Diagnosis and Management of Abnormal

Professor Hassan NasratChairman Department of Obstetrics and

Gynecology

Pattern of Normal Labour

• Normal Labour: Regular Uterine Contractions (force) That Cause Progressive Dilation And

Effacement Of The Cervix (Passage) Descent of the Fetal Head (Passenger)

•

Definition: Normal Labor

Pattern of Normal Labor (Stages and Phases)

Consequence of Abnormal Labor (Dystocia)

Types of Abnormal Labour

Diagnosis Abnormal Labour

Causes of Abnormal Labour

Management of Abnormal Labor

• Regular Uterine Contractions (force)

• That Cause Progressive Dilation And Effacement Of The Cervix (Passage)

• Descent of the Fetal Head (Passenger)

Normal Labor

Definitions (Normal and Abnormal Labor)

Consequence of Abnormal Labor ((Dystocia)

Pattern of Normal Labor (Stages and Phases)

Types of Abnormal Labour

Diagnosis Abnormal Labour

Causes of Abnormal Labour

Management of Abnormal Labor

Duration:

Pattern of Progress of Normal Labour:

• Second stage: Time from complete cervical dilatation to expulsion of the fetus Head Descent

• Third stage: Time from expulsion of the fetus to expulsion of the placenta

latent

Active

Acceleration Phase

Maximum slope

Deceleration phase

• First stage:

Time from the onset of labor until complete cervical dilatation Cervical Changes

Characteristics of the average cervical dilatation curve for nulliparous labor. Friedman EA: 1978.)

First Stage

Second Stage

Latent phase - Contractions short, mild, irregular - cervical changes softening, effacement, and dilatation

Active phase Accelerate cx dilation at least 1 to 2 cm/ h

Head Descent

Characterized by: short, mild, irregular uterine contractions and cervical changes (i.e. softening, effacement, and dilatation) (< 1 cm/h).

latent phase:

• Starts at 3 to 5 cm dilation cervical dilation.

• Accelerate to at least 1 to 2 cm/ h (depending on parity) per hour and the fetus descends into the birth canal

Active phase :

Cx changes

The partogram

Duration of “Normal” Labour

First Stage

Duration 6-8 2-10 hRate of cervical Dilatation 1 cm/h >1.2 cm/ hDuring Active Phase

Duration >3o/m-3h 5-30/m

Second Stage

Primigravida Multigravida

Definitions (Normal and Abnormal Labor)

Consequence of Abnormal Labor

Pattern of Normal Labor (Stages and Phases)

Types of Abnormal Labour

Diagnosis Abnormal Labour

Causes of Abnormal Labour

Management of Abnormal Labor

Consequence of Abnormal Labor

Short Term On the Mother: • Postpartum hemorrhage.• Increased rate if traumatic complications: Lacerations, injuries

to adjacent organs.• Increased risk of infection (prolonged labor)• Increased rate of difficult operative delivery.

Long Term Consequences:

• Psychological trauma of Traumatic Experience

On the Fetus: {increased rate of perinatal morbidity and mortality }• Potential Complications of traumatic delivery• Low Apgar score• Neonatal complications (Birth Asphyxia, trauma ..etc.)

Definitions (Normal and Abnormal Labor)

Consequence of Abnormal Labor

Pattern of Normal Labor (Stages and Phases)

Types of Abnormal Labour

Causes of Abnormal Labour

Diagnosis Abnormal Labour

Management of Abnormal Labor

• Protraction disorders: refer to slower-than-normal labor progress.

• Arrest disorders: refer to complete cessation of progress.

Protraction and arrest disorders may occur in both the first and second stage of labor

Types – Of Labor Abnormalities: (for each Stage)

• Precipitate Labour: Complete Deliver within 1 hour

Classification Of Labor Abnormalities By Stages:

Abnormalities in the Latent Phase:

Abnormalities in the Active Phase

Second Stage Abnormalities:

Prolonged (prolonged) Latent Phase (20 Hours For The Nullipara And 14 Hours For The Multiparous Woman .Occur In 4-6%)

Protracted Active Phase

Secondary Arrest of Cervical Dilation

Failure of Head Descent Arrest of Head Descent

Second Stage

Latent phase - Prolonged Latent Phase

Active phase-Protraction-Secondary Arrest of Cervical Dilation

Head Descent

-Failure -Arrest

Latent Phase

An Abnormally Long Latent Phase (4-6%)

-20 Hours For The Nullipara-14 Hours For The Multiparous Woman .

Prolonged Latent Phase Is Responsible For 30 % Abnormalities In Nulliparas And Over 50 % Of

Abnormalities In Multiparous Women

Role of Epidural analgesia:

Dystocia due to cephalopelvic disproportion:(Absolute) :

Absolute CPD: True disparity between fetal and maternal pelvic dimensions e.g. Macrosomia, Hydroceph, Contracted pelvis.

