepancy is because the ACOG did a recent study revising the definition. I believe UpToDate says the original definition was merely failure of progression at 4 cm or more, with sufficient contractions (defined as 200 montevideo units for 2 hours).

So if that question said that the contractions were inadequate (if you recall, it said that the contractions were adequate), would you start oxytocin for the patient? I'm thinking yes, based on the content of this thread, but I wanted to make sure. The question says that since the contractions are adequate, it would be the wrong idea to start oxytocin.

 

[Apoplexy__]

So if that question said that the contractions were inadequate (if you recall, it said that the contractions were adequate), would you start oxytocin for the patient? I'm thinking yes, based on the content of this thread, but I wanted to make sure. The question says that since the contractions are adequate, it would be the wrong idea to start oxytocin.

Good point, didn't even think about that. UWorld does explicitly say oxytocin isn't indicated (risk of tachysystole outweighs benefit) in protracted labor with adequate contractions in that question I cited. So it looks like oxytocin in protracted labor is only indicated in inadequate contractions, like you're saying.

I'm assuming most NBME Q's wouldn't be this tricky, but it might be good to keep in the back of your head.

 

[lordman]

I'm assuming most NBME Q's wouldn't be this tricky, but it might be good to keep in the back of your head.

I am quoting your last line only for some reason. What I noticed in severaly USMLE-style questions, especially, those mind-blowing, it's important to have a broad knowledge about the topic. In many occasions, either due to stuck thinking process or lack of time, we need to eliminate choices and pick a one. USMLE guys do their bests in listing close answers that are really confusing! In other words, if that question showed up, I am sure they will list that oxytocin thing. For someone who is does not know much about the topic or does not remember well from rotations, they will keep wasting time which choice to pick!