Dysfunctional Labour by Abhishek Jaguessar
Transcript of Dysfunctional Labour by Abhishek Jaguessar
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Failure to progress
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Stages of labor
Stage I
Latent phase
Active phase: . Acceleration. Maximum slope
. Deceleration
Stage II
Phase 1 Phase 2Stage III
Stage IV
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Latent phaseActive phase
2ndstage1st stage
max slope
acceleration
dec
Time (hours)
Cervical dilatation
(cm)Friedman labor curve in nulliparous
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Labor duration (Friedman,1978)
Variable Nulliparas (h) Multiparas(h)
Latent phase
mean 6.4 4.8
upper limit 20.1 13.6
Active phase
mean 4.6 2.4
dilatation rate(cm/h) 1.2 1.5
Second stage
mean 1 0.5
upper limit 2.9 1.1
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Dysfunctional laborDefinition
Any deviation in normal
progress of labor , either incervical dilatation or in descent
of the presenting part
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Etiology
1. Malfunctionin the myogenic, neurogenic, or
hormonal mechanisms of uterine activity.
2. Malpresentation, fetal anomalies, uterine
malformation, pelvic tumors, overdistension of
the uterus, CPD
3. Extrinsic factors: sedation, anxiety,anesthesia, supine position, unripe cervix,
chorioamnionitis
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ClassificationFreidman (1989) :
1. Prolonged latent phase2. Protraction disorders:1.Protracted active phase
2. Protracted descent
3. Arrest disorders:1.2ndry arrest of cervical dilatation2. Prolonged deceleration phase
3. Arrest of descent
4. Failure of descent
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ACOG (1995):
1. Protractiondisorders Slower thannormal2.Arrest disordersComplete cessation ofprogress
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e s1.Hypotonic dysfunctiona.Prolonged latent phaseb.Prolonged active phasec. Prolonged decelerationphased. Prolonged 2nd stage2.Hypertonic dysfunction
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r n o en :1.Disorders of dilatation:a. Prolonged latent phaseb. Protracted active phase
c. Secondary arrest2.Disorders of descent:
a. Failure of descentb. Protracted descentc. Arrest of descent.
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Philpott (1979)1. Prolonged latent
phase2. Primary dysfunctional
labor
3 2ndry arrest of labor
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Early diagnosis1. Partogram: In active phase
Alert line: drawn from cervical dilatation
on admission ,at a rate of 1 cm /h
Action line: drawn 2 h to the right of alertline (Philpott,1972).
2. Nomogram (Studd,1973):labor stencil: a series of curves from patient
admission cervical dilatation to 10 cm.
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Prevention
O,
Driscol method of activemanagement of labor (1969)
Diagnosis of labor 1 h: ARM
2h:cervical dilatation
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Prolonged latent phaseDefine
Freidman: > 20 h in PG, > 14 h in MGfrom onset of labor(difficult to determine)
Philpott:> 6h in PG , > 4h in MG fromadmission in labor.
IncidencePG: 4% MG: 1%
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Etiology
1. Wrong diagnosis of labor
2.Excess sedation3. An abnormal or high presenting part
4. PROM5.Idiopathic.
Risks
are created by aggressive intervention.If membranes are intact, no risk , only
maternalanxiety.
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TreatmentTrue labor or not: PV, CTG, palpation of the
cervix & reexamine after 4h:1.C stop or no cx changes: not in labor
2. C persist & no cervical changes: sedation.3. C. persist & cx changes : ARM + Syntocinon
drip.A. In 85% labor will progress rapidly .
B.In 15% adequate C will not cause cxdilatation. If after 4-8 h of syntocinon, thecervix is not further dilated, CS.
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Primary dysfunctional laborDefine
Cx. Dil. < 1cm/h before normal active phase hasbeen established
Incidence
PG: 20% MG: 8%
Etiology
1. Inefficient C.: the commonest2. CPD: 1/ 3
3. Malpresentation or malposition
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Risks
1. F. distress
2. Maternal fear & anxiety , dehydration &acidosis
3. Incordinate u. activity.Treatment
Exclude CPD, ARM + oxytocin drip.15%: vag. Delivery
35%: instrumental delivery
50%: CS for F. distress.
