This document discusses abnormal labor and delivery, including induction and augmentation of labor. It describes various methods for inducing labor, including medical methods using oxytocin or prostaglandins, and surgical methods like amniotomy. It lists many indications for inducing labor. It also discusses factors that make induction more likely to be successful, like cervical status and gestational age. Complications of induction and prolonged labor are outlined. Nursing care during induced and prolonged labor is also summarized.

1. Chapter two
ABNORMAL LABOR
AND DELIVERY
BY GEBREMARYAM T BSC MW

2. Induction and
Augmentation of Labor

3. Cont…
Induction: - Induction is the initiation of labour by
artificial means for medical or obstetric reasons.
Labour is induced when it is considered that the
health or well being of the mother and or fetus
would be adversely affected if the pregnancy
continued.
Augmentation: - Is to increase or to speed it up
when the progress of labour is slow. Also known as
acceleration of labour.

4. Cont…
1. Induction of labour
Labour is induced by the following three
methods
1. Medical
By giving intravenous oxytocin infusion
(syntocinon)
By administering prostaglandin orally and vaginaly
2. Surgical (ARM) – also known as amniotomy.
Rupture of the membranes is performed to
stimulate uterine contraction. Usually ruptured
using an amnihook (Kocher’s)
3. Combination of the two methods above

5. Indications for induction
1. Prolonged pregnancy
After 42 weeks of gestation the rate of placental
deterioration is increase and the well being of the fetus
is in danger due to placental insufficiency.
2. Pre – eclampsia
Done that maternal health is at risk due to pre –
eclampsia
Fetus from placental insufficiency.
Due to fear of placental insufficiency induction is done
after 37 wks completed in pre eclampsia.
If the pre – eclampsia is serious for the fetus and
mother it is done before 30 wks
If persistent protein urea is presentation induction is
done at after 34 wks completed.

6. [
3. Evidence of diminished fetal well – being.
Placental insufficiency severe enough to affect fetal
well – being is characterized by intra uterine growth
retardation.
Reduced fetal movements and movements and
abnormal fetal heart sound is the diagnostic
measure.
4. The older primigravida
Placental insufficiency is more common in
primigravida aged over 35 years. For this reason
induction is recommended at term to avoid
additional risk to the fetus.

7. 5. Poor obstetric history
Still birth or IUGR in a previous pregnancy tends
to recur so induction is done at term.
6. Spontaneous rupture of membranes. If the
membranes rupture spontaneously after 34 weeks
gestation and labour does not commence with in 12
– 24 hours it should be induced due to fear of intra
– uterine infection.
7. Previous large baby
A previous baby whose birth weight was over 4 kg
may indicate the need for induction between 38 –
40 weeks of gestation.

8. 8. Diabetes mellitus
Necessary to induce labour between 36 and 38
weeks of gestation for fear of IUFD and fetal
macrosomia. If good control is not achieved during
pregnancy.
9. Rhesus – Iso – immunization
When rhesus antibodies are present it is then
necessary to induce labour to arrest haemolysis.

9. 10. Unstable – lie – after correction
If placenta praevia and pelvic abnormalities have
been excluded as causes of unstable lie labour may
induced after the lie has been corrected and made
longitudinal and cephalic presentation.
11. Genital herpes
In a woman with a history of genital herpes labour
is frequently induced if the disease in remission
after 38 wks. This avoids c/s for active herpes at the
onset of spontaneous labour.

10. 12. Previous precipitate labour
As precipitate labour tends to recur induction is
sometimes performed at 38 weeks.
13. Placental abruption
Once maternal shock has been treated by
intravenous fluid replacement it is usual to induce
labour by ARM. This relieves increased intra –
uterine pressure caused by retro placental
hemorrhage and controls bleeding by allowing the
uterus to contract and empty

11. 14.Social reasons.
Some times a woman may wish the baby to be born
for family reasons or simply because she is fed up.
15. Intra – uterine death
Labour may be induced once IUFD has been
confirmed due to fear of coagulation defects.

12. Contra indications of induction
In general any condition that is contraindication for
spontaneous labor and vaginal delivery should be
contra indication for induction of labor. Contra
indications may include but are not limited to the
following.

