Title: unsatisfactory progress of labour

Summary

33 years old gravida three, para four at 38th week 1 day of period of gestation presented with unsatisfactory progress of labour lasted more than 8 hours, with history of gestational diabetes.

Baby was in occipto transverse position, with type I moulding and caput 3x3 cm noted.

Introduction

a. Background of study

Unsatisfactory progress of labour is basically a difficult labour or abnormally slow progress of labour. To define abnormal labor, a definition of normal labor must be understood and accepted. Normal labor is defined as uterine contractions that result in progressive dilation and effacement of the cervix. By following thousands of labors resulting in uncomplicated vaginal deliveries, time limits and progress milestones have been identified that define normal labor. Failure to meet these milestones defines abnormal labor, which suggests an increased risk of an unfavorable outcome. Thus, abnormal labor alerts the obstetrician to consider alternative methods for a successful delivery that minimize risks to both the mother and the infant.

A prolonged first phase of labour may result from oversedation or from entering labour early with a thickened or uneffaced cervix. It may be misdiagnosed in the face of frequent prodromal contractions. Protraction of active labor (second stage) is more easily diagnosed and is dependent upon the 3 P' s; power, passage and passenger –the baby itself.

b. Rational and significance of choosing the case

To understand both normal and abnormal labour, one must understand the normal physiology on labour itself.

Therefore, through this case, the researcher can study the mechanism of abnormal labour, factors involved in unsatisfactory progress of labour and the management taken to handle the progress of the labour itself.

In a way, this case itself is combinations of few case presentations itself; unsatisfactory progress of labour from shoulder dystocia and a case of retained placenta. However, this case study was solely based on the shoulder dystocia.

History of admission

a. Patient biography

Name initials : Mdm. SOAge : 34Sex : femaleReligion : IslamCivil status : marriedRace : MalayOccupation : housewifeAdmission : 24/3/2010Clerking : 24/3/2010

b. Chief complaintPatient is referred from Hospital Tanah Merah for management of unsatisfactory progress of labour –emergency lower saggital caesarean section. Patient presented with pervaginal bleeding, associated with regular contraction, full dilatation of cervix.

History of presenting illness

Patient was G5 P4 at 38 weeks 1 day of period of gestation. She was GDM on DKI insulin regime with current glucose level was 6.2 mmol/L –the diabetes is well controlled. She was sent to HRPZ II for unsatisfactory labour after poor progression within 8 hours.

Prior to the admission at Hospital Tanah Merah, she was experiencing abdominal pain, and per vaginal leaking. Immediately, she was sent to the hospital by her husband and admitted in the labour room. She was then admitted for active progress of labour but it lasted more than 10 hours. Then, she is referred to Hospital Raja Perempuan Zainab II for further management; lower sagittal caesarean section. However, patient already started to engage in second stage of labour –the baby head delivered at 2230, but poorly progressing. Thus, shoulder dystocia suspected.

The baby was born at 2330 –baby boy weight 4.5+ kg. After the birth of the baby, the placenta remained in the uterus for more than 30 minutes –retained placenta suspected which then leads to manual removal of placenta.

Review of system

system Finding

Cardiovascularno significant findings such as palpitation, lower limb oedema, orthopnea, syncope, dizziness, etc.

EndocrineNo significant findings such as moon features, exophthalmos, tremor, acromegaly, etc.

GastrointestinalNo significant findings such as diarrhoea, constipation, altered bowel movement, etc.

GenitourinaryNo significant findings such as dysuria, oliguria, haematuria, incontinence, nocturia, etc.

HematopoieticNo significant findings such as pallor, jaundice or bleeding tendency, etc.

Musculoskeletal No significant findings such as myalgia, arthralgia or arthritimyalgia, arthralgia or arthritis, etc.s, etc.

NeurologicNo significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc.

RespiratoryNo finger clubbing, no accessory muscle used during respiration, no shortness of breath, no noisy breathing, no hemoptysis, no night sweats.

Skin, hair, nailsNo significant findings. The skin colour is normal according to his race; with hair growth distribution is normal. Nail is normal, no clubbing, koilonychia, leukonychia, etc.

