Abnormal labor: Protraction and arrest disorders

By Dr. Burhan F MD

objectives
• At the end of this presentation students will able to:• Define Abnormal labor: Protraction and arrest disorders. • Describe causes of Protraction and arrest disorders. • Explain management of Protraction and arrest disorders. • Use partograph for management of labor.
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NORMAL LABOR
•  Labor refers to uterine contractions resulting in progressive dilation and effacement of the cervix, and accompanied by descent and expulsion of the fetus • Friedman divided labor into three stages: First stage: time from the onset of labor until complete cervical dilatation • Second stage: time from complete cervical dilatation to expulsion of the fetus • Third stage: time from expulsion of the fetus to expulsion of the placenta

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Abnormal labor
Managing Labor Using the Partograph 4

Prolonged latent phase • Definition : prolonged latent phase is defined as 20 hours for the nullipara and 14 hours for the multiparous woman ( def ‘a’) when latent phase lasts longer than 12hrs for nullipara and 6hrs for parous women (def ‘b’) Latent phase longer than 8 hours (WHO definition) 5 .

Factor contributing • Prematurely admistered sedation and analgesia • Poor cervical condition • Myometrial dysfunction • false labor 6 .

significance • Increased risk of subsequent labor abnormality • Increased cesarean delivery rate • Low APGAR score • Increased perineal laceration febrile morbidity& intrapartum blood loss 7 .

Treatment • Adequate rest with therapeutic sedation /narcosis morphine /pethidine • Augmentation with oxytocin less preferred option 8 .

Active phase abnormalities • 25% of nulliparas &15% of multiparous womens develop active phase abnormalities. This makes it the commonest labor abnomality 9 .

5cm/hr of cervical dilatation for nullipara & multipara respectively • <1cm/hr of cervical dilatation for a minimum of 4 hrs (WHO defn) • Protracted descent: defined as < 1cm/hr of descent of fetal head for nullipara &<2cm/hr for multipara.2cm/hr & 1. 10 .Protraction disorders • Protracted active phase dilatation:-defined as less than 1.

Arrest disorders • Arrest of cervical dilatation :no change in cervical dalitation for >2hrs period for both nulliparas &multiparas • Arrest of descent : no demonstrable descent of the head for more than 1hr for both nulliparas & multiparous 11 .

Labor pattern Diagnostic criteria for abnormal patterns in active labor Nullipara Multipara First stage Duration (no anesthesia) Duration (anesthesia) Protracted dilation Arrested dilation 16.5 cm/h >2 h 61 minutes 131 minutes >2 h 12 Second stage Duration (no anesthesia) Duration (anesthesia) Arrest of descent (epidural) .2 cm/h >2 h 132 minutes 185 minutes >3 h 12.6 hours 19.0 hours <1.5 hours 14.9 hours <1.

causes • CPD • Inadequate uterine contraction • Malpresentation & malposition 13 .

Management • Before making dx active phase abnormalities make sure that women is in active phase. • Evaluate for CPD. • If the cause is CPD do C/S • Reevaluate for malposition & malpresentation &mange depending on types of Managing Labor Using the Partograph 14 . 30% of protraction & 50% arrest disorders associated with CPD.

Mx cont…… • Evaluate uterine function 1. Amniotomy if the head is fixed &membrane is intact & observe for 30-60minute  B.<180 mv unit A. If no improvement after Amniotomy initiate oxytocin augmentation Managing Labor Using the Partograph 15 .If hypotonic dysfunction .

Uncoordinated uterine action:dx by internal monitoring Responds favorably for oxytocin augumentation In the absence of CPD 16 .Mx cont……. 2.

Poor progression in the second stage • What is prolonged second stage of labor? • Arrest of descent: no descent for > 2hr for primi & multi • Protracted descent:< 1cm/hr in nullipara & <2cm/hr in multi • NB the duration of second stage has no relationship to perinatal out come if fetal distress & traumatic deliveries are excluded 17 .

Mx • Depends on cause • CPD :-C/s • Inadequate uterine contraction:oxytocin • Malposition manage accordingly • Inadequate maternal voluntary effort managed with appropriate encouragement & instruction. 18 .

Partograph Managing Labor Using the Partograph Managing Labor Using the Partograph 19 .

caput • Color of amniotic fluid – Maternal well being: • Pulse. blood pressure. temperature. ketones or protein in urine – Progress of labor: • Cervical dilatation • Descent of presenting part • Duration and frequency of contractions Managing Labor Using the Partograph 20 .The Partograph • The partograph is used to assess: – Fetal well being: • Fetal heart rates and pattern • Degree of molding. respiration • Urine output.

Malaysia and Thailand No intervention in latent phase until after 8 hours If action line was reached during active phase.WHO Partograph Trial World Health Organization (WHO) evaluated impact of partograph on labor management and outcome Conducted randomized. 21 . considered: ◦ Oxytocin augmentation ◦ Cesarean section ◦ Observation and Labor Using the Partograph treatment supportive Managing WHO 1994. multi-center trial in hospitals in Indonesia.

869 (86.WHO Partograph Trial (cont.21% p 0.9%) 341 (3.001 0.4%) 7.028 8.) All Women Total childbirths Labor > 18 hours Labor augmented Postpartum sepsis Normal Women Mode of childbirth Spontaneous cephalic Forceps Before Implementation 18.5%) < 0.428 (83.1% 0.3%) 227 (2.023 0.254 6.002 0.4% 9.230 3.4% 20.7% 0. Managing Labor Using the Partograph 22 .005 WHO 1994.70% After Implementation 17.

and time of ruptured membranes • Fetal heart rate: Record every half hour • Amniotic fluid: Record the color at every vaginal examination: – – – – I: membranes intact C: membranes ruptured. gravida. date and time of admission. hospital number. clear fluid M: meconium-stained fluid B: blood-stained fluid Managing Labor Using the Partograph 23 .Using the Partograph • Patient information: Name. para.

