Medical Academy named after S.I.

Georgievsky
of «Crimean Federal University
named after V.I. Vernadsky»
Department of obstetrics & gynecology №2

LECTURE:
«Аnomalies of
labor activity».
The diagnosis of abnormal labor (dystocia) has four
major etiologic categories:
• 1) the “passage,” or pelvic architecture;
• 2) the “passenger,” or fetal size, presentation, and
position;
• 3) the “powers,” or uterine action and cervical
resistance;
• 4) the “patient” and “provider.”
REVIEW OF NORMAL UTERINE ACTION:
• Regular interval.
• Interval gradually shortens.
• Intensity gradually increases.
• Discomfort in the back and abdomen.
• Associated with cervical dilatation.
• Discomfort not relieved by sedation.
• REVIEW OF NORMAL UTERINE
CONTRACTIONS POLARITY OF UTERUS: when
upper segment contracts, lower segment relaxes.

• PACEMAKERS: two pacemakers situated at each

corners of uterus generating the contraction in
coordinated manner.

• PATTERN OF CONTRACTIONS: uterine

contraction starts at corners, propagates towards lower
uterine segment with decrease in the duration and
intensity of contraction as it moves away from
pacemaker.
PARAMETERS OF UTERINE CONTRACTION:
• BASAL TONE: 5-20mmHg.
• PEAK PRESSURE: around 60 mm Hg pressure.
• FREQUENCY OF CONTRACTION: аdequate
uterine contractions are 1 in 3 minutes lasting for 45
seconds with good relaxation in between.
ASSESSMENT OF
CONTRACTION
• CLINICAL PALPATION.
The perception of uterine
contractions via abdominal
palpation requires a pressure more
than 10 mmHg above the resting
pressure.
• EXTERNAL ELECTRONIC
MONITORING consists of a
tocodynamometer with external
transducer on the abdomen over the
fundus.
• It can provide the frequency and an
estimate of the duration of
contractions and interval between
them but does not provide information
concerning intensity and tone.
• INTRAUTERINE PRESSURE CATHETER.
• Internal pressure monitoring is accomplished by
transcervical insertion of an open-ended plastic
cannula, which is filled with fluid and attached to
a pressure transducer, or insertion of a disposable
pressure transducer into the amniotic cavity after
rupture of membranes. Internal intrauterine
pressure monitoring provides estimates of resting
uterine tone and the duration, frequency, and
intensity of contractions. The term estimates is
used because, with ruptured membranes, the
uterus is not a closed fluid system; intrauterine
pressures also vary according to the position of
the patient.
QUANTITATIVE MONITORING:
Data - measured most commonly using Montevideo
units (MVU).
Montevideo unit - the sum of the intensity of each
contraction in a 10 minute period (in mmHg).
Adequate uterine activity - contraction pattern that
generates > 200 MVUs.
DEFINITION OF ABNORMAL UTERINE
ACTION:
• Any deviation from normal pattern of uterine
contractions affecting the normal course of labor is
designated as abnormal uterine contraction.
• Over all labor abnormalities occur in 25%
nulliparous and 10% multiparous.
DISORDERS OF ANY INDEX OF
UTERINE ACTIVITY ARE POSSIBLE:
• uterine tone,
• rhythm,
• frequency and coordination of contractions,
• intervals between labor pains,
• delivery duration.
Uterine contractility
patterns in labor:
A. Typical normal labor.
B. Subnormal intensity, with
frequency greater than
needed for optimum
performance.
C. Normal contractions but
too infrequent for efficient
labor.
D. Incoordinate activity.
E. Hypercontractility.
CLASSIFICATION OF ABNORMAL LABOR:
1. Pathological preliminary period (false labor).
2. Uterine inertia (hypotonic dysfunction):
• primary,
• secondary,
• inadequate voluntary expulsive forces .
3. Excessive uterine activity (hypertonic dysfunction).
4. Incoordinative uterine activity (hypertonic dysfunction):
• dyscoordination,
• hyperactivity of lower uterine segment,
• circulative dystocia (contractile ring),
• uterine tetania.
ETIOLOGY OF UTERINE CONTRACTIONS ABNORMALITIES:
• excess maternal nervous sickness and emotions (maternal exhaustion);
• impairment of nervous mechanisms of labor regulation as a result of previous acute and
chronic infectious diseases, nervous system disorders:
• pathological changes of uterine cervix and uterus;
• “Cephalopelvic disproportion” - is a disparity between the size or shape of the
maternal pelvis and the fetal head, preventing vaginal delivery, and is similar to arrest
disorder. This may be caused by the size or shape of the pelvis and/or the fetal head, or
a relative disparity as a result of malpresentation of the fetal head.
• hydramnion, oligohydramnion;
• multiple pregnancy;
• overterm pregnancy;
• administration of excess anesthesia;
• inadequate usage of uterotonic drugs.
