DEFNITION OF LABOR

⚫ WHO 2018 :Spontaneous in onset, low-risk at the start of labor and remaining so
throughout labor and delivery. The infant is born spontaneously in the vertex position
between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in
good condition.
 STAGES OF LABOUR:

First stage – Time from onset of labor to complete

cervical dilation.
Latent phase -gradual cervical change
Active phase- rapid cervical change.
Inflection point multigravida 5cm
primigravida 6 cm

Second stage – Complete cervical dilation to fetal

expulsion.
Passive phase -complete cervical dilation to
onset of active maternal expulsive efforts
Active phase -beginning of active maternal
expulsive efforts to expulsion of the fetus)

Third stage: Time from fetal expulsion and placental

expulsion.

 • Prolonged latent phase

⚫First stage disorders Prolongation disorder

Latent phase
Active phase
⚫Second stage disorders Protraction
• Protracted active phase dilatation
• Protracted descent

⚫Failure of descent disorders Disorders

⚫Shoulder dystocia
• CPD and Obstructed labour
• Prolonged deceleration phase
• Secondary arrest of dilatation
• Arrest of descent
Arrest disorders • Failure of descent

 PROLONGED LATENT PHASE

Latent phase exceeding
>20 hours in nulliparous (newer)
>14 hours in multiparous

RISK FACTORS:
• Unfavourable cervix
• Transverse Lie
• Occipitoposterior
position
• Sedation
• Analgesia

 MANAGEMENT OF PROLONGED LATENT PHASE

A prolonged latent phase should not be indication for caesarean delivery

Contractions Contractions+ no Contractions + cervical

subside cervical change changes

False labour Theraupetic rest ARM+Oxytocin

Oxytocin

PROTRACTED ACTIVE FIRST STAGE

FRIEDMAN CONTEMPORARY
<1.2 Cm/hr in nullipara <0.5-0.7 cm/hr in nullipara
<1.5 cm/r in multipara <0.5-1.3 cm/hr in multipara

PROTRACTED DESCENT:
< 1 cm/hr nullipara
<2cm/hr multipara

 ARRESTED ACTIVE FIRST STAGE

Arrest of cervical dilation:

Cervical dilation ≥6 cm dilation , ruptured membranes and
With Adequate Contractions : No cervical change for >/= 4 hrs
With Inadequate contractions: No cervical change for >/= 6 hrs

Management- Cesarean section

Arrest of descent
No change of station in 1 hr

 MANAGEMENT
• For patients with protracted active phase
1. Administer oxytocin (if not already started) -for women with slow progress is reasonable
even in the absence of documented hypo-contractile uterine activity
2. Amniotomy (if membranes are not already ruptured) if there has been adequate fetal
descent to a safe fetal station (eg, -2 or lower) for amniotomy
3. If fetal head high and not well applied to the cervix- begin oxytocin but delay amniotomy
4. Progress not adequate on oxytocin alone for 4-6 hrs - consider performing an amniotomy
5. Controlled amniotomy is performed if the head is still high and not well applied to the
cervix

 PROLONGED SECOND STAGE

Diagnosis of second stage arrest when no progress (descent/rotation)

• Nulliparous women > 3 hours (> 4 hours with epidural)

• Multiparous women > 2 hours (> 3 hours with epidural)
ACOG

Causes
• CPD
• Deep transverse arrest
• Persistent OP
• Fetal macrosomia (> 4 kg- diabetics, >4.5 kg – non diabetics)
• Epidural analgesia

 MANAGEMENT
• Oxytocin augmentation — After 60 to 90 minutes of adequate pushing
• If descent is minimal (ie, <1 cm) or absent
• uterine contractions are less frequent than every 3 minutes.
• Physical issue (eg, malposition or malpresentation, macrosomia, small maternal pelvis)
• Avoid operative delivery (vacuum, forceps, cesarean) as long as the fetus continues to
descend and/or rotate to a more favorable position for vaginal delivery, and fetal heart rate
pattern is not concerning

 PRECIPITATE LABOR

Definition: Total duration of 1st + 2nd Stage < 3 hours.

\

• Rate of cervical dilatation

• Nullipara -Dilatation > 5cm/Hr.
• Multipara ≥10 cm/hr

Precipitous delivery result from abnormally low resistance of the birth

canal, abnormally strong uterine contractions, lack of awareness of
painful contractions, or combination of these

 SHOULDER DYSTOCIA

• Failure to deliver the fetal shoulders with gentle downward traction on the fetal
head, requiring additional obstetric maneuvers to effect delivery
• Prolongation of head-to-body delivery time > 60 seconds.
• Incidence of shoulder dystocia 0.2% to 3% ACOG 2014

RCOG 2012

 MANAGEMENT OF SHOULDER DYSTOCIA:

ALARMER
for shoulder dystocia
A:Ask for help
L:Lift/hyperflex legs
A:anterior shoulder
disimpaction
R:Rotation
M:Manual removal of posterior
arm
E:Episiotomy
R:Roll over onto all fours

 OBSTRUCTED LABOUR
• Inability of presenting part of fetus to progress into birth canal, despite
strong uterine contractions

ETIOLOGY

• Fault of passage:
• Contracted pelvis
• Abnormal pelvis (android, anthrapoid)
• Fault of passenger:
• Macrosomia
• Malpresentation and position
• Transverse lie
• Brow presentation
• Occipito-posterior
• Compound presentation
• Malformed fetus

• Clinical features: Management

• Continuous pain Hydration, Correct acid-base status
• Increased bearing down Antibiotics
Empty bowel, bladder Cesarean delivery safer mode of
• Maternal exhaustion termination
• Cross–match Blood
No descent despite good
contractions Exclude Uterine rupture

• Examination
P/A- Upper segment -hard, tender
Lower segment- thinned, tender
Pathological retraction ring (Bandl’s ring)
(An hourglass constriction ring of the uterus, called
Bandl's ring, has been estimated to occur in 1 in 5000
live births )
Fetal parts not well felt.

P/V- Vagina hot, foul smelling discharge

Caput and moulding

 COMPLICATIONS
• MATERNAL • FETAL
Dehydration Fetal asphyxia
Sepsis Intra cranial hemorrhage
Uterine rupture Pneumonia due to ascending infection
Post partum hemorhage Fetal demise
Hypovolemic shock
VVF/RVF
Annular detachment of cervix

 HYPOTONIC UTERUS:

⚫ Most common abnormality.

No basal hypertonus,uterine contractions have a normal synchronous pattern,
But pressure during contraction is unable to dilate the cervix
Uterine activity - not sufficiently strong / not appropriately coordinated to dilate
the cervix and expel the fetus.
Etiology:
Contracted Pelvis
Fetal malposition Treatment:
Abnormal uterus Augmentation
Psychological factors with oxytocin
Excessive sedation /analgesia