Cesarean Deliveries for Lack of Progress in Labor

ABSTRACT & COMMENTARY

Synopsis: Lack of progress in labor is an important reason for cesarean deliveries and many of these procedures are done during the latent phase of labor or in the second stage of labor before it is prolonged.

Source: Gifford DS, et al. Obstet Gynecol 2000;95:589-595.

To estimate the prevalence of lack of progress in labor as an indication for unplanned cesarean delivery and to compare the course of labor in women with this diagnosis and established criteria for lack of progress in labor, Gifford and associates performed a retrospective review of medical records as well as postpartum telephone interviews to collect data from 733 women who delivered full-term singleton infants weighing between 2500-4500 g in vertex presentation. Births were sampled from 18 hospitals in Los Angeles county, with more than 1500 deliveries annually and 12 hospitals in Iowa, with more than 500 births each year. Only nulliparous and primiparous patients were studied. Gifford et al asked the following questions regarding progress in labor: 1) Was the patient in the active phase of labor at the time of the cesarean? 2) If the patient reached the active phase of labor, did she have a protraction disorder? and 3) If the patient reached complete dilatation, was there evidence of a prolonged second stage? Cesarean delivery was attributed to lack of progress in labor if the physician’s notes included terms usually associated with lack of progress such as dysfunctional labor, cephalopelvic disproportion, failure to progress, protracted labor, arrest of dilatation, or arrest of descent. While lack of progress in labor was a reason for the cesarean delivery, it was not necessarily the only reason. Gifford et al compared the characteristics of the patient’s labor to the criteria established by the American College of Obstetricians and Gynecologists (ACOG) for the diagnosis of lack of progress.

Lack of progress was a reason for 68% of unplanned cesarean deliveries. At least 16% of the women studied, or 24% of those who had a cesarean delivery for lack of progress, were in the latent phase of labor as defined by ACOG criteria. Furthermore, the second stage was not prolonged in 36% of the women who reached complete dilatation.

Gifford et al conclude that lack of progress in labor is an important reason for cesarean deliveries and that many of these procedures are done during the latent phase of labor, or in the second stage of labor before it is prolonged according to criteria established by ACOG.

Comment by Steven G. Gabbe, MD

Lack of progress in labor or dystocia is responsible for 30% of all cesarean deliveries performed in the United States each year and ranks second only to repeat cesarean delivery as an indication for this procedure. In 1989, the diagnosis of lack of progress of labor as an indication for cesarean delivery reached nearly 12%, —three times higher than in 1970. To determine how often cesarean deliveries are performed for lack of progress in labor, Gifford et al colleagues studied delivery records from large urban and smaller rural hospitals. The study sample included only women who were nulliparous or primiparous. To determine if the patients had abnormal labor patterns as defined by ACOG, Gifford et al compared the documentation of the progress of labor with the criteria established for active labor, protraction disorders, and prolonged second stage. They found that a large proportion of cesarean deliveries for lack of progress were actually performed in the latent phase of labor, 16% at 0-2 cm cervical dilatation and 24% at 0-3 cm. Gifford et al were able to calculate the slope of the active phase in 80% of the study subjects, and 98% did meet the criteria for a protraction disorder.

It is important to note that in this study, lack of progress in labor was only one of the indications for the cesarean delivery. In 51% of these cases, an indication other than lack of progress was recorded and most often it was non-reassuring fetal status. Nevertheless, it is concerning that so many patients underwent a cesarean delivery for lack of progress while still in the latent phase of labor. Determining what factors influenced the obstetrician to make this decision could go a long way in helping us develop strategies to lower the cesarean delivery rate.

Which of the following is the most common indication for cesarean delivery in the United States?

a. Non-reassuring fetal heart tracing.

b. Repeat cesarean delivery

c. Cesarean delivery for lack of progress in labor.

d. Fetal Macrosomia.

e. Breech presentation