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2ndry arrest of laborDefine
Active phase started normally( cervicaldilatation reached 5-7 cm ) then cervical
dilatation stop or slows significantly within 2 hIncidence
PG: 6% MG: 2%
Etiology1.CPD:50%
2. Malposition
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Risks
F. distress: rareTreatment
Exclude CPD , ARM & Syntocinon dripNo progress after 4 h : CS (15% ).
O, Driscol advised oxytocinregardless of pelvimetry.
C i l dil t ti T f d f ti l
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Prolonged
latent phase
Primary
dysfunctionallabor
Secondary
arrest
Cervical dilatation
(cm)
Time (hours)
Types of dysfunctional
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Prolonged decelerationphaseDefineArrest or slow of cervical dilatation after 8 cm
(PG > 3h , MG > 1h)
Etiology1. CPD 2. Uterine exhaustion
Risks
1. High incidence of shoulder dystocia2. Forceps is difficult
Treatment
S ntocinon is not helpful. C.S.
El h t l (2000) d t i
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Elnashar et al (2000) compared oxytocin
infusion alone & with propranolol in the
management of DL (Primary DL & 2ndryarrest).
The study group (50 women) was given propranololI.V. in a dose of 2 mg to be repeated after one hour if
there was no response in cervical dilatation.
The control group (50 women) & the study groupreceived oxytocin infusion for at least 4 hours & for
maximum of 6 hours & if there was no response,CS
was done.
Th i ifi t diff i th d
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There were a significant differences in the drug-
delivery interval (2.2 vs 3.7 hours) & CS rate (20 vs
38 %) between the study & the control groups.Between the two groups, no statistically significant
differences were observed in low Apgar scores or
incidence of admissions to the NICU.
Conclusion: Propranolol combined with
oxytocin infusion in management of DL safelyshortened the drug-delivery interval & reduced
CS rate.
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Activemanagement oflaborDr Aboubakr Elnashar
First introduced by O,
Driscolet al (1969) in Dublin.
Many modifications
P t l
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Protocol1.This approach to management is confined to
nulliparas.2. Patient education during pregnancy: signs &
symptoms of labor
3.Strict criteria for diagnosis of labor:painful uterine contractions as well as
complete effacement of the cervix,
ruptured membranes orpassage of blood stained mucous
The diagnosis of labor is made within 1 hr of
presentation.
4 E h i l b i i d t
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4.Each woman in labor is assigned to
trainedprofessional companion.
5.Amniotomy within 1 hr of admission.6.Strict criteria for diagnosis of abnormal labor
progress. partogram or labor graph.
7.Oxytocin high dose infusion:
if progress of labor is < 1 cm/h over 2 h.
Oxytocin infusion is begun at 6mu/min &increased by 6 mu/min every 15 min until 7
C/15min. or 40 mu/min.
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8.Assess FHR by auscultation
intermittently Continuous electronic fetalheart rate monitoring is used only if there is
me conium stained amniotic fluid
9.All methods ofpain reliefare freelyavailable.
10. C.S if no delivery12 hr post admissionor if fetal scalp ph sampling revealed fetal
compromise.
B fit
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Benefits
1.Prevention ofdysfunctional labor
2.Decrease the incidence ofprolonged laborfrom 30% to 7% (Boylan,1997)
3.Decrease incidence ofoperative delivery.
4. Decrease maternalinfectious mrbidity5.Decrease incidence ofC.S to 4.8% (Lopez-
Zeno,1992).Some found no decrease in CS rate (Fraser et
al,1993) & others found anincrease in CS rate
(Boylan et al,1993).
A i t f h t i
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Amniotomy for shortening
spontaneous labour
Fraser et al, The Cochrane Library, 2, 2001.
Routine early amniotomy is associated with
both benefits and risks.Benefits include a reduction in labor
duration( between 60 and 120 minutes) and
a possible reduction in abnormal 5-minuteApgar scores.
N t f th h th i th t ti
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No support for the hypothesis that routine
early amniotomy reduces the risk of CS.
Indeed there is a trend toward an increasein CS. An association between early
amniotomy and CS for fetal distress isnoted in one large trial.
This suggests that amniotomy should be
reserved for women with abnormal labor
progress.