Abnormal labor

BY ALEMAYEHU G 1
 objective
 At the end of this session students should able to know:
 Definition of abnormal labor (dystocia)

 Discuss classifications of abnormal labor patterns

 Outline etiologies of abnormal labor

 Discuss the diagnosis of abnormal labor

 Describe management options of abnormal labor patterns

BY ALEMAYEHU G 2
Definition of Abnormal labor
An abnormal labor is any labor in which the pattern of labor progress is significantly different
from accepted and recognized patterns of labor progress in terms of cervical changes, decent of
fetal presenting part or profile of uterine contractions
Dystocia ( difficult labor) is often used interchangeably to denote an abnormal labor pattern

BY ALEMAYEHU G 3
Classifications of abnormal labor
patterns – Four major groups
Prolongation disorders

Protraction disorders

Arrest Disorders

Precipitate labor

BY ALEMAYEHU G 4
Prolongation Disorders
Only one prolongation disorder recognized

Prolonged latent phase of labor

◦ Definition – A latent phase lasting more than 14 hours in a multigravida and 20 hours in a primigravida

◦ Challenge in diagnosis is often due to the problem in diagnosing the exact time of onset of labor

BY ALEMAYEHU G 5
Protraction Disorders
Two protraction disorders

Protracted cervical dilatation

A cervical dilatation less than 1.2 cms per hour in the multigravida and 1.5 cms per hour in the
primigravida during active labor

Protracted descent
Descent of the fetal presentation less than 1 cms per hour in the multigravida and 2 cms per hour in
the primigravida

BY ALEMAYEHU G 6
Arrest Disorders
Three arrest disorders

Secondary Arrest of Cervical Dilatation

No cervical dilatation for 2 or more hours in the active phase of labor

Arrest of descent
No descent for more than 2 hours

Failure of descent
No descent of fetal presentation for more than 3 hours

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Precipitate labor
Precipitate labor means labor that end in expulsion of fetus within less than three hours

Two precipitate labor disorders

Precipitated dilatation :- rate of cervical dilatation 5cm per hour in primigravida and 10 cm per
hour in multigravida

Precipitated descent

BY ALEMAYEHU G 8
Risk factor for abnormal labor
Older maternal age Short stature(less than 150 cm)
Pregnancy complication High station at full dilatation
Non reassuring fetal heart rate Chorioamnionitis
Epidural anesthesia Post term pregnancy
Macrosomia obesity
Pelvic contraction
Occiput posterior position
nulliparity

BY ALEMAYEHU G 9
Etiologies of abnormal labor – related to one of the four
P’s of labor determinants
Abnormalities of the powers
Primary power – uterine contraction

Secondary power – maternal expulsive efforts

Abnormalities of the passages

Contraction of the bony pelvis –inlet, midpelvic , outlet

Soft tissue dystocia – tumor previa, vaginal septa etc

Abnormalities of the passenger

Psychological and physician factor

Often due to stress of labor affecting autonomic nervous system and suppress release of oxytocin
from the posterior pituitary

Delays in early identification of labor progress

BY ALEMAYEHU G 10
Abnormalities of the powers – Etiologies
Primary uterine inertia – abnormal uterine contraction frequencies, duration and
intensity that is due to inherent myometrial dysfunction
Mainly affects primigravid labors without other additional factors
Secondary uterine inertia – causes
Prolonged labor ab
Malpresentations/ malpositions
Epidural analgesia
 Uterine myomata
Dehydration and electrolyte imbalances
Fetopelvic disproportion
Abruptio placentae with couvaliare uterus

BY ALEMAYEHU G 11
Abnormalities of the passenger (fetus) leading to dystocia
Fetal macrosomia (fetal weight grater than 4000g)

Multifetal gestation ( twin baby)

Congenital anomalies – e.g. hydrocephalus, ascituss

Malpresentations/malpositions –e.g shoulder presentation,persistent brow presentation,mento

posterior,and persistent or direct occipito posterior

BY ALEMAYEHU G 12
Abnormalities of passages
Bony dystocia
◦ Contracted pelvis: if one of internal diameters of the pelvis are shortned by 0.5 cm or more. Classified
in to:
i. Generaly contracted pelvis – contracture of inlet ,mid cavity and outlet.
ii. Inlet contracture – APD <10 cm or TD <12 cm
iii. Midcavity contracture – APD <11.5cm and TD <9.5 CM
iv. Outlet contracture –BTD <8cm

Soft tissue dystocia:

i. Cervical dystocia – cervical stenosis, cervical cancer
ii. Vaginal - vaginal septum, incomplete atresia,gartner duct cyst…etc
iii. Pelvic mass- myoma, ovarian cyst.

BY ALEMAYEHU G 13
Causes of contracted pelvis
Abnormal shape of pelvis –android and platypelloid type pelvis
Nutritional deficiency- vitamin D deficiency rickets in child hood and osteomalacia in adult.
Disease or injury in the spines – kyphosis,scoliosis,pelvic tumor, fracture and limbs “
poliomyelitis in childhood”
Congenital disorder of spines, pelvis and limb

BY ALEMAYEHU G 14
Diagnosis of abnormal labor patterns - Steps
Document following parameters against time on partograph
 Uterine contraction profile
 Cervical dilatation/effacement
 Descent of fetal presentation

Unsatisfactory progress of labor is defined as:

◦ Cervical dilatation to the right of the alert line on partograph

◦ Prolonged labour is labour which lasts more than twelve hours in the active phase.

BY ALEMAYEHU G 15
contin……
Compare against normal patterns for respective parity, identify
any deviations and then classify into respective abnormal
patterns
 Look for specific etiology responsible for the abnormal labor
patterns by carefully assessing the five determinants of labor
progress (P’s of labor)

BY ALEMAYEHU G 16
Evaluation for causes of abnormal labor patterns – Assessment of
the four P’s of labor
Assessment of powers of labor – three ways
Palpation of uterine contractions
External tocodynamometer
Intrauterine pressure catheter monitoring
Maternal exhaustion, vital signs, blood glucose and evidence of dehydration

Assessment of the passenger

Size, number, presentation, position and anomalies of the fetus by Leopold's
palpations and ultrasonography

Assessment of the passages

Bony pelvis – clinical pelvimetry
Soft tissue dystocia – vaginal exam

Assessment of maternal emotional status and pain control

Fearfull physician and early admission of mother.

BY ALEMAYEHU G 17
Management of abnormal labor – depends on specific etiology
diagnosed
In first level facility: Review maternal condition and refer
Volume replacement or maternal hydaration
Amniotomy or ARM
Active monitoring of labor by partograph
Reassess labor progress in 2 hours

BY ALEMAYEHU G 18
In higher level facility:
 Power abnormalities
 Uterine inertia – Augmentation
 Secondary powers failure – Instrumental assistance
 Passenger abnormalities
 If foetal head >2/5 palpable deliver by CS
 If foetal head < 2/5 palpable assist delivery by instrument.
 Destructive deliveries in cases of fetal deaths
 Abnormalities of the passages
 Often Caesarean delivery
 Episiotomy for perineal level obstruction

BY ALEMAYEHU G 19
THANK YOU !!!

BY ALEMAYEHU G 20