• After months of relative inactivity during pregnancy, the uterus contracts more
and more often in the weeks before birth. Occasional uterine contractions have
taken place throughout pregnancy, but they have been so sporadic and weak
that they have had no effect on the cervix.
• Contractions during last weeks of pregnancy irregular and imperceptible to the
mother but they are more frequent and coordinated than earlier ones.
• These contractions were first described by an English doctor named John
Braxton. Hicks in 1872, and hence they became known by his name.
• If Braxton Hicks contractions increase and become rhythmic late in the
pregnancy, they are referred to as "false labor."
• The pathological preliminary period is characterized by painful, intermittent
by force and sensation dilating pains, which arise against the background of
increased uterine tone. The pains are similar to la­bor pains, but do not lead to
structural changes and cervical dilata­tion. The pains stimulate the pregnant
woman, lead to the violation of the diurnal sleep rhythm and total activity.
• The duration of patho­logical preliminary period makes more than 8-12 h.
• The pathological preliminary period is observed in women with functional
changes of central nervous system regulation (fear of labor, neurosis),
neurocirculatory dystonia, endocrine system malfunction, vegetative
disorders.
• The pathological preliminary period may direct­ly turn into uterine inertia.
• Treatment:
• sedatives - diazepam in the dose of 10-40 mg intramuscularly or intravenously (10-20 mg
into 20 ml of 0,9 % NaCl slowly), general dose is 40 mg; promedol 2% 1-2 ml i/m.
• prescription of prostaglandines’ synthesis inhibitors: indometacine in the daily dose 200-
250 mg should prescribed during 3-5 days, its initial dose is 125 mg (25 mg – per os, 100
mg – per rectum).
• spasmolytics (papaverine 2% 2-4 ml i/m, drotaverini 4 ml i/m, baralgini 5 ml i/v)
• calcium antagonists should be prescribed also: niphedipine in the dose 10 mg every 15
minutes. Its general dose is 30 mg.
• if it is ineffective — single-stage application of tocolytic thera­py with beta-adrenoreceptor
agonists (hexoprenalin 25 mg (5 ml) diluted in 500 ml of sodium chloride isotonic solution
and introduced i.v. drop-by-drop slowly 10-15 drops per min);
• preparation to delivery by intravaginal introduction of pros­taglandin E2.
CONTRAINDICATIONS TO BETA-ADRENOCEPTOR AGONISTS APPLICATION:
• hypersensitivity;
• premature placenta detachment;
• uterine hemorrhage;
• endometritis;
• extragenital pathology at decompensation stage;
• myocarditis;
• thyroid gland hyperfunction;
• glaucoma;
• hypertensive disorders during pregnancy;
• diabetes mellitus type I;
• сhorionamnionitis;
• dead fetus syndrome;
• heart failure.
Side effects of beta-adrenoreceptor agonists:
headache;
vertigo;
tremor;
tachycardia;
ventricular extrasystole;
heart pains,
ABP reduction.
• If tachycardia arises (>120 b/min), introduction of verapamil and potassium
preparations is administered to the parturient woman.
• A second type of abnormal contraction pattern, called hypotonic
dysfunction, is more common.
• Powerless labor (PL) is a condition with insufficient intensity,
duration and frequency of labor pains, therefore smoothing,
dilation of the uterine neck and fetus advancement at its
correspondence with pelvic dimensions are decelerated.
• There are differentiated primary and secondary types of PL. Pri­
mary PL arises at the very beginning of delivery and lasts during
the period of dilation. PL arising after a period of long-term regular
birth activity and manifesting itself with typical signs indicated
above is called secondary.
• PL may be diagnosed during 4-6 h of clinical observation and during 2 h if
hysterography is possible.
• Excessively intensive birth activity develops unexpectedly. Strong labor pains
take place in a short interval of time, uterine contractions frequency is more
than 5 in 10 min, which promotes quick and suffi­cient dilation of the uterine
orifice.
• Parturition is considered rapid if it lasts less than 6 h in primipara women and
4 h in multipara women, and accelerated — less than 4 and 2 h accordingly.
Such types of delivery cause injuries of the uterus and fetus (deep ruptures of
the uterus, vagina, peri­neum, premature detachment of normally located
placenta, hypot­onic bleeding, cord rupture, cerebral hemorrhage,
cephalohematomas).
• Abnormal labor describes complications of the
normal labor process:
• · slower – than – normal progress (protraction,
prolonged disorders) or
• · a cessation of progress ( arrest disorders).
 Abnormal Labor Patterns (according to labor stages) by A. Friedman

