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Dysfunctional labor

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  • 1. Failure to progress Benha University Hospital, Egypt Aboubakr Elnashar
  • 2. Is Dysfunctional Labour important? Primary indication of CS UK, 2001 % Fetal distress 22 Failure to progress 20 Repeat CS 14 Breech 11 Maternal request 7 Others 25 Proper understanding of the pathophysiology & appropriate treatment, is important for reduction CS rate Aboubakr Elnashar
  • 3. •Normal labour Stages Duration •Dysfunctional labour Definition Etiology Classification Diagnosis Types Prevention •Active management of labour Protocol Benefits •Recommendations OUTLINE Aboubakr Elnashar
  • 4. Normal labor Aboubakr Elnashar
  • 5. Stage I Latent phase Active phase: . Acceleration . Maximum slope . Deceleration Stage II Phase 1 Phase 2 Stage III Stage IV Aboubakr Elnashar
  • 6. Aboubakr Elnashar
  • 7. 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 Aboubakr Elnashar
  • 8. Aboubakr Elnashar
  • 9. Dysfunctional labor Aboubakr Elnashar
  • 10. Definition Any deviation in normal progress of labor, either in cervical dilatation or descent of the presenting part, despite the presence of uterine contraction Aboubakr Elnashar
  • 11. Etiology •Power: Dysfunctional uterine activity: 75% (Steer et al, 1985) Malfunction in the myogenic, neurogenic, or hormonal mechanisms of uterine activity. •Passenger: Malpresentation, malposition, fetal anomalies •Passages: -Uterine malformation, pelvic tumors, uterine over distension, cervical stenosis from previous surgery -CPD •Extrinsic factors: Patient not in labor, sedation, anxiety, anesthesia, supine position, unripe cervix, chorioamnionitis Aboubakr Elnashar
  • 12. Classification • Freidman (1989) 1. Prolonged latent phase 2. Protraction disorders: a. Protracted active phase b. Protracted descent 3. Arrest disorders: a. 2ndry arrest of cervical dilatation b. Prolonged deceleration phase c. Arrest of descent d. Failure of descent Aboubakr Elnashar
  • 13. • ACOG (1995) 1. Protraction disorders Slower than normal 2. Arrest disorders Complete cessation of progress Aboubakr Elnashar
  • 14. •Fields 1.Hypotonic dysfunction a.Prolonged latent phase b.Prolonged active phase c. Prolonged deceleration phase d. Prolonged 2nd stage 2.Hypertonic dysfunction Aboubakr Elnashar
  • 15. •Shifirin & Cohen(1998) 1.Disorders of dilatation: a. Prolonged latent phase b. Protracted active phase c. Secondary arrest 2.Disorders of descent: a. Failure of descent b. Protracted descent c. Arrest of descent. Aboubakr Elnashar
  • 16. •Philpott (1979) 1. Prolonged latent phase 2. Primary dysfunctional labor 3. 2ndry arrest of labor. Aboubakr Elnashar
  • 17. Diagnosis 1. Partogram: •Recording of the condition of the mother, the condition of the fetus, and the progress of labour Aboubakr Elnashar
  • 18. A. CONDITION OF THE FETUS I. FHR. II. Memb & Liq: I= intact, C= clear, M= meconium B= blood, A= abscent III. Moulding: 0 (separated); + (touching); ++(overlap); +++ (severe overlap) Aboubakr Elnashar
  • 19. B. PROGRESS OF LABOUR I. Cervical dilatation (cm). Plot x In active phase Alert line: drawn at a rate of 1 cm /h cervical dil The mean rate of the slowest 10% of normal PG Action line: drawn 4 h to the right of alert line. Intervention should take place II. Descend: Plot O (amount of head palpable above pelvic brim) and Position III. Contractions: Frequency/10 m, Duration & Intensity: stippled (<20 sec, weak); striped (20-40 sec, moderate); complete (>40 sec, strong). Aboubakr Elnashar
  • 20. C. CONDITION OF THE MOTHER I. Medications: Oxytocin, Drugs, IV Fluids II. V/S: B.P, P, T. III. Urine: Vol, alb, ketones Aboubakr Elnashar
