poor progress of labour


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poor progress of labour

  1. 1. POOR PROGRESS OF LABOUR Dr.M.Thirukumar Consultant obstetrician and Gynaecologist Teaching Hospital Batticaloa
  2. 2. What is the importance? <ul><li>1/3 of caesarean section, mainly in nulliparous –due to poor progress of labour. </li></ul><ul><li>Uncommon in multiparous- only in 2% </li></ul><ul><li>The rates of dystocia differs among practitioners mainly due to difference in labour management. </li></ul><ul><li>Success in decreasing the incidence of dystocia among nulliparous will have impact on overall rate of caesareans birth </li></ul>
  3. 3. Labour <ul><li>Regular, frequent uterine contraction which leads to progressive cervical effacement and dilatation </li></ul><ul><li>to culminate progressive descend of fetus to have vaginal delivery. </li></ul>
  4. 4. Progress of Labour <ul><li>Effacement (thinning) </li></ul><ul><li>Dilatation (opening) </li></ul><ul><li>Descent (progress through the birth canal) </li></ul><ul><li>Delivery of the baby and placenta </li></ul>
  5. 5. The Labour Curve <ul><li>First stage - A: latent phase; B + C + D: active phase; B: acceleration; C: maximum slope of dilation; D: deceleration; E: second stage. Adapted from: Friedman. Labor: Clinical evaluation and management, 2nd ed, Appleton, New York 1978. </li></ul>
  6. 6. Definition of the first stage <ul><li>Latent first stage of labour – when </li></ul><ul><li>-there are painful contractions, and </li></ul><ul><li>-there is some cervical change, including cervical effacement and dilatation up to 4 cm. </li></ul><ul><li>Established first stage of labour – when: </li></ul><ul><li>regular painful contractions, and </li></ul><ul><li>progressive cervical dilatation from 4 cm. </li></ul>
  7. 7. Disorders of labour <ul><li>3 major disorders </li></ul><ul><li>1)prolonged latent phase </li></ul><ul><li>2)primary dysfunctional labour </li></ul><ul><li>3)secondary arrest </li></ul>
  8. 9. Latent Phase Labour <ul><li><4 cm dilated </li></ul><ul><li>Contractions may or may not be painful </li></ul><ul><li>Dilate very slowly </li></ul><ul><li>Can talk or laugh through contractions </li></ul><ul><li>May last days or longer </li></ul><ul><li>May be treated with sedation, hydration, ambulation or rest. </li></ul>
  9. 10. <ul><li>During latent phase changes occurs in </li></ul><ul><li>-collagen content of the cervix </li></ul><ul><li>-ground substance of the cervix </li></ul><ul><li>-hydration state of the cervix </li></ul><ul><li>so remodelling effacement of the cervix occur </li></ul>
  10. 11. <ul><li>Duration of latent phase </li></ul><ul><li>Primi -20 hours(average-8.6 hours) </li></ul><ul><li>Multi -14 hours(average 5.3 hours) </li></ul>
  11. 12. Management of latent phase <ul><li>Reassurance </li></ul><ul><li>Pain relief </li></ul><ul><li>Mobilisation </li></ul><ul><li>Augmentation with oxytocin increases </li></ul><ul><li>-caesarean rates by 10 fold </li></ul><ul><li>-3 fold increase in law apgar score </li></ul>
  12. 13. Active Phase Labour <ul><li>At least 4 cm dilated </li></ul><ul><li>Regular, frequent, usually painful contractions </li></ul><ul><li>Dilate at least 1.2-1.5 cm/hr </li></ul><ul><li>Are not comfortable with talking or laughing during their contractions </li></ul>
  13. 14. Duration of the first stage <ul><li>varies between women, </li></ul><ul><li>first labours last on average 8 hours and are unlikely to last over 18 hours. </li></ul><ul><li>Second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours. </li></ul>
  14. 15. Definition of delay in the established first stage <ul><li>needs to take into consideration all aspects of progress in labour and should include: </li></ul><ul><li>cervical dilatation of less than 2 cm in 4 hours for first labours </li></ul><ul><li>cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours </li></ul>
  15. 16. <ul><li>descent and rotation of the fetal head </li></ul><ul><li>changes in the strength, duration and frequency of uterine contractions. </li></ul>
  16. 17. Primary dysfunctional labour <ul><li>Poor progress in active phase of labour(up to 7 cm dilation of the cervix) </li></ul><ul><li>Affects 26% of nullipara </li></ul><ul><li>8% of multipara </li></ul>
  17. 18. Causes of dystocia <ul><li>1)inefficient uterine activity is a significant factor. Due to </li></ul><ul><li>-induction of labour </li></ul><ul><li>-inadequate stimulation of contraction </li></ul><ul><li>-failure of uterine response to stimulation </li></ul><ul><li>2) relative disproportion due to deflexion of the fetal head-OPP,asynclitism,inaduate cephalic flexion </li></ul>
  18. 19. <ul><li>3) Cephalo pelvic dispropotion </li></ul>
  19. 20. Possible outcome of primary dysfunctional labour <ul><li>It leads to-obstructed labour </li></ul><ul><li>- infection </li></ul><ul><li>- uterine rupture </li></ul><ul><li>-PPH </li></ul><ul><li>70% of nullipara and 80% of multipara will respond to oxytocin </li></ul>
  20. 21. Secondary arrest <ul><li>Cessation of cervical dilation following a normal period of active phase dilatation. </li></ul><ul><li>i.e after 7 cm of cervical dilation </li></ul><ul><li>Affects 6% of nulliparae and 2 % of multiparae </li></ul><ul><li>CPD is more likely to be associated with it </li></ul>
