Abnormal Labour and it Management

 Definitions
 Stages and Phases of Normal Labour
 Causes of Abnormal Labour
 Types of Abnormal Laobur
 Diagnosis and Management of Abnormal
Labour
 Normal labor refers to the presence of regular
uterine contractions that cause progressive dilation
and effacement of the cervix and fetal descent.

Abnormal labor, dystocia, and failure to

progress :
Terms used to describe a difficult labor pattern that
deviates from that observed in the majority of
women who have spontaneous vaginal deliveries.

This problem is the most common indication for primary

cesarean birth, accounting for three times more cesarean
deliveries than malpresentation or fetal heart rate
abnormalities
 latent Acceleration Phase

• First stage: Maximum slope

Active

Deceleration phase

Time from the onset of labor until complete cervical dilatation

• Second stage:
Time from complete cervical dilatation to expulsion of the fetus

• Third stage:
Time from expulsion of the fetus to expulsion of the placenta
 Active phase

Second
Stage

Latent phase
ETIOLOGY OF PROTRACTION AND ARREST
DISORDERS :

Abnormal labor can be the result of one or more

abnormalities:

o The cervix.
o The uterus.
o The maternal pelvis.
o The Fetus (i.e., power, passenger, or pelvis).
THE SECOND STAGE

The median duration varies in nulliparous and multiparous

women is 50 and 20 minutes, respectively.

The upper limit of duration associated with a normal

perinatal outcome had been defined as two hours ( but
was subsequently lengthened)

Other factors may affect its duration:

Epidural analgesia, duration of the first stage, parity,
maternal size, birth weight, and station at complete
dilation.
The normal duration of 2nd stage of labor should be based upon parity and
presence of regional anesthesia, with no intervention as long as the fetal heart
rate pattern is normal and some degree of progress is observed.
 Symphysis Pubis

Sacral
Promon
tory

Vaginal examination to determine the diagonal conjugate

Normal uterine activity

Quantitatives Assessment:
- Palpation.

- External tocodynamometry.

- Internal uterine pressure catheters.

95 % of women in labor will have 3-5 contractions per 10 minutes.

Quantifying assessment:
The Montevideo units (i.e., the peak strength of contractions in
mmHg measured by an internal monitor multiplied by their frequency
per 10 minutes)

90 % of women in spontaneous active labor achieved contractile

activity > 200 Montevideo units (in 40 % reaches 300 units).
CLASSIFICATION – Of Labor Abnormalities:

•Protraction disorders: refer to slower-than-normal

labor progress.

• Arrest disorders: refer to complete cessation of

progress.

Protraction and arrest disorders may occur in both the first and second stage of
labor

It is important to emphasize that the rates of cervical change listed in Table 1 are
two standard deviations from the mean and thereby used to define abnormal;
they do not represent the mean or median rates.
INCIDENCE – In one large series, the incidence or protraction or
arrest disorders in the first stage of labor was 13 percent [12], second
stage abnormalities appeared to be as common [6].
latent phase: begins as short, mild, irregular uterine
contractions that soften, efface, and begin to dilate the cervix
(< 1 cm/h).

Active phase: starts at 3 to 5 cm dilation cervical dilation

accelerate to at least 1 to 2 cm/ h (various depending on
parity) per hour and the fetus descends into the birth canal
ends when the cervix is fully dilated

The total duration of labor also varies between nulliparous

and parous parturients. One report of 25,000 women at
term revealed the average duration of active labor (onset
defined as 3 cm dilation) in nulliparous and parous women
was 6.4 and 4.6 hours, respectively
Latent Phase

begins as short, mild, irregular uterine contractions that soften, efface, and
begin to dilate the cervix

The average duration of latent phase in nulliparous and multiparous

women is 6.4 and 4.8 hours

An abnormally long latent phase is defined as 20 hours for the nullipara

and 14 hours for the multiparous woman .Occur in 4-6%

Prolonged latent phase is responsible for 30 % abnormalities in nulliparas

and over 50 % of abnormalities in multiparous women
Risks Of Prolonged Latent Phase:
Mothers: Higher risk of cesarean delivery (due
to maternal exhaustion) and longer hospital stay
.

The newborns: Higher rate of perinatal morbidity

but not mortality

- are more likely to require neonatal

intensive care unit admission.
- have meconium at birth.
- have depressed Apgar Score.
CONTRIBUTING FACTORS to Prong longed Latent Phase:

• The State of the Cervix: Women with more favorable cervices at the onset
of labor have a shorter latent phase.

