ABNORMAL LABOR

dr. Syukri Delam, SpOG

Departement of Obstetric and Gynaecology

Universitas Riau
 Normal Labor
“Uterine contractions of sufficient intensity, frequency, and
duration to bring about demonstrable effacement and
dilation of the cervix ” 1
1st stage of labor
Latent phase : cervical dilatation 1 – 3 cm
Active Phase : cervical dilatation 4 – 9 cm
2nd stage of labor : complete dilatation of cervical uterine – fetal delivery
3rd stage of labor : expulsion of the placenta
4th stage of labor : observation post delivery

ACOG Practice Bulletin No. 49 Dystocia and Augmentation of Labor, VOL. 102, NO. 6, December 2003
 Friedman Curve of Normal Labor

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill
Education; 2018.
 Abnormal Labor
“Prolonged pregnancy or dystocia is defined as abnormal or slower progress of labor.”
Abnormal Diagnostic Criteria Preferred treatment Exceptional treatment
Pattern
Nulliparas Multiparas

1st Stage of Labor

Latent Prolonged > 20 h > 14 h Bed rest Oxytocin or cesarean delivery for selected
Phase latent phase indication
Active Protracted :
Phase - Dilatation <1 – 1.2 cm/h <1 < 1.5 cm/h Expectant and support C- section for CPD
- Descent cm/h < 2 cm/h
Arrested : • Rest if exhausted
- Dilatation No dilatation in 2 h Evaluation for CPD : • C section if :
- Descent No descent in 1 h - CPD : C - Section Cervical dilation ≥6 cm in a patient with ruptured
- No CPD : Oxytocin membranes, with :
• No change in the cervix for ≥4 hours despite
adequate contractions
• No change in the cervix for ≥6 hours with
inadequate contractions

2nd Stage of Labor > 2 h or > 3 h in > 1 h or > 2 h in

regional regional
anesthesia anesthesia

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 Factors affecting successful labor

Power
Passage
Passanger
 POWER
Abnormality in :
• Uterine contractility
• Maternal expulsive effort

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill
Education; 2018.
 ▫ Normal Uterine Contraction
▫ Amplitude
⬝ Latent phase : 20 – 30 mmHg above resting tone
⬝ Active phase : 30 – 50 mmHg above resting tone
⬝ 2nd stage : 100 – 150 mmHg above resting tone
▫ Frequency
⬝ Latent phase : every 3 – 5 minutes ( 2 – 3 times / 10 min)
⬝ Active phase : every 2 – 4 minutes ( 3 – 5 times / 10 min)
▫ Duration
⬝ Early : 30 – 60” / contraction
⬝ Later : 60 – 90” / contraction

Lindgren L: The influence of uterine motility upon cervical dilatation in labor. Am J Obstet Gynecol 117:530, 1973
 ▫ Abnormal Uterine Contractility
Hypotonic uterine contraction
• Low amplitude (weak) Primary dysfunction :
contractions were never
• Infrequent
normally established

Hypertonic uterine contraction

Secondary dysfunction :
• Elevated resting pressures contractions were once
• Decreased coordination, as well adequate and became weaker
as a delayed fall to baseline as labor progressed, usually
uterine tone (> 2 minutes) after 4 cm dilation
• Increased contraction frequency
(> 5x/10’)  tachysystoles
Althous JE, et al: Cephalopelvic disproportion is associated with an altered uterine contraction shape in the
active phase of labor. Am J Obstet Gynecol 2006; 195: 739-42
 Abnormal Maternal Pushing Effort

Heavy sedation or regional analgesia may reduce the

reflex urge to push and may impair the ability to contract
abdominal muscles effectively.

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill
Education; 2018.
 Management
Medication
Pain releiver and IV
Operative Delivery
fluids , amniotomy Vaginal / abdominal

01 02 03 04

Observation Uterotonic
Close observation Oxytocin administered in
and partograf uterine inertia cases
 PASSAGE
Abnormality in :
• Pelvic
• Lower genitalia tracts (soft tissue dystocia)

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill
Education; 2018.
 PELVIC

▫ Pelvic Capacity (Contracted pelvic) ▫ Pelvic type

⬝ Pelvic inlet ⬝ Gynecoid
⬝ Midpelvis ⬝ Anthropoid
⬝ Pelvic outlet ⬝ Android
⬝ Plathypeloid