Phase of labor Labor Limits for abnormality

pattern Nulliparous labor Multiparous
labor
Latent phase of Prolonged labor phase (no progress > 21 hour > 14 hours
cervical stage from latent to active phase of labor)
Active phase of Prolonged active phase of labor < 1.2 cm / hour < 1.5 cm / hour
cervical stage Secondary arrest ( no change for > 2 hours > 2 hours
“cervical dilatation )
Prolonged deceleration phase > 3 hours > 1 hour
Pelvic stage Impossibility to descend < 1 cm / hour < 2 cm / hour
Protracted descend < 1 cm /hour < 2 cm / hour
Arrest of descend > 1 hour > 1/2 hour
All stages Precipitous labor < 4 hours < 2 hours
Prolonged Latent Phase Labor
• Latent phase labor lasting longer than 20 hours in the nullipara or
more than 14 hours in the
• paras women is considered a «prolonged latent phase» (defined
(1963) by Friedman and Sachtleben).
Factors that affect the duration of the latent phase include :

1. Excessive sedation: conduction

analgesia.
2. Poor cervical conduction: (eg. thick,
uneffaced or undilated)
3. False labor.
• Women with a prolonged latent phase risk
exhaustion and an increased risk of uterine infection
(chorioamnionitis).
• Rest is preferable for correcting prolonged latent
labor because unrecognized false labor was
common, with strong sedation 85 % of females
begin active labor and 10 % cease contraction (false
labor) and 5 % develop recurrent abnormal latent
labor and require oxytocin stimulation.
• Arrest of Active Labor
• Normal labor progresses at a rate of no less than 1.2 cm/hour (for
first babies) to 1.5 cm/hour (for subsequent babies). If active labor
progresses more slowly than this, an "arrest of labor" has occurred.
Protraction defined as a slow rate of cervical dilatation or descent.
i.e < 1.2 cm dilatation / hour or < 1 cm / hour for nullipara or < 1.5
cm / hour or < 2 cm / hour for multipara.
• The arrest of labor may be simple slowing of the labor below the
expected rate, or may represent a complete arrest, in which there is
no further progress for at least 2 hours. Arrest of dilatation defined
as 2 hr with no cervical change or arrest of descent as 1 hour
without fetal descent.