Head and neckNormal head size, shape and symmetry; no skull enlargement, bossing, etc. no significant findings of the neck such as webbing, goitre, etc.

Reproductive As stated

Comprehensive health history

a. Antenatal historyThis is unplanned but wanted pregnancy. Her pregnancy was noticed after missing 1-2 weeks of her period, but no conformation test was done. Her first booking was done at KK Tanah Merah was 12/10/2009, 7th week of her pregnancy. Her L.M.P was noticed at 27/8/2009 and her E.D.D was 4/6/2010 revised with ultrasound.

b. Obstetrics and gynaecology historyHer obstetrics history was incomplete.

c. She attained menarche at 15 years old with regular cycle of 28 days with flow of 5 days. She does not experiencing any dysmenorrhea, menorrhagia, postcoital bleeding or dyspareunia. She had Pap smear before and the result was normal.

d. Past medical & surgical historyNo significant medical or surgical history

e. Family historyNo known family history of diabetes, hypertension, asthma, IHD, malformation, multiple pregnancies, or mental illness in the family.

f. Social historyShe is a housewife and her husband work as construction labour. Her children was taken care by her husband at home, Tanah Merah district. Currently, they do not experiencing any financial difficulties. She does not consume alcohol or smoke, but her husband is a casual smoker. She denies any constitutional sex.

g. Allergies and medications historyNo known drug or food allergies to date. She is taking only supplements provided for her pregnancy.

Physical examination

At admission, she was already in state of active labour. She was in labour pain, alert and conscious. Her pregnancy weight was 69, with height of 158 cm. her body mass index is 27.64 kg/m2. Her vital sign were as recorded at the labour room;

Blood pressure : 126/63 mmHgHeart rate : 83 beat per minuteRespiratory rate : 19 breaths per minuteTemperature : 37°C

She does not appear to be anaemic, or jaundice. Oedema of the lower limb is not present. Hydration and hygiene was good. There was no goitre. Examination of breast cannot be demonstrated. Patient was already in stage of labour. The pregnancy was singleton; by evidence of two poles, cephalic presentation. Estimated baby weight was about 3.2-3.4 kg.

Vaginal examination reveals that there is a tear at right vaginal wall, and hematoma. Os is fully dilated and effaced. Per vaginal examination revealed the position of the fetus was left occiput anterior, stationed at +2, with the baby already descending with push by the mother. There was moulding with grade I, and caput of 3x3 cm. At speculum examination, there was hematoma at right vaginal wall due to rupture. The cervix is effaced, with the os fully dilated and reaching 1+ stationed. The position of the fetus is currently left occipito transverse. There were findings such as moulding type I, and caput of 3x2 cm. the liquor is clear. The fetal heart rate was at range of 120-130 beat per minute.

Impression: the patient already engaged in active phase of labour but the progress was very poor –it lasted more than 8 hours for both first and second stage of labour. Sign of obstruction noted with moulding type I and caput 3x2 cm. Even so, fetal is not in distress with normal range of heart beat.

Patient was referred to Hospital Raja Perempuan Zainab II for lower sagittal caesarean section. However, the baby was already engaged and the mother was already in bearing-down phase of second stage of labour. Therefore, the labour progress was preceded without lower sagittal caesarean section.

Summary

33 years old G5 P4 at 38th week 1 day of period of gestation currently presented with unsatisfactory progress of labour.

1) Patient was a known case of gestational diabetes mellitus on DKI regime2) Relative cephalo-pelvic disproportion due to macrosomia3) Occipito Transverse position of fetus4) Presence of moulding type I5) Indication of caput 3x3 cm

Diagnosis

33 years old Malay lady G5 P4 of 38th week POG is diagnosed for unsatisfactory progress of labour –deep transverse arrest.

The diagnosis was based on physical findings. Per vaginal examination revealed type I moulding of the baby and caput 3x2 cm noted. Speculum examination revealed that the baby was in left occipito transverse position. There was also a tear and hematoma noted at the vaginal wall.