• Sedation and analgesia/anesthesia may slow the latent phase:

PROGNOSIS :

The diagnosis of prolonged latent phase must not be confused with a

protraction or arrest disorder in the active phase of labor.

Women with prolonged latent phase are not more prone to developing
subsequent protraction and arrest disorders than parturients with a normal
latent phase
MANAGEMENT OPTIONS OF A PROLONGED
LATENT PHASE:

Therapeutic rest
Oxytocin
Amniotomy
Cervical ripening
Hypocontractile uterine activity

 It refers to uterine activity that is either not sufficiently

strong or not appropriately coordinated to dilate the
cervix and expel the fetus.

 Is the most common cause of protraction or arrest

disorders in the first stage of labor.

 It occurs in 3 to 8 percent of parturients and can be

quantified as uterine contraction pressures less than 200
Montevideo units.
Causes of Dystocia

Dystocia due to cephalopelvic disproportion (Relative or Absolute) :

• This diagnosis is currently based upon slow or arrested labor during the active
phase.

• Absolute: true disparity between fetal and maternal pelvic dimensions.

• Relative: due to fetal malposition (e.g., extended or asynclitic fetal head) or

malpresentation (mentum posterior, brow), rather than a.

Dystocia due to malposition:

5 % of cephalic presenting fetuses experience malposition with persistent occiput
posterior (OP) position or transverse arrest.

Role of Epidural analgesia:

APPROACH TO THE PATIENT WITH ABNORMAL LABOR

Prevention: by proper management of labor:

 The diagnosis of labor.

 Monitoring of labor progress.

 assessment of maternal and fetal well-being.

(Women should undergo cervical examination every one to two hours
once active labor is diagnosed to determine whether progression is
adequate)

 The use of partogram

Management of Dystocia in the first stage:

Options f management include

Amniotomy •
• Oxytocin for treatment of Hypo contractile uterine activity

Low dose regimens: (to avoid uterine hyperstimulation)

High dose regimens: (shorten labor )

Oxytocin is typically infused to titrate dose to effect, as prediction of

a women's response to a particular dose is not possible
Active Phase Arrest

Diagnosis:

When There Is No Progress (Protraction Disorder

Persists) Despite Oxytocin Therapy To Achieve > Or =
200 Montevideo Units For Greater Than Two Hours.

Treatment:

Cesarean Delivery Is Typically Performed At This Point

 Dystocia in the second stage

Risk factors include:

nulliparity, diabetes, macrosomia, epidural anesthesia,
oxytocin usage, and chorioamnionitis

 Continued observation.
 Attempt at operative vaginal delivery.
 Cesarean delivery.
Observation:
Most women with a prolonged 2nd stage ultimately deliver
vaginally.
Suggested noninvasive interventions:

- changes in maternal position.

- continuous emotional support of the parturient
- delaying pushing if the fetal head is high in the pelvis at
full dilatation and the woman has no urge to do so
- active management using high dose oxytocin.

Operative vaginal delivery :

The choice of instrument require careful assessment of the
mother and fetus.

success is dependent upon the training and skill of the

obstetrician.
Occiput posterior position
Risks:
- Longer second stage.
- higher incidence of operative delivery.
- larger episiotomies.
- more severe perineal lacerations.

Management of OP:

 Operative Delivery From OP Position.

 Manual Or Instrumental Rotation To Occiput Anterior.
 Cesarean Delivery.

A small increase in second stage length in the presence of a reassuring fetal heart
rate, favorable clinical assessment of fetal relative to maternal size, and progress
in the second stage does not mandate rotation or operative delivery.
:RECOMMENDATIONS

A general labor management algorithm is outlined in Figure 3 (show figure

:3). The key points are listed below
• Monitor progress in active labor with cervical exams at 1 to 2 hour
intervals.
If the patient in active labor fails to progress adequately for two hours, •
then intact membranes should be ruptured and oxytocin administered to
achieve uterine contractions greater than 200 Montevideo units. These
patients can be observed for two to four hours as long as clinical
assessment of fetal and maternal size is favorable and the fetal heart rate is
.reassuring
The decision to perform an operative vaginal delivery (eg, extraction or •
rotation) in the second stage versus continued observation or cesarean birth
is based upon clinical assessment of mother and fetus and the skill and
.training of the obstetrician