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
▫ PELVIC INLET
⬝ Posteriorly : prom­ontory and alae of the
sacrum
⬝ Laterally : linea terminalis
⬝ Anteriorly : horizontal pubic rami and the
symphysis pubis

▫ MIDPELVIS
At the level of the ischial spines

▫ PELVIC OUTLET
⬝ Laterally : two ischial tuberosities.
⬝ Anteriorly : descending inferior rami of the
pubic bones
⬝ Posteriorly : tip of the sacrum

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 PELVIC INLET

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 Contracted Pelvic Inlet
Contracted pelvic inlet :
Anteroposterior diameter of the inlet (CV) is < 10 cm or
Transverse diameter is < 12 cm

Signs of Contracted Pelvic inlet :

▫ Marked asynclitism
▫ Absence of Descent
▫ Floating of the head freely over the pelvic inlet or rests
more laterally in one of the iliac fossae
Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 Mid Pelvis

• Interischial spinous : 10 - 10.5 cm;

• Anteroposterior from the lower border of the
symphysis pubis to the junction of S4-5 : 11.5 –
13.5 cm

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 Contracted Midpelvis
Contracted Midpelvis :
▫ Suspect midpelvic contraction : interspinous diameter < 10 cm.
▫ Midpelvic contracted : interspinous diameter < 8 cm
▫ Pelvic sidewalls convergent
▫ Narrow sacroschiatic notch

Signs of Contracted Midpelvis :

▫ Transverse arrest

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 PELVIC OUTLET

Inter tuberosity distance 10 – 11 cm

Anteroposterior distance 11 – 12.5 cm
 Contracted Pelvic Outlet
Contracted pelvic inlet :
▫ Interischial tuberous diameter of 8 cm or less

Signs of Contracted Pelvic Outlet :

▫ Often accompanied with midpelvis contraction
▫ Increased risk of dystocia

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
 PELVIC TYPE (Caldwell-Moloy classification)

Modified from Callahan TL, Caughey AB, Heffner LJ, eds. Blueprints in Obstetrics and Gynecology. Malden, MA:
Blackwell Science; 1998;4
 LOWER GENITALIA TRACT
▫ Uterine myomas
▫ Ovarian tumor
▫ Bladder distention
▫ Excess adipose tissue
▫ Uterine malposition
▫ Cervical stenosis or neoplasm.
▫ Partial vaginal or vulvar atresia
▫ Bartholin’s or Gartner’s duct cysts
▫ Vaginal septum
▫ Large condylomata, hematomas, and neoplasms.
 PASSANGER
Abnormality in Fetal :
• Size
• Lie
• Presentation
• Position
• Attitude

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill
Education; 2018.
 Fetal Head Diameter
▫ Smallest diameter of fetal head
when entering the pelvic cavity
is the
▫ Suboccipito-bregmatic
diameter (AP) which is
approximately 9.5 cm and
Biparietal (Transverse)
▫ which is approximately
▫ 9.5 – 9.8 cm

Cunningham, F. Gary, et al. Williams Obstetrics, 25th Edition. New York: McGraw-Hill Education; 2018.
Lie
Position Presentation
 The fetal head can overcome minor degrees of pelvic
contracture by molding which can decrease the BPD by 0.5
cm without fetal injury.

More severe Molding

Tentorial tears, intracranial hemorrhage, severe skull pressure

(increased risk of scalp necrosis or skull fracture
 Complication from CPD

Mother Fetus
 Vesicovaginal  Cord prolapse
 Vesicocervical  Prolonged labor
 Rectovaginal fistula  Increase in maternal and fetal
infections, uterine rupture, postpartum
hemorrhage, abnormal presentation or
position, and maternal and neonatal
trauma.
 Asynclitism

▫ Moderate degrees of asynclitism  the rule in normal labor.

