Other indications included abnormal presentation (2.6%), fetal distress (2.3%), and other problems (3.2%). In 1990, the overall rate was 23.6%, with 7.1% for the indication of “failure to progress” or dystocia and 8.5% for a repeat procedure. According to the National Center of Health Statistics, in the United States in 2005, 30.2% of pregnancies were delivered by cesarean. Multiparous women usually labor quickly and meet all expected milestones without the need for significant intervention.Ībnormal labor is a common indication for cesarean delivery. Thus, nulliparous women are more likely to develop labor abnormalities that require intervention. As a result, the myometrium of the multipara usually maintains effective contractile activity. In multiparous women, less uterine force is required, and the tissues of the reproductive outlet, having been stretched by the previous delivery, have less resistance. In nulliparous women, more uterine force is required to overcome resistance in the reproductive tract, and the uterus tends to be less effective in maintaining effective uterine contractions. In the simplest terms, labor is the force of uterine contractions overcoming the resistance of the female reproductive tract, including the lower uterine segment, cervix, vagina, and perineum. Figure 24.3 is an example of a labor curve showing the difference in labor patterns expected between nulliparas and multiparas. Nulliparous women and multiparous women behave fundamentally differently in labor. Other terms for a labor curve include partogram, labor graph, and parturograph. ![]() After each examination, the progress in labor should be documented graphically on some form of a labor curve and a plan formulated with regard to future examinations and potential interventions. More experienced obstetricians often will perform examinations every 2 to 3 hours, depending on the presentation of the patient. Early in their training, residents should be encouraged and allowed to perform examinations hourly so that full educational opportunities are gained. Cervical examinations should be performed periodically to confirm that progress is being made. In the second stage of labor, from complete dilation until delivery, again one can anticipate the laboring woman gaining a minimum of 1 cm of station of the fetal head in relation to the maternal pelvis per hour. The deceleration phase likely is an aberration of the mathematic analysis of Friedman’s original data and as such is likely not a physiologic event. ![]() In the active phase, a minimum of 1 cm of dilation per hour can be anticipated ( Table 24.2). The cervix usually is effaced and <4 cm dilated. The acceleration phase occurs when the active phase of labor starts. The first stage of labor is divided into the acceleration phase, active phase, and deceleration phase. This curve was developed by Emanuel Friedman based on the observation of several thousand laboring women. The normal labor curve is shown in Figure 24.2. ![]() With fewer inductions of labor and improved management of labor, a decline in the cesarean delivery rate can be expected. This fundamental lack of understanding often leads to unnecessary induction of labor, which has an a priori risk of cesarean delivery of at least 25%, or to inadequate augmentation of abnormal labor. One reason for the continued high rate of cesarean delivery is a poor understanding of the labor process and the lack of an organized approach to the management of labor. An expanded definition advanced by Bowes is that dystocia is “any complication or circumstance that interferes with the progress of labor and vaginal delivery that endangers mother or fetus.” Most authorities agree that the number of cesarean deliveries remains excessively high. ![]() Dystocia, translated, means “difficult birth” and includes all abnormalities that may occur in women during labor. The four primary indications for cesarean delivery include dystocia, elective repeat cesarean delivery, fetal distress, and abnormal fetal presentation. From 1970 to 2005, the cesarean delivery rate in the United States increased from 5% to 30%.
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