At Parkland Hospital, women are admitted if active labor is diagnosed or if ruptured membranes are conirmed. Labor is defined as cervical dilation of 3 to 4 cm or more in the presence of uterine contractions. Management guidelines direct that a pelvic examination be performed approximately every 2 hours. Inefective labor is suspected when the cervix does not dilate within approximately 2 hours of admission. Amniotomy is then performed, and labor progress determined at the next 2-hour evaluation. In women whose labors do not progress, an intrauterine pressure catheter is placed to assess uterine function. Hypotonic contractions and no cervical dilation after an additional 2 to 3 hours result in stimulation of labor using the high-dose oxytocin regimen described in Chapter 26 (p. 509). The goal is uterine activity of 200 to 250 Montevideo units for 2 to 4 hours before dystocia can be diagnosed. If hypotonic contractions are strongly suspected, internal monitors may be placed with amniotomy and again cervical change and contraction pattern are assessed in 2 hours. Conirmation of deicient Montevideo units at that time may prompt oxytocin augmentation for maternal or fetal indications.
Dilation rates of 1 to 2 cm/hr are accepted as evidence of progress after satisfactory uterine activity has been established with oxytocin. This can require up to 8 hours or more before cesarean delivery is performed for dystocia. The cumulative time required to efect this stepwise management approach permits many women to establish efective labor. This management protocol has been evaluated in more than 20,000 women with uncomplicated pregnancies. Importantly, these labor interventions and the relatively infrequent use of cesarean delivery did not jeopardize the fetus-newborn.
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