Investigation

Investigation Reason to support

Full blood count

To look for hemoglobin, white blood cell and platelet levels. To ensure she is stable enough for any emergency surgery, to rule out any ongoing infection, anemia that may cause poor tolerance of blood loss during delivery.

Grouping, Screening, Hold (GSH) Patient might need transfusion

Full blood countinvestigation unit referenceWbc 20.7 109/L 4-10Rbc 3.61 1012/L 3.8-4.8Hgb 59 g/L 120-150Hct 28.1 36-46Mcv 77.8 fL 77-97Mch 24.7 Pg 27-32Mchc 31.7 g/dL 315-345Rdw-cv 13.9 % 11.6-14.0Plt 336 109/L 150-400

% 109/L 109/L

Neutrophil 87.9 18.16 2-7Lymphocyte 7.1 1.47 1.0-3.0Monocyte 5.0 1.03 0.2-1.0Eosinophil 0.0 1.03 0.02-0.10Basophil 0.0 0.01 0.9-12

Comments:The haemoglobin level is lower than the reference range. According to the WHO (1975), pregnancy anaemia is defined as haemoglobin level below 110 g/L as this cannot be explained by physiological haemodilution that occurs in pregnancy. If this cut-off value is used in Asian countries, 40-80% of Asian women are considered anaemic during pregnancy.

During pregnancy there is also an increase in white cells from about 7 x 10^9 to 15 x 10^9 per litre solely due to a neutrophilia. This was noted in her CBC & differential blood result. In spite of this, note that other causes of a raised neutrophil count must be excluded. In her case, clinically she is well with no sign or symptoms suggesting active infection.

Patient labour progress

G5P4 at 38th week 1 day by period of gestation, referred from hospital Tanah Merah for management of unsatisfactory progress of labour.

1) Patient presented with right vaginal wall hematoma 2) Os full dilated, membrane absent, clear liquor, moulding type I, with caput of 3x3 cm.3) Patient is then put into lithiotomy position –the baby head is delivered 2230, shoulder

dystocia is suspected.4) Episiotomy was done, McRobert manoeuvre was done, and suprapubic pressure was

applied to assist the delivery of the head. The baby was stuck about 2 minutes.5) Baby boy was born; poor breathing, poor muscle tone, baby is pink with heart rate >100

beat per minute. Birth weight is 4.5 kg –requires intubation, ventilator supported at 0000H

6) Patient had retained placenta, estimated blood loss was 500 cc.7) The mother is still conscious, pale appearance, uterus contracted.8) Blood oozing about ¼ L, placenta is at vagina. Control cord traction attempted. –it is

failed9) MRP was done at 2340H.

a. IV ampicilin, IV flagyl 500 mgb. Hartman’s solution, IV pitocin 40 ϋc. CBD was inserted

10) The mother develop 1° post partum haemorrhage 2° to retained placenta11) Estimated blood loss was about 800cc,12) Mother is then transfused about 20 pack cell red transfusions.

Summary of labour

Madam SO, Para 5, the pregnancy was singleton, longitudinal lie, and vertex. A baby boy was born through spontaneous vaginal delivery. Estimated blood loss was about 800 cc. Placenta weight is 0.9 kg. Episiothomy was done due to relative CEPHALO PELVIC DISPROPORTION because of big baby.

Stage of labour 1) 10,00 hour2) 02,32 hour3) 01,13 hour

Total time taken was 13,45 hour.

Discussion

Labour consists of a series of rhythmic, involuntary, progressive contractions of the uterus that cause effacement (thinning and shortening) and dilation of the uterine cervix. To define abnormal labour, a definition of normal labour must be understood and accepted. By following thousands of labours resulting in uncomplicated vaginal deliveries, time limits and progress milestones have been identified that define normal labour. Failure to meet these milestones defines abnormal labour, which suggests an increased risk of an unfavourable outcome. This can be clearly identified by using partograph when plotting the progress of labour.

Dystocia of labour is defined as difficult labour or abnormally slow progress of labour. Other terms that are often used interchangeably with dystocia are dysfunctional labour, failure to progress (lack of progressive cervical dilatation or lack of descent), and cephalopelvic disproportion (CPD).