  • 21. Aboubakr Elnashar
  • 22. WHO partogram, 2002 Simple & easy to use. The latent phase has been removed . Plotting on begins in the active phase when the cervix is 4 cm dilated. Aboubakr Elnashar
  • 23. Aboubakr Elnashar
  • 24. Aboubakr Elnashar
  • 25. 2. Nomogram (Studd,1973): labor stencil: a series of curves from patient admission cervical dilatation to 10 cm (not the patient onset of labour) Aboubakr Elnashar
  • 26. Aboubakr Elnashar
  • 27. Prolonged latent phase Define Freidman: > 20 h in PG, > 14 h in MG from onset of labor (difficult to determine) Philpott: > 6h in PG, > 4h in MG from admission in labor. (8 & 6) Incidence PG: 4% MG: 1% Aboubakr Elnashar
  • 28. Etiology 1. Wrong diagnosis of labor 2. Excess sedation 3. An abnormal or high presenting part 4. PROM 5.Idiopathic. Aboubakr Elnashar
  • 29. Risks If membranes are intact, no risk , only maternal anxiety. Risks are created by aggressive intervention. Aboubakr Elnashar
  • 30. Management •Oxytocin augmentation: does not increase vaginal delivery rate, 10 fold increase in CS rate increase in low Apgar score (WHO, 1994) {Ib} •Careful explaination •Adequate analgesia Aboubakr Elnashar
  • 31. Primary dysfunctional labor Define •Cx. Dil. < 1cm/h before normal active phase has been established •Poor progress during active phase of labour: cervical dil <1 cm/h for 2 consecutive hrs. Aboubakr Elnashar
  • 32. Primary dysfunctional labour Prolonged active phase of labour Aboubakr Elnashar
  • 33. Primary dys labour [inadequate uterine contractions} corrected with oxytocin Aboubakr Elnashar
  • 34. Incidence PG: 25% MG: 8% Etiology 1. Poor/inco-ordinate C: the commonest 2. CPD: 1/ 3 3. Malpresentation or malposition Aboubakr Elnashar
  • 35. Risks 1. F. distress 2. Maternal fear & anxiety, dehydration & acidosis 3. Obstructed labour, maternal infection, uterine rupture & pph {II}. Aboubakr Elnashar
  • 36. Management •Exclude CPD, ARM + oxytocin drip. CS: No progress for 2 to 4 h (regardless of oxytocin dosage or duration of oxytocin) after adequate contraction pattern has been achieved on maximum oxytocin dose (NCH,2004) Aboubakr Elnashar
  • 37. 2ndry arrest of labor Define •Cessation of cervical dilatation following a normal period of active phase dilatation •Active phase started normally( cervical dilatation reached 5-7 cm ) then cervical dilatation stop or slows significantly within 2 h Incidence PG: 6% MG: 2% Aboubakr Elnashar
  • 38. Etiology Any factor implicated in PDL 1.CPD: 50% 2. Malposition Risks F. distress: rare Aboubakr Elnashar
  • 39. Management •Exclude CPD, ARM & Syntocinon drip CS: No progress after 4 h O, Driscol advised oxytocin regardless of pelvimetry. Aboubakr Elnashar
  • 40. SECONDARY ARREST Aboubakr Elnashar
  • 41. 0 1 2 3 4 5 6 71 4 7 10 13 16 19 Prolonged latent phase Primary dysfunctional labor Secondary arrest Cervical dilatation (cm) Time (hours) Types of dysfunctional Aboubakr Elnashar
  • 42. Prolonged deceleration phase (secondary arrest in declarative phase) Define Arrest or slow of cervical dilatation after 8 cm (PG > 3h , MG > 1h) Etiology 1. CPD 2. Uterine exhaustion Risks High incidence of shoulder dystocia Treatment Syntocinon is not helpful. C.S. Aboubakr Elnashar
  • 43. Stage II Labor • Assessment at least every 30 minutes x2: 1. Descent of the fetus (>1 cm/h). 2. Rotation of the fetus. Aboubakr Elnashar
  • 44. • If no progress in Stage II: (NCH, 2004) 1. Evaluation of mat position & f position. 2. Change mat position 3. Evaluation of fluid balance 4. Oxytocin augmentation unless contraindicated 5. When the above measures fail: operative vaginal delivery (vacuum extraction or mid/low forceps) unless contraindicated. Aboubakr Elnashar
