DYSTOCIA IN NULLIPAROUS WOMEN - Incidence, outcomes, risk indicators, and women’s experiences

Sammanfattning: Aim: To estimate the incidence of dystocia, to describe outcomes of labour with dystocia and augmentation, to identify anthropometrical-, life style-, obstetric- and clinical risk indicators for dystocia, to elucidate nulliparous women’s experiences of prolonged labours and to describe some aspects of the midwifery care during labour and delivery. Design: A multi-centre cohort study with prospectively collected data within nine obstetric departments in Denmark. Study group: Nulliparous women in term spontaneous labour with a singleton infant in cephalic presentation. Methods: Follow up of 2810 nulliparas using data from self-administered questionnaires supplemented with clinical data-records and interviews with ten mothers post partum, analysed in Grounded Theory. Inclusion: May 2004-July 2005. Findings: The cumulative incidence of dystocia was 37%. The diagnosis was given in 42% of cases in the labour's first stage and in 58% in second stage. Increasing incidence of dystocia was seen with increasing maternal age, lower height and higher BMI. Women with dystocia had more caesarean deliveries, more ventouse, more non-clear amniotic fluid and more post partum haemorrhage than women delivered without dystocia, and their neonates were more often given lower Apgar scores after 1 minute, but not after 5 minutes. Increasing maternal age, small stature (<160cm), prepregnancy overweight (BMI: 25.0-29.9) and a caffeine intake of 200-299 mg/day were associated with increasing risk of dystocia. No association was found between dystocia and alcohol intake, smoking, night sleep and options for resting during the day. Athletics or heavy gardening > 4 hours per week appeared ‘protective’ for dystocia whereas intensive physical training was associated with higher risk. The following variables, present at admission to hospital, were associated with dystocia during labour: dilatation of cervix < 4 cm, tense cervix, thick lower segment, fetal head above the inter-spinal diameter, and poor fetal head-to-cervix contact. Birth weight 4000-4499 gr and epidural analgesia were also associated with dystocia. Women with dystocia experienced less midwifery care, less participating in decision making and less presence of the midwife in the delivery room, a conflict between the expectation of having a natural delivery and actually having a medical delivery and a feeling of separation between mind and body. Interacting with the midwife had a major influence on feelings of losing and regaining control. The core category was named Dialectical Birth Process and comprised three categories: Balancing natural and medical delivery, Interacting, Losing and regaining control. Conclusions: A dystocia incidence of 37% in this selected group of term nulliparas with no indication for induction or caesaran delivery contributes to reflection on the need for reconsidering the criteria for diagnosing dystocia and for examining if the negative outcomes are related to the cause of dystocia or to the augmentation. There may be avoidable causes of dystocia opening up avenues for prevention. Having a better understanding of the specific mechanisms between the identified anthropometrical and life style risk indicators and dystocia should however be addressed in future studies. The strongest risk indicator was use of epidural analgesia. Further studies on this exposure are recommended. A dialectical process was identified in the women’s experiences of non-progressive labour. The process was susceptible to interaction with the midwife; especially her support to the woman’s feeling of being in control.