This patient was involved actively in labour for more than 8 hours since admission to the Hospital Tanah Merah. The progress of labour was very slow indeed. According to the history, she was known case of gestational diabetes mellitus on insulin treatment –complication of diabetes in pregnancy includes macrosomia which may cause cephalo-pelvic disproportion thus, poor progress of labour.

A study Okun et al2 shows that maternal diabetes is one of the strongest risk factors associated with giving birth to an infant that is considered large for gestational age. Pregestational and gestational diabetes result in fetal macrosomia in as many as 50% of pregnancies complicated by gestational diabetes and in 40% of those complicated by type 1 diabetes mellitus. Studies of macrosomic infants of diabetic mothers reveal a greater amount of total body fat, thicker upper-extremity skin fold measurements, and smaller ratios of head to abdominal circumference than macrosomic infants of nondiabetic mothers.

Friedman’s original paper in 1955 defines labour of 3 stages1:The first stage starts with uterine contractions leading to complete cervical dilation and is divided into latent and active phases. Latent phase, irregular uterine contractions occur with slow and gradual cervical effacement and dilation. The active phase is demonstrated by an increased rate of cervical dilation and fetal descent. The second stage of labour is defined as complete dilation of the cervix to the delivery of the infant. The third stage of labour involves delivery of the placenta.

Normal progress of labour depends on 3P, which are passenger (infant size, fetal presentation like occiput anterior, posterior, or transverse), Pelvis or passage (size, shape, and adequacy of the pelvis), and power (uterine contractility). At any event that resulting disruption of the 3, will lead to unsatisfactory progress of labour.

Indicator for abnormal progress of labour

Indication Nullipara Multipara

Prolonged latent phase >20 h >14 h

Average second stage 50 min 20 min

Prolonged second stage without (with) epidural

>2 h (>3 h) >1 h (>2 h)

Protracted dilation <1.2 cm/h <1.5 cm/h

Protracted descent <1 cm/h <2 cm/h

Arrest of dilation* >2 h >2 h

Arrest of descent* >2 h >1 h

Prolonged third stage >30 min >30 min

How to recognize unsatisfactory progress of labour? The simplest test to evaluate is to plot patient’s labour progress by partograph.

Prolonged latent phase is not indicative of dystocia in itself because this diagnosis cannot be made in the latent phase. The treatment of choice is rest for several hours. Approximately 85% of patients treated progress to the active phase. Approximately 10% will cease to have contractions, and the diagnosis of false labour may be made. Approximately 5% of patients in whom therapeutic rest fails and in patients for whom expeditious delivery is indicated, oxytocin infusion may be used.

Amniotomy is often used and has become an accepted practice once the patient has reached the active phase of labour, although it has not been shown to result in shorter labour. It is not recommended in the latent phase of labour because it may only serve to increase the risk of intrauterine infection or cord prolapse. Anecdotal reports have stated that simply repositioning the patient frequently relieves a seemingly obstructed labor. Although not studied rigorously, there appears to be little harm in this maneuver. In theory, it may unseat an asynclitic or malrotated presenting part and allow it to engage in the pelvis more effectively

Limited studies have shown improvement in dysfunctional labor with use of a beta-blocker. In cases of dysfunctional labor resulting from functional dystocia or an abnormal uterine contractility pattern and in which oxytocin implementation has not improved the outcome, a beta-blocker may be considered. Low-dose administration of intravenous propranolol in abnormal labor augmented with oxytocin reduced the need for cesarean delivery, particularly among patients with inadequate uterine contractility

Conclusion

Unsatisfactory progress of labour is a difficult labor or abnormally slow progress of labor. Other terms that are often used interchangeably with dystocia are dysfunctional labor, failure to progress (lack of progressive cervical dilatation or lack of descent), and cephalopelvic disproportion (CPD).

References

1. Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol. Dec 1955;6(6):567-89.

2. Okun N, Verma A, Mitchell BF, Flowerdew G. Relative importance of maternal constitutional factors and glucose intolerance of pregnancy in the development of newborn macrosomia. J Matern Fetal Med. Sep-Oct 1997;6(5):285-90.