• Active phase abnormalities are the most common abnormalities of

labor about 25% of nullipara and 15% of multipara.
• Friedman subdivided active phase problems into protraction and
arrest disorders.
There are essentially only two causes for an arrest of labor:
• Inadequate contractions, or
• Mechanical impediment to the progress of labor.

Contractions may be inadequate because they are too

infrequent (more than 4 minute intervals), or do not last
long enough (less than 30 seconds). Often in this situation,
they are neither frequent enough nor long enough.
Mechanical impediments to labor may include:
• Absolute feto-pelvic disproportion, in which the maternal pelvis is not large enough to
allow the baby to pass through the birth canal.
• Relative feto-pelvic disproportion, in which there is a snug fit, but given time and
adequate contractions, the baby can safely negotiate the birth canal
• Fetal malposition, in which the fetal head is presenting in a less favorable position (for
example, occiput posterior, or with fetal hand preceding the head, or a transverse lie)
• Asynclitism, in which the fetal head is angled slightly to one side, making it more
difficult for a clear passage through the birth canal.
• ______________________________________________________________
• Graphic documentation of progressive cervical dilatation and effacement facilitates
assessing a patient’s progress in labor and identifying any type of abnormal labor
pattern that may develop.
• Primary uterine inertia occurs from the early onset of labor and lasts during the its second
stage until the end of labor.
Primary uterine inertia is characterized by such signs as:
• Inadequate uterine activity;
• Lack of the progressive cervical effacement and dilation;
• Station of presenting part in the pelvic inlet (- 3 station) for a long period of time and slowly
descent of the fetus in the case of “cephalopelvic disproportion” absence;
• Increased duration of labor;
• Maternal exhaustion and impairment of fetal well-being.
Diagnosis of primary uterine inertia is made during dynamic monitoring for woman during 2-3
hours. Important clinical evaluation of labor duration is the rate of cervical dilation. If, the
cervical dilation to 6 cm is absent if from the onset of labor in nulliparous women have been
passed 12 hours and in multiparous women have been passed 6 hours, the diagnosis of primary
uterine inertia has been made.
Secondary uterine inertia occurs after adequate uterine contractions and manifests by decreasing of uterine
contractions strength, duration and frequency later.
Secondary uterine inertia as a rule is presented in the end of the cervical stage of labor and in the pelvic stage.
Its frequency is 2,4 % to all number of labor. The causes of secondary uterine inertia are the same, as primary
uterine inertia has had. But, as a rule, secondary uterine inertia is more common as a result of:
• “cephalopelvic disproportion” in clinic contracted pelvis, hydrocephalia, fetal malpresentations, transversus
and oblique fetal lies, tumors in true pelvis;
• “unripe” uterine cervix, its scar’s changes;
• vaginal stenosis;
• breech presentation;
• expressed pain in uterine contractions;
• inadequate usage of amniotomy;
• endometritis;
• administration of excess and inadequate anesthesia, uterotonic and spasmolytics drugs.
It is very important to differentiate secondary uterine inertia with “cephalopelvic” disproportion for preventing
obstetric complications. Arrest of descent over a 2 hour-period is suggestive of either “cephalopelvic”
disproportion or ineffective uterine contractions.
• Management of abnormal labor in the case of uterine inertia
Induction of labor is the stimulation of uterine contractions before
the spontaneous onset of labor, with the goal of achieving delivery.
Augmentation of labor is the stimulation of uterine contractions that
began spontaneously but are either too infrequent or too weak, or both.
• Stimulation of labor is usually carried out with several ways:
• intravenous administrated 5 units (1 ml) oxytocin in 500 ml 0,9 % isotonic solution NaCl
(dilute intravenous solution) with the initiated dose 6-8 drops per minute to 40 drops per
minute;
