ABNORMAL LABOUR AND ITS

MANAGEMENTS

ARSLAN ALI 18/167

 WHAT IT IS?

• Labour becomes abnormal when there is poor progress (as evidenced by a

delay in cervical dilatation or descent of the presenting part) and/or the fetus
shows signs of compromise.
• Progress in labour is dependent on the ‘3 Ps’ as described previously (powers,
passages, passenger).
• Abnormalities in one or more of these factors can slow the normal progress
of labour.
POOR PROGRESS IN
LABOUR
STAGE ONE
Defined as cervical dilation of less than 2cm in 4 hours, usually associated with failure of
decent and rotation of the fetal head.

Powers • efficiency of uterine

contractions
The three variables related to
progress in labour • the fetus (its size,
Passenger presentation and position)

• uterus, cervix and bony

Passages pelvis
POWERS – DYSFUNCTIONAL UTERINE
CONTRACTIONS
Most prevailing cause of poor progress in labour; characterized by weak
and infrequent contractions. Evident in primigravida and older women.
4-5 contractions per 10 minutes is considered ideal.
 WHAT TO DO ?
• Offer hydration, good pain relief and emotional support

• Repeated vaginal examination after every 2 hours

• In case of confirmed delay, artificial rupture of membranes should be performed

• Begin oxytocin infusion to augment contractions in case no progress post ARM in further 2 hours

• Initially, infusion is commenced at a slow rate and increased carefully every 30 mins with
continuous fetal monitoring
 CONTINUED..
• Failure in progress, despite 4-6 hours of augmentation with oxytocin, results usually in
Caesarean section

• Extreme caution is taken while augmenting a multiparous woman with oxytocin due to
chances of uterine rupture in a truly obstructed labour

• Augmentation with oxytocin is contraindicated if there are concerns regarding fetal condition
CEPHALOPELVIC DISPROPORTION
Anatomical disproportion between the fetal head and maternal pelvis ;
essentially because of large head, small pelvis or combination of both .
 • unusually small due to previous fracture or metabolic
Pelvis bone disease

• constitutionally large, macrocephaly caused by

Head obstructive hydrocephalus, fetal thyroid or neck
tumors
 CPD SUSPECTED IF
• Slow progress despite adequate
contractions
• Fetal head not engage
• Vaginal examination: severe
moulding and caput formation
• Head poorly applied to the cervix
MANAGAMENT
• As long as, CTG is reactive, oxytocin can
be given to primigravida in mild to
moderate CPD
• Relative CPD may be overcome by
correcting the malposition
o from deflexed OP position to flexed
OA position
• Oxytocin should never be used in
multiparous women in suspected CPD.
• If CPD is confirmed, deliver by C-section
 PASSENGER -
MALPRESENTATIONS
More common in high parity and carry a risk of uterine rupture if labour
is allowed to continue
•a
o Face presentations may apply themselves poorly to the cervix
and labour will progress slowly but vaginal delivery is still
possible.

o Brow (mento-vertical diameter) presentation is too large to fit

through the bony pelvis (13 cm) unless flexion occurs or
hyperextension to a face presentation.

o Shoulder presentations can not be delivered vaginally

PASSAGES – ABNORMALITIES OF
THE BIRTH CANAL
● Abnormalities of uterus and pelvis
● fibroids in the lower uterine segment can prevent descent of the fetal head.
● a non-compliant cervix that effaces but fails to dilate because of severe scarring
or rigidity, usually as a result of previous cervical surgery such as a cone biopsy.
This is called “Cervical Dystocia”.
● Caesarean section may be necessary.
POOR PROGRESS IN
LABOUR
STAGE TWO
•a
o Birth is expected to take place within 3 hours of the start of the active
second stage in a nulliparous , and 2 hours in multiparous.

o Delay is diagnosed if delivery is not imminent in the above mentioned

time.

o Instrumental birth can be considered for prolonged second stage labor if

head is engaged and bishop score is high. Otherwise C- section is
performed.

o The cause of second stage delay can again be classified as abnormalities

of powers, passengers or passages.

Power – Secondary
Uterine Inertia
Most usual cause of 2nd stage
delay and may be exacerbated
by epidural analgesia.
Having achieved full dilatation
the contractions become weak
and ineffectual.
Associated with maternal
dehydration, exhaustion and
ketosis.
Passenger – Occipito –
Posterior Position of Fetal
Head
Head will either have to
undergo long rotation to
occipito-anterior or be
delivered in the OP position
i.e face to pubes.
Passage – Narrow
‘Android’ mid Pelvis
Prevents internal rotation,
may result in arrest of
descent of the head at the
level of ischial spines in the
transverse position this
condition is called deep
transverse arrest.

Treatment is with rehydration

and intravenous oxytocin if no
mechanical problem is
anticipated (primiparous).
PATTERNS OF ABNORMAL
PROGRESS IN LABOUR
The use of a partogram to plot the progress of labour improves the detection
of poor progress.
 Prolonged Latent occurs when the latent phase is longer than 3-8 hours.
Phase It is best managed with analgesics, mobilization and
reassurance.

Primary Dysfunctional means poor progress in the active phase of labour

(<2cm cervical dilation/4 hours), more common in
Labour primiparous women.

occurs when progress slows or stops in the active phase,

Secondary Arrest typically after 7 cm dilatation.
 Risk Factor or Poor Prognosis in Labour

Dysfunctional
Small Woman Big Baby Malpresentation
Uterine Cavity

Soft Tissue /
Early Membrane
Malposition Pelvic
Rupture
Malformation
 FETAL COMPROMISE
One of the most common reasons for medical intervention during labour is the well being
of the fetus .

Fetal Hypoxia :

• Reduction in placental blood flow associated with contractions may exacerbate distress in an
already compromised fetus leading to fetal hypoxia and eventually acidosis

• May present as meconium staining or an abnormal CTG but neither of these can confirm fetal
hypoxia

• Stained meconium can be passed as a sign of fetal maturity and CTG carries a very high false
positive rate.
 MANAGEMENT
• Monitor CTG continuously
• Carry out vaginal examination to exclude malpresentation or cord prolapse and to
assess the progress of the labour
• If the cervix is fully dilated, deliver the baby vaginally using forceps.
• If the cervix is not fully dilated but is at least 3 cm dilated, fetal blood sampling can
be done.
• If normal, allow labour to continue, repeat sampling every 30-60 mins if CTG abnormalities
1 persist

• - If abnormal, immediate C-Section delivery

2
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