  21. 22. Assessment in secondary arrest <ul><li>1) fetal size-fundal height >40 cm in this stage is due to large baby </li></ul><ul><li>2)degree of engagement(fifth palpable) </li></ul><ul><li>3)position of the presenting part </li></ul><ul><li>4)signs of obstruction </li></ul><ul><li>5)any pelvic mass </li></ul>
  22. 23. <ul><li>6)descent of presenting part with contraction </li></ul><ul><li>7)contraction frequency </li></ul><ul><li>8)fetal well being </li></ul>
  23. 24. station <ul><li>SO assess following before any intervention </li></ul><ul><li>1)EFW-fundal height > 40 cm at this stage is large baby </li></ul><ul><li>2)Degree of engagement </li></ul><ul><li>3)Position of the presenting part </li></ul><ul><li>4)Evidence of obstruction </li></ul><ul><li>5)Any pelvic mass </li></ul>
  24. 25. Engagement <ul><li>entrance of the largest diameter of the presenting part into the true pelvis. </li></ul><ul><li>In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. </li></ul><ul><li>Once engaged, fetus does not go back up. Prior to engagement occurring, the fetus is said to be &quot;floating&quot; or ballottable. </li></ul>
  25. 26. Position of the presenting part <ul><li>Determine by COUNTING SUTURE TECHNIQE </li></ul><ul><li>Junction of 3 suture lines is posterior fontanel </li></ul><ul><li>Junction of 4 suture lines-anterior fontanel </li></ul>
  26. 28. Occiput transverse positions   Occiput anterior positions   Fetal position
  27. 29. Degree of flexion/Attitude <ul><li>If only posterior fontanel is felt-it is well flexed fetal head. Here the cervix is regularly dilated </li></ul><ul><li>If only anterior fontanel is felt-It is deflexed head(face /mento vertex presentation) </li></ul><ul><li>If both fontanels are felt .-it is partially deflexed head. Here the cervix is also irregularly dilated </li></ul>
  28. 30. Types of attitude
  29. 31. Complete flexion- <ul><li>(a) normal attitude in cephalic presentation. &quot;chin is on his chest.&quot; This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery. </li></ul>
  30. 32. Moderate flexion <ul><li>(b) - head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway. </li></ul>
  32. 34. Poor flexion or marked extension <ul><li>. it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed. </li></ul>
  33. 35. Hyperextended <ul><li>. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally. </li></ul>
  34. 36. Asynclitism <ul><li>One parietal bone presents at a higher plane than other ,with the head in the transeverse position as it enters the pelvis. </li></ul><ul><li>Anterior asynclitism –physiological </li></ul><ul><li>Posterior asynclitism is unfavourable and may indicate dispropotion </li></ul>
  36. 39. Management of poor progress in labour <ul><li>Decide whether it is safe to continue the labour </li></ul><ul><li>If obstruction of labour / fetal distress-need operative delivery </li></ul><ul><li>decide whether expectant policy is appropriate </li></ul>
  37. 40. Management of poor progress in labour <ul><li>(1)One to one care </li></ul><ul><li>- it decreases the likelihood of medication for pain relief, instrumental delivery,C/S, </li></ul><ul><li>APGAR <7in 5 minutes </li></ul><ul><li>-encourage to adopt whatever the position comfortable-sitting, reclining,lateral semi recumbent position </li></ul>
  38. 41. <ul><li>(2) Maternal hydration and pain relief </li></ul><ul><li>-40 % of nulliparous will respond to normal saline infusion </li></ul><ul><li>-edidural or narcotics </li></ul><ul><li>(3) Mobilization </li></ul><ul><li>(4) Amniotomy – if not done earlier </li></ul>
  39. 42. <ul><li>If delay in the established first stage of labour is suspected, amniotomy should be considered for all women with intact membranes. </li></ul><ul><li>perform a vaginal examination 2 h .and if progress is less than 1 cm a diagnosis of delay is made. </li></ul>
  40. 43. <ul><li>When delay in the established first stage of labour is confirmed the use of oxytocin should be considered </li></ul>
  41. 44. 5) Oxytocin for augmentation <ul><li>-evaluate clinical situation i.e exclude obstructed labour and fetal distress .also consider maternal wishes in decision making. </li></ul><ul><li>-for poor progress due to inefficient/ in coordinate uterus contraction. </li></ul><ul><li>-60-80% of patients will respond to oxytocin by improving cervical dilation. </li></ul>
  42. 45. <ul><li>perform a vaginal examination 4 hours after commencing oxytocin in established labour. If there is less than 2 cm progress after 4 hours of oxytocin, further obstetric review is required to consider caesarean section. If there is 2 cm or more progress, vaginal examinations should be advised 4-hourly. </li></ul>
  43. 46. <ul><li>Titrate every 30 minutes till 4 contraction for 10 min with each last 40 seconds. </li></ul><ul><li>Moniter continuously –CTG </li></ul><ul><li>If augmentation exceeds 8 hours duration it is unlikely to result in successful vaginal delivery </li></ul><ul><li>8% of muliparae and 22% of nulliparae -fail to respond to oxytocin </li></ul>
  44. 47. Ways to reduce the poor progress of labour <ul><li>Correct diagnosis of labour.(Pay attention on effacement of the cervix) </li></ul><ul><li>Good midwifery care in labour room. </li></ul><ul><li>Sustaining the morale of the woman and her partner </li></ul><ul><li>Maintain hydration well </li></ul><ul><li>Provide adequate analgesia </li></ul><ul><li>maintain the partogram </li></ul>
  45. 48. <ul><li>THANK YOU </li></ul>