Causes of Abnormality (Dystocia) Protraction or Arrest) Of Active Phase:

Relative CPD: Dystocia due to malposition: E.G. Occiput posterior (OP), Mentum posterior, Brow

Occipitofrontal Diameter

Diameter of the OP Position

Risks: - Longer second stage.- higher incidence of operative delivery.- larger episiotomies.- more severe perineal lacerations.

Occiput posterior position

A small increase in second stage length in the presence of a reassuring fetal heart rate, favorable clinical assessment of fetal relative to maternal size, and progress in the second stage does not mandate rotation or operative delivery.

Management of OP:

Operative Delivery From OP Position. Manual Or Instrumental Rotation To Occiput Anterior. Cesarean Delivery.

Diagnostic Criteria For Abnormal Pattern in Active Labour

Active Phase

Protracted (slow) Dilation <1.2 /h <1.5 /hArrested Dilation >2/ h >2 / h

Arrest of Descent (epidural) >3/ h >2/ hArrest of descent (no epidural) >2/ h >1/ h

Second Stage

Nulligravida Multigravida

Curves of Normal and Abnormal Labor

Prolonged Latent Phase

Protracted Active Phase

2ry Arrest of Dilation

Prolonged Latent Phase

Protracted Active Phase

2ry Arrest of Dilation

Definitions (Normal and Abnormal Labor)

Consequence of Abnormal Labor

Pattern of Normal Labor (Stages and Phases)

Types of Abnormal Labour

Diagnosis Abnormal Labour

Causes of Abnormal Labour

Management of Abnormal Labor

ETIOLOGY OF PROTRACTION AND ARREST DISORDERS :

Abnormal labor can be the result of one or more abnormalities (i.e. The Passage, The passenger and the Force):

o The cervix.o The maternal pelviso The Fetus. o The uterus.

The Passage

The Passenger

The Force

Definitions (Normal and Abnormal Labor)

Consequence of Abnormal Labor

Pattern of Normal Labor (Stages and Phases)

Types of Abnormal Labour

Diagnosis Abnormal Labour

Causes of Abnormal Labour

Management of Abnormal Labor

Diagnosis of Abnormal Labor

Risk Factors The Partogram

Management of Abnormal Labor

Prevention: by proper management of labor:

The diagnosis of labor.

Monitoring of labor progress.

assessment of maternal and fetal well-being. (Women should undergo cervical examination every one to two hours once active labor is diagnosed to determine whether progression is

adequate)

The use of partogram

APPROACH TO THE PATIENT WITH ABNORMAL LABOR

MANAGEMENT OPTIONS OF A PROLONGED LATENT PHASE:

• Therapeutic rest

• Oxytocin

• Amniotomy

• Cervical ripening

Diagnosis:

When There Is No Progress (Protraction Disorder Persists) Despite Oxytocin Therapy For Greater Than Two Hours.

MANAGEMENT OPTIONS OF

Active Phase Arrest

Treatment:

Cesarean Delivery Is Typically Performed At This Point

• Amniotomy • Oxytocin for treatment of Hypo contractile uterine activity Low dose regimens: (to avoid uterine hyperstimulation) High dose regimens: (shorten labor )

Management of Dystocia in the first stage:

Oxytocin is typically infused to titrate dose to effect, as prediction of a women's response to a particular dose is not possible

Options f management include

It refers to uterine activity that is either not sufficiently strong or not appropriately coordinated to dilate the cervix and expel the fetus.

Is the most common cause of protraction or arrest disorders in the first stage of labor.

It occurs in 3 to 8 percent of parturients and can be quantified as uterine contraction pressures less than 200 Montevideo units.

Defect in The Force: (Hypo contractile uterine activity)

Continued observation.

Attempt at operative vaginal delivery.

Cesarean delivery.

Prolonged (Dystocia) in the second stage

Risk factors include: nulliparity, diabetes, macrosomia, epidural anesthesia, oxytocin usage, and chorioamnionitis

Observation: Most women with a prolonged 2nd stage ultimately deliver vaginally.

Suggested noninvasive interventions:

- changes in maternal position. - continuous emotional support of the parturient - delaying pushing if the fetal head is high in the pelvis at full dilatation and the woman has no urge to do so

- active management using high dose oxytocin.

Operative vaginal delivery :

The choice of instrument require careful assessment of the mother and fetus.

success is dependent upon the training and skill of the obstetrician.

Sacral Promon

tory

Vaginal examination to determine the diagonal conjugate

Symphysis Pubis