• intravenous administrated 5 mg (1 ml) prostaglandin F2a in 500 ml 0,9 % isotonic solution
NaCl with the initiated dose 6-8 drops per minute to 25-30 drops per minute;
• combine intravenous administration of 2,5 units of oxytocin and 2,5 mg of prostaglandin
F2a in 500 ml 0,9 % isotonic solution NaCl with the initiated dose 6-8 drops per minute to
40 drops per minute.
• The mother should never be left alone while the oxytocin
infusion is running. Uterine contractions must be
evaluated continually and oxytocin shut off immediately if
contractions exceed 1 minute in duration or if the fetal
heart rate decelerate significantly. When either occurs,
immediate discontinuation of the oxytocin nearly always
correct the disturbances, preventing harm to mother and
fetus. The oxytocin concentration in plasma rapidly falls,
since the mean half-loaf of oxytocin is approximately 5
minutes.
• Caution: oxytocin has potent antidiuretic action, water intoxication may lead
to convulsion, coma, and even death.
• The following precautions should be observed when using oxytocin to treat
hypotonic dysfunction:
• 1. The patient must be in true labor, nor false or prodromal labor. labor must
have progressed to 3-5 cm of dilatation. One of the most common mistakes
in obstetrics is to try to stimulate labor in women who have not been in
active labor.
• 2. There must be no other discernible evidence of mechanical obstruction to
save delivery.
• 3. Do not use oxytocin in cases involving abnormal presentations of the
fetus and marked uterine overdistention such as gross hydramnios, a large
singleton fetus, or multiple fetuses.
• 4. In general, women of high parity (more than five deliveries)
should not be given oxytocin because their uteri rupture more
readily than those of women of lower parity.
• 5. The condition of the fetus must be good, as evidence by a
normal heart rate and lack of heavy contamination of the amniotic
fluid with meconium.
• 6. The frequency, intensity, and duration of contractions – and
uterine tone between contractions, must not exceed those of normal
spontaneous labor.
• 7. Continuous electronic monitoring of the fetal heart and uterine
activity should be maintained.
• Amniotomy, or artificial rupture of membranes, is also advocated for
patients with prolonged latent phase. It is believed that after amniotomy
the fetal head will provide a better dilating force than would the intact bag
of waters. In addition, there may be a release of prostaglandins, which
could aid in augmenting the force of contractions. Before amniotomy is
performed, the presenting part should be firmly applied to the cervix so
as t minimize the risk of causing an umbilical cord prolapse. Amniotomy
is usually performed with as “amnihook”, a thin, plastic rod with a sharp
hook on the end. The end is guided to the open cervical os with
examiner’s fingers, and the hook is used to snag and tear the amniotic sac.
The fetal heart rate should be evaluated both before and immediately
after rupture of the membranes.
• Should fetal or maternal distress occur, prompt
intervention is warranted. If this happens during the
second stage of labor with vertex low in the pelvis,
forceps or vacuum can be used to effect a vaginal
delivery. In all other cases, cesarean section may
have to be carried out. Distress of either mother or
fetus in the first stage of labor usually mandates
cesarean delivery.
• Inadequate voluntary expulsive forces is characterized by
insufficiency of abdominal prelum muscles or woman’
sickness. It manifests by elongation of pelvic stage of
labor. bearing down efforts become frequent, low strength,
weak. Arrest of presenting part is common. Elongation of
cervical stage of labor leads to female external genitalia
edema, signs of adjacent organs compression should be
presented, endometritis in labor should developed. A fetus
may be die from asphyxia.
• With full cervical dilatation, women usually feel the urge to “bear down” or
“push” each time the uterus contracts. Typically, the laboring woman inhales
deeply, closes her repetitively to increase intraabdominal pressure throughout
of the uterus and the abdominal musculature propel the fetus down the
vagina and through the vaginal outlet.

