Labour Dystocia

Dystocia is the broader clinical term encompassing abnormal, difficult, or prolonged labor from any cause, of which prolonged labor and obstructed labor (see those entries) represent points along a spectrum of increasing severity.

The term is often used clinically to describe difficult progress attributable to the "three Ps": power (uterine contraction inadequacy), passenger (fetal size, presentation, position, or, rarely, anomaly), and passage (bony pelvis or soft tissue).

Systematic assessment of each of the three Ps in turn: palpation and, where available, intrauterine pressure catheter assessment of contraction adequacy; vaginal examination for fetal position, station, and degree of molding/caput; and clinical assessment of pelvic capacity, alongside consideration of estimated fetal size.

Partograph monitoring, as detailed in the Prolonged Labour entry, remains the primary tool for identifying dystocia in real time.

Management follows directly from identifying which of the three Ps is the dominant contributor, as detailed in the Prolonged Labour entry: oxytocin augmentation for a power problem with confirmed inadequate contractions, positional changes and, where appropriate, instrumental delivery or cesarean for a passenger problem (malposition, macrosomia), and cesarean section for a genuine passage problem where vaginal delivery is not achievable
Adequate analgesia, hydration, and emotional support throughout, given the physical and psychological toll of prolonged, difficult labor
Careful reassessment at defined intervals rather than open-ended augmentation, to avoid delaying necessary escalation to cesarean where true disproportion exists
Vigilance for progression to obstructed labor (see that entry) if dystocia is not appropriately managed

Referral: obstetric-led care throughout, with senior review triggered by partograph action line crossing or failure to respond to initial corrective measures.

Preterm Labour

Onset of regular uterine contractions with cervical change before 37 completed weeks gestation.

Risk factors include previous preterm birth (the strongest predictor), multiple pregnancy, uterine or cervical anomaly, cervical insufficiency, infection (chorioamnionitis, bacterial vaginosis, UTI), polyhydramnios, and antepartum hemorrhage.

Clinical assessment of contraction frequency and cervical examination (dilation, effacement)
Transvaginal ultrasound cervical length: a length under 15 mm supports a high risk of imminent delivery; a length over 15 mm makes preterm birth within 7 days unlikely
Fetal fibronectin (a biomarker present in cervicovaginal fluid), a negative result has a high negative predictive value for delivery within 7 to 14 days and can avoid unnecessary intervention; used particularly when cervical length is equivocal (15 to 30 mm)
Exclude and treat infection: MSU, high vaginal swab, and, where membranes are ruptured, assessment for chorioamnionitis (see PPROM entry)

Tocolysis to delay delivery by 48 hours, allowing time for corticosteroids and, where relevant, in-utero transfer to a unit with appropriate neonatal facilities: nifedipine 20 mg PO loading dose, then 10 to 20 mg PO every 6 to 8 hours (maximum 24 hour dose per local protocol, commonly up to 60 to 160 mg/day), or atosiban (oxytocin receptor antagonist) by IV infusion where available; tocolysis is generally not continued beyond 48 hours and is avoided where there are contraindications (chorioamnionitis, severe pre-eclampsia, abruption, or non-reassuring fetal status)
Corticosteroids for fetal lung maturation: betamethasone 12 mg IM, 2 doses 24 hours apart, given for anticipated preterm delivery between roughly 24 and 34+6 weeks (up to 35+6 in some protocols); a single rescue course may be considered if delivery remains imminent more than 1 to 2 weeks after an initial course, per specialist guidance
Magnesium sulfate for fetal neuroprotection: given before anticipated delivery under 30 to 32 weeks (threshold varies by protocol), typically 4 g IV loading dose over 15 to 30 minutes, then 1 g/hour maintenance, reduces the risk of cerebral palsy in survivors
Group B streptococcus prophylaxis if status unknown or previously positive: benzylpenicillin 3 g IV loading dose, then 1.5 g IV every 4 hours until delivery (alternatives per allergy status: cefazolin, clindamycin, or vancomycin depending on allergy severity and local resistance)
Antibiotics are not given routinely for preterm labor with intact membranes in the absence of confirmed infection, given lack of proven benefit and some evidence of harm in this specific context
Mode and timing of delivery individualized by gestation, presentation, and fetal status

Referral: obstetric-led care with neonatal team involvement; in-utero transfer to a tertiary unit with appropriate NICU facilities if delivery under roughly 27 to 28 weeks is anticipated and local facilities are insufficient.

Labour Dystocia

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management