▫ If severe  cepha­lopelvic disproportion
 Malpresentation
▫ Non vertex presentation : manual or forceps rotation is no longer
advocated
⬝ Brow presentation  2/3 convert to either face or occipital
presentation. If brow presentation persist  C- Section
⬝ Face presentation :
⬝ Mentum posterior  C Section
⬝ Mentum anterior  follow the progress of labor
▫ Compound presentation
Brow presentation Face presentation Compound presentation
 Malposition
▫ Persistent occiput presentation position :
⬝ Predisposed by anthropoid-type pelvis (narrowing midpelvis)
⬝ Forceps rotation with Kielland Forceps or with Classic Forceps with
Scanzoni Manuever
▫ Transverse occiput position
⬝ Predisposed by Platypelloid and Android pelves (narrow AP
diameter)
⬝ No signs of CPD  Forceps rotations
⬝ CPD (+)  C – Section.
 Fetal Macrosomia

▫ Typically, fetuses weighing more than 4000 g account for nearly 10%
and fetuses weighing 4500 g or more represent approximately 1% of
all deliveries.

▫ Macrosomic infants have a threefold increase in morbidity (eg :

shoulder dystocia, meconium aspiration, asphyxia, brachial plexus
injury, placenta previa, traumatic midforceps, and fetopelvic
disproportion)
 Fetal Anomali

▫ Hydrocephalus
▫ Craniosynostosis
▫ Conjoined twins
▫ Abdominal masses
 MANAGEMENT

Examination
Pelvimetry to asess CPD
and ability for vaginal
birth, Us Exam
Medication
To prevent sepsis, reduce
pain, and prevent acidosis

1 2 3 4 5

ANC Observation Postnatal

Antenatal detection of Close observation Observation and
previous pregnancy, with partograf and history taking for
especially in small Vs assessment further pregnancy
stature women
▫ ASSISTED VAGINAL
DELIVERY
 TYPES OF ASSISTED VAGINAL BIRTH

Vacuum – assisted Vaginal Delivery

Forceps – assisted Vaginal Delivery

 Classification of Assisted Vaginal Delivery
▫ Outlet
⬝ Fetal skull has reached perineum (visible Scalp at introitus vagina)
▫ Low
⬝ Fetal skull at station +2cm (below the ischial spines) but not on
perineum
▫ Mid
⬝ Fetal head is no more than 1/5th palpable per abdomen
⬝ Leading point of skull at station 0 or +1cm (below the ischial spines)
 Indications and Contraindications
Indications for AVB

 Fetal - compromise
 Maternal
• Lack of progress (prolonged 2nd stage of labor)
• Shortens 2nd stage of labor
• Maternal disease contraindicated to bear down (e.g. cardiac; cerebral
vasc. malformation; myasthenia)
• Exhausted
 Combined fetal and maternal indications
 Indications and Contraindications
(Absolute) contra-indications for AVB

 Non vertex : Brow or Face presentation

 Not engaged
 Not fully dilated
 CPD

(Relative) contra-indications for AVB

 Suspected fetal bleeding disorders e.g. allo-immune thrombocytpaenia; male fetus with
haemophilia
 Predisposition to fracture e.g. OI
 Vacuum birth should be avoided < 32 weeks’ and used with caution between 32-36
weeks’ (<2500 gr)
 Assisted Vagina Delivery Requisite

▫ F : Fully Dilatation of cervix uteri

▫ O : occiput presentation
▫ R : Ruptured of membrane
▫ C : CPD - NOT
▫ E : Engaged
▫ P : Position known
▫ S : Suitable cup (Vacuum)
 Vacuum vs Forceps
 “Selection of the appropriate instrument and decisions
about the maternal and fetal consequences should be based
on clinical findings at the time of delivery.”*

 A meta-analysis comparing vacuum extraction to forcep

delivery showed that vacuum extraction was associated
with significantly less maternal trauma and less need for
general and regional anesthesia**
*ACOG Practice Bulletin #17 (June 2000)
**Johnson RB. The Cochrane Library Issue 4, 1999
Classification of Forceps
 Classification of Vacuum cup

▫ Soft vs. Rigid

⬝ Soft cups were more likely to fail to achieve vaginal
delivery (OR 1.65; 95% CI 1.19-2.29)**
⬝ Soft cups were associated with less scalp injury (OR
0.45; 95% CI 0.15-0.60)**

** Johanson, R, Menon, V. Soft versus rigid vacuum

extractor cups for assisted vaginal delivery. Cochrane
Database Syst Rev 2000
Cup Position

Rules of Three in Failure of Vaccum :

• 3 pulls, at 3 contractions, no progress

• 3 times off: after one failed attempt, reassess
carefully before reassembling
• After 30 minutes of ordering with no progress
THANK YOU