• Causes of inadequate expulsive forces – conduction analgesia is likely to

reduce the reflex urge for the woman to “push” and at the same time may
impair her ability to increase intra-abdominal pressure. Loss of
consciousness associated with general anesthesia certainly imposes these
adverse effects, as does heavy sedation.
• EXCESSIVE UTERINE ACTIVITY (UTERINE HYPERACTIVITY) is characterized
by high strength of uterine contractions and increasing of their frequency. Uterine tone is
increased also. The frequency of its pathology is 0,8 %.
• The main cause of this disorder is hyperexcitability of nervous system in woman.
Impairment of fetoplacental circulation, placental abruptio, deep cervical and vaginal
ruptures should be presented in uterine hyperactivity. Fetal molding is absent in labor,
that’s why intracranial hemorrhages and fetal trauma in labor are common.
• Management of abnormal labor in the case of uterine hyperactivity
• For elimination of excessive uterine forces tocolysis by b-adrenomimetics (Partusisten,
Bricanil, Ritodrine.) is very effective. hexoprenalin 25 mg (5 ml) diluted in 500 ml of 0.9
% NaCl is prescribed intravenously with the rate 6-8 drops in one minute.
• Anesthesia with Phtorotan is indicated in such cases also.
 Tocographic criteria of birth activity assessment
Hypo- Norm Hyper­
dynamics dynamics
Labor pains frequency per 10 min <2 2-5 >5
Basal tone, mm of mercury <8 8-12 >12
Labor pains intensity (amplitude), <30 30-50 > 50
mm Hg
Labor pains duration, sec <50 60-100 > 100
Irregular rhythm, min 3 1-2 <1
Activity, Montevideo units <100 100-250 > 250
 Birth activity assessment by cervical dynamics
Hypo- Norm Hyper­dynamics
dynamics
Latent phase (duration) > 7.5 h (5) <
(Smoothing of the uterine cervix, the rate 0.35 cm/h
of dilation up to 3—4 cm)
Active phase (duration) > 2-3 h (1-1.5) <
(The rate of dilation from 4 to 8 cm) 1.5 cm/h
Deceleration phase (duration) > 1.5-2 h (1-1.5) <
(The rate of dilation from 8 to 10 cm) 1.0 cm/h) (1.5)
Duration of the 1ststage > 18 (14) 10-12 h (6-7) <4

Note: Figures for multipara women are given in brackets.

• INCOORDINATIVE UTERINE ACTIVITY is characterized by absence adequate coordinate uterine
contractions between different uterine parts: right and left its sides, upper and lower uterine parts, different its
regions. Its frequency is 1-3 %.
• The main causes of incoordinate uterine contractions are:
• · uterine abnormality;
• · uterine cervix dystocia;
• · flat amniotic sac;
• · impairment of uterine innervating;
• · damaging of uterine regions as a result of inflammatory, degenerative and neoplastic changes.
• Incoordinative uterine activity is characterized by painful, irregular and frequent uterine contractions. “Unripe”
cervix and slow its dilation, preterm rupture of amniotic fluid, flat amniotic sac is common. Presenting part is
movable or fixated to the pelvic inlet for a long period of time. Woman in labor has been tired later and the
arrest of presenting part is presented..
• It is very important to differentiate incoordinative uterine activity with uterine inertia, “cephalopelvic”
disproportion for different ways of these disorders management.
• The frequency of discoordinated birth activity (DBA) makes 1-3%. There are no
coordinated contractions in different uterine parts (right and left, superior and inferior parts,
violation between uterine parts up to fibrillation and tetanus). It usually de­velops at the 1st
stage of delivery till the uterine neck dilates to 5-6 cm.
• The clinical picture is characterised by the hypertone of the infe­rior segment, irregular,
strong, sharply painful parodynia that reminds the picture of threatening hysterorrhexis.
• Clinical signs:
• pain;
• violated rhythm of labor pains;
• no dynamics of cervical dilation;
• no head advancement;
• hypertone of the inferior uterine segment (reverse gradient);
• spasmodic parodynia (uterine tetany);
• dystonia of the cervix.
THANK YOU FOR YOUR ATTENTION!