) Molding: ◦ 1: sutures apposed ◦ 2: sutures overlapped but reducible ◦ 3: sutures overlapped and not reducible Cervical dilatation: Assess at every vaginal examination. mark with cross (X) Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour Action line: Parallel and 4 hours to the right of the alert line Managing Labor Using the Partograph 24 .Using the Partograph (cont.

) • Descent assessed by abdominal palpation: Part of head (divided into 5 parts) palpable above the symphysis pubis. the sinciput (S) is at the level of the symphysis pubis Managing Labor Using the Partograph 25 . At 0/5. recorded as a circle (O) at every vaginal examination.Using the Partograph (cont.

) • Hours: Time elapsed since onset of active phase of labor (observed or extrapolated) • Time: Record actual time • Contractions: Chart every half hour. palpate the number of contractions in 10 minutes and their duration in seconds – Less than 20 seconds: – Between 20 and 40 seconds: – More than 40 seconds: • Oxytocin: Record amount per volume IV fluids in drops/minute every 30 minutes when used • Drugs given: Record any additional drugs given Managing Labor Using the Partograph 26 .Using the Partograph (cont.

Using the Partograph (cont. acetone and volume: Record every time urine is passed Managing Labor Using the Partograph 27 .) • Temperature: Record every 2 hours • Pulse: Record every 30 minutes and mark with a dot (•) • Blood pressure: Record every 4 hours and mark with arrows • Protein.

The Modified WHO Partograph Managing Labor Using the Partograph 28 .

Sample Partograph for Normal Labor Managing Labor Using the Partograph 29 .

• Unsatisfactory progress of labor is defined as: Unsatisfactory Progress of Labor – Latent phase longer than 8 hours – Cervical dilatation to the right of the alert line on partograph – Woman has been experiencing labor pain for 12 hours or more without delivery Managing Labor Using the Partograph 30 .

Prolonged Active Phase • Diagnose prolonged active phase if cervical dilatation is to the right of the alert line on the partograph Managing Labor Using the Partograph 31 .

Partograph Showing Prolonged Active Phase Managing Labor Using the Partograph 32 .

obstruction. rupture membranes  Assess uterine contractions: ◦ If less than three contractions in 10 minutes. malposition or malpresentation  General methods of labor support may improve contraction and accelerate progress Managing Labor Using the Partograph 33 . suspect cephalopelvic disproportion. each lasting more than 40 seconds. each lasting less than 40 seconds.Management of Prolonged Active Phase of Labor  If no signs of cephalopelvic disproportion or obstruction and membranes are intact. suspect inadequate uterine activity ◦ If three contractions or more in 10 minutes.

deliver by cesarean section • If fetus is dead. deliver by craniotomy or cesarean section Management of Prolonged Active Phase: Cephalopelvic Disproportion Managing Labor Using the Partograph 34 .• Diagnose cephalopelvic disproportion if there is secondary arrest of cervical dilatation and descent of presenting part in presence of good contractions • If cephalopelvic disproportion is confirmed.

the cervix is fully dilated and the head is at 0 station or below. deliver by vacuum extraction Managing Labor Using the Partograph 35 .Management of Prolonged Active Phase: Obstruction Diagnose obstruction if there is secondary arrest of cervical dilatation and descent of presenting part with: ◦ ◦ ◦ ◦ ◦ ◦ ◦ large caput third degree moulding cervix poorly applied to presenting part edematous cervix ballooning of lower uterine segment formation of retraction band or maternal and fetal distress If fetus is alive.

deliver by cesarean section • If fetus is dead deliver by craniotomy or cesarean section Rupture of an unscarred uterus is usually caused by obstructed labor. Managing Labor Using the Partograph 36 .) • If fetus is alive.Management of Prolonged Active Phase: Obstruction (cont. the cervix is fully dilated and the head is at 0 station or below. deliver by vacuum extraction • If fetus is alive but the cervix is not fully dilated or if the fetal head is too high for vacuum extraction.

the most probable cause of prolonged labor is inadequate uterine activity Managing Labor Using the Partograph 37 . each lasting less than 40 seconds • If contractions are inefficient and cephalopelvic disproportion and obstruction have been excluded.Management of Prolonged Active Phase: Inadequate Uterine Activity • Diagnose inadequate uterine activity if there are less than three contractions in 10 minutes.

continue oxytocin infusion and re-examine after 2 hours. deliver by cesarean section ◦ If progress continues. every effort should be made to rule out disproportion in a multigravida before augmenting with oxytocin Managing Labor Using the Partograph 38 . Hence. Continue to follow progress carefully Inefficient contractions are less common in a multigravida than in a primigravida.)  Rupture membranes and augment labor using oxytocin  Reassess progress by vaginal examination 2 hours after good contraction pattern with strong contractions is established: ◦ If there is no progress between examinations.Management of Prolonged Active Phase: Inadequate Uterine Activity (cont.

Partograph Showing Inadequate Uterine Contractions Corrected with Oxytocin Managing Labor Using the Partograph 39 .

1 version 2011 • WHO guide line • Addis Ababa university management protocol for labor & deliveries • Williams text book of obstetrics .references • Up To Date 19.

Thank you for your Attention .

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