  • 45. Contraindications of Vacuum extraction: Presenting part is too high Doctor is inexperienced F distress with inability to do timely operative vaginal delivery Patient refuses When using vacuum extraction or forceps application with a suspected macrosomic infant, be aware of the risk of shoulder dystocia. 6. CS Aboubakr Elnashar
  • 46. Prevention O,Driscol method of active management of labor (1969) • Diagnosis of labor • 1 h: ARM • 2h: cervical dil <1 cm /h: oxytocin drip Aboubakr Elnashar
  • 47. Active management of labor •First introduced by O, Driscol et al (1969) in Dublin. •Many modifications Aboubakr Elnashar
  • 48. Protocol 1.This approach to management is confined to nulliparas. 2. Patient education during pregnancy: signs & symptoms of labor Aboubakr Elnashar
  • 49. 3.Strict criteria for diagnosis of labor: • Painful ut contractions as well as complete effacement of the cervix, ROM or passage of blood stained mucous The diagnosis of labor is made within 1 hr of presentation. Spontaneous contractions at least 2/15 min & at least 2 of the following: Complete effacement of cervix Cervical dilation 3 cm or greater SROM (NGC,2004) Aboubakr Elnashar
  • 50. 4.Each woman in labor is assigned to trained professional companion. 5.Amniotomy within 1 hr of admission. Contraindications (NGC,2004): Presentation unknown, floating or unstable Cervix dilated <3 cm Patient refuses Aboubakr Elnashar
  • 51. 6.Strict criteria for diagnosis of abnormal labor progress: partogram or labor graph. Cervical checks should indicate at least 1 cm/h. {Frequent cervical checks afford the best opportunity for prevention of failure to progress}. Aboubakr Elnashar
  • 52. 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. Aboubakr Elnashar
  • 53. 8.Assess FHR by auscultation intermittently Continuous electronic FHR monitoring is used only if there is meconium stained AF. Aboubakr Elnashar
  • 54. 9.All methods of pain relief are freely available. •Parenteral analgesics: nalbuphine hydrochloride [Nubain], butorphanol tartrate [Stadol], meperidine [Demerol], or Hydroxyzine hydrochloride [Vistaril] •Epidural or intrathecal narcotics for patients in active progressing labor Aboubakr Elnashar
  • 55. 10. C.S: a. No delivery12 hr post admission b. Fetal scalp ph sampling revealed fetal compromise. Aboubakr Elnashar
  • 56. Benefits 1.Prevention of dysfunctional labor. 2.Decrease the incidence of prolonged labor from 30% to 7% (Boylan,1997) 3. Decrease mat infectious morbidity 4. Decrease incidence of operative delivery. Not confirmed by other studies 4. Decrease incidence of C.S to 4.8% (Lopez-Zeno,1992). Some found no decrease (Fraser et al,1993) others found an increase (Boylan et al,1993). Aboubakr Elnashar
  • 57. Recommendations Aboubakr Elnashar
  • 58. The Cochrane Library (Fraser et al, 2001) Routine early amniotomy • Reduction in: 1. Labor duration (between 60 and 120 min) 2. Use of oxytocin 3. Abnormal 5-min Apgar scores. • Increase in: CS for fetal distress Amniotomy should be reserved for women with abnormal labor progress. Aboubakr Elnashar
  • 59. NICE (Sept, 2007) • Active management of labour (one-to-one continuous support; strict definition of established labour; early routine amniotomy; oxytocin if labour becomes slow) should not be offered routinely. •In normally progressing labour, amniotomy should not be performed routinely. •Combined early amniotomy with use of oxytocin should not be used routinely. Aboubakr Elnashar
  • 60. Aboubakr Elnashar
  • 61. Benha University Hospital, Egypt Email: elnashar53@hotmail.com Aboubakr Elnashar