Ld

Active Management of Labor

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Active Management of Labor, Labor Dystocia Management, Failure to Progress Management

  • See Also
  1. Labor Dystocia
  2. Labor Dystocia Prevention
  3. Labor Augmentation (Oxytocin Augmentation)
  • Indications
  1. Failure to Progress
  • Management
  • Stage 1
  1. See Labor Coaching
  2. Consider Oxytocin Augmentation
  3. Consider Amniotomy
    1. Shortens labor duration without reducing chance of successful NSVD
  4. Indications for cesarean delivery (arrested labor)
    1. Cervical dilation 6 cm AND
    2. No cervical change
      1. At 4 hours if adequate contractions (>200 Montevideo Units) or
      2. At 6 hours if inadequate contractions
  • Management
  • Stage 2
  1. Consider Oxytocin Augmentation
  2. Avoid exhausting mother early
    1. Consider delayed maternal pushing (laboring down)
      1. Consider not pushing until involuntary urge to push
      2. Consider waiting until vertex approaches introitus
      3. Lemos (2017) Cochrane Database Syst Rev (3):CD009124 [PubMed]
    2. Nulliparous patients with Epidural Anesthesia should be encouraged to start pushing on full cervical dilation
      1. Cahill (2018) JAMA 320(14): 1444-54 [PubMed]
      2. (2019) Obstet Gynecol 133(2): e164-73 [PubMed]
  3. Consider assisted Vaginal Delivery
    1. Vacuum Assisted Delivery
    2. Forceps Assisted Delivery
  4. Perineal Laceration prevention
    1. Avoid routine episiotomy (associated with worse perineal Lacerations and greater healing complications)
    2. Warm perineal compresses may reduce risk of third and Fourth Degree Perineal Lacerations
      1. Aasheim (2011) Cochrane Database Syst Rev (5):CD002006 [PubMed]
    3. Shorter pushes as the head is crowning may reduce perineal Lacerations
  5. Consider correction of malposition: Occiput Posterior
    1. See Manual Rotation in Occipitoposterior Presentation
    2. Maternal repositioning to hands and knees
      1. Not shown to assist in conversion to Occiput Anterior or to reduce Cesarean Section rates
      2. Hunter (2007) Cochrane Database Syst Rev (4): CD001063 [PubMed]
  6. Maternal position change
    1. Walking and upright position is preferred over supine
    2. Position mother curling forward from hips
  7. Consider Intravenous Fluid
    1. Normal Saline infusion of 250 ml/h (instead of 125 ml/hour) may result in decreased labor duration and fewer C-Sections
      1. Ehsanipoor (2017) Acta Obstet Gynecol Scand 96(7): 804-11 [PubMed]
  • Management
  • Dystocia refractory to above management
  1. See Arrest of the Second Stage of Labor
  2. Consider Cesarean Section
  • Preventive Measures
  1. See Labor Dystocia Prevention
  • References
  1. Shields (2000) ALSO, F:1-14
  2. Dresang (2015) Am Fam Physician 92(3): 202-8 [PubMed]
  3. LeFevre (2021) Am Fam Physician 103(2): 90-6 [PubMed]
  4. Peaceman (1996) Am J Obstet Gynecol 175(2):363-8 [PubMed]
  5. Shields (2007) Am Fam Physician 75(11):1671-8 [PubMed]