13. Absolute contra indications
Gross CPD
Transverse and oblique lie
Footling breech
Upper segment uterine scar
Active genital herpes
Extensive genital wart
Pelvic tumor obstructing the birth canal
Placenta praevia
Acute fetal distress
Two or more previous lower uterine segment
cesarean scar

14. Relative contra indications
Grande multiparity
Bad obstetric history
Twin pregnancy
Prematurity
Macrosomia
One previous lower segment c/s

15. Favorable factors for induction
The successful induction of labour depend up on
The period of gestation.
When gestation is more than 38 weeks induction of
labour is more likely successful as the nearer to term
of pregnancy.
Level of presenting part
When three – fifths of the head or less is palpable
above the pelvic brim
Sensitivity of the uterus
Condition of the cervix -If cervix is well effaced
induction is successful

16. Bishop Score
Defn - A method of assessing the favorability of the
cervix prior to induction of labour.
Five different features are considered and each is a
warded a score of between 0 and 3.

17. Bishop’s Score
Parameters) 0 1 2 3
1 Dilatation of Cx Closed 1 – 2 3 – 4 5 – 6
2 Consistency of Cx Firm Medium Soft
3 Effacement of Cx 0 – 30% 40 – 50% 60 – 70% Above 80%
4 Position of the Cx Posterior Midline Anterior
5 Station of the
presenting part
- 3 -2 -1 , 0 +1, +2

18. If the score is 6 and above the condition of
the cervix favorable for induction.
If the score is 5 and below the condition of the cervix
is unfavorable for induction.

19. Preparation for induction of labour
Psychological preparation
Liaison with other department
- Involve specialist such as pediatrician and
diabetic team
Bowel preparation
- Enema if the woman is constipated
Admit pt 2 hrs before handle
Empty bladder

20. Induction of labour by oxytocin infusion
A. For multi para mother
1. Add 2 unit of oxytocin in 1000 ml of D/W running
at 10 drops/min if no contraction double the drop
every 20 min until it reaches 80 drops.
2. If no contraction add 2 unit of oxytocin in the
same bag and start with 40 drops and double the
drop after 20 min if no contraction and stop at
80drops.
3. If no contraction add again another 2 unit in the
same bag and start with 40 drops and double the
drop after 20 min if no contraction and stop at
80drops. The maximum dose for multi
gravida mother is 6 units.

21. B. For primigravida mother
1. Add 5 unit oxytocin in 1000ml of D/W running 10
drops/min if no contraction doubles the drop every
20 min always stop at 80drops.
2. If no contraction add 5 unit oxytocin in the same
bag and start with 40drops and double the drop
after 20 min if no contraction. Always stop at
80drops
3. If no contraction add again another 5 unit
oxytocin in the same bag and start with 40 drops
and double the drop after 20 min if no contraction.
Always stop at 80drops. The maximum dose
for primigravida mother is 15 units

22. The aim to increase oxytocin drop is to achieve 3 – 5
contraction per 10 min lasting up to 40 – 60
seconds.
Indication to stop the oxytocin drip
Fetal distress
Deterioration in maternal condition
Strong and frequent contraction with no relaxation
Strong contractions lasting over 60 seconds

23. Indications for oxytocin drip
To induce labour (start)
To accelerate (quicken) = augmentation of labour
To prevent or treat PPH

24. Nursing care and observation
Set up drip as instructed by the doctor and control the
rate of flow
Label and attach the following on the bag. Oxytocin
unit, dose, time, started
Check FHB every 15 min
B/P and pulse every 30 min
Temperature every 4 hrs
Check contraction every 30 min
Empty bladder
Urine test for ketones
Anti pain
Watch the progress of labour on the partograph
Control input and out put

25. Complications of induction
1. Over stimulation of the uterus
Results in strong contractions which last more
than 60 seconds and occur more frequently.
Relaxation between contractions is inadequate.
2. Ruptured uterus
- May result from over stimulation if any CPD is
present
3. Amniotic fluid embolism – rare
Which may be caused by strong contraction

26. Fetal distress
Cord prolapse
Premature separation of placenta
Infection
Prematurity
Unforeseen CPD leading to obstructed labor

27. Surgical induction methods
1. Sweep membrane
Is when the chorion is separated the cervix by the
finger. This is a simple and often successful
procedure. When Cx ripe
2. Amniotomy
Usually done in conjunction with synotocinon drip.
Problem is that once the membranes are ruptured
if labour doesn’t start c/s will have to be done
usually after 24 hours of ARM

28. Contra indications
High head
Unripe cervix
Malpresentaiton
IUFD (danger of infection)

29. Preparation for amniotomy
Make sure bladder is empty
Check FHB
Careful abdominal palpation
Explain the procedure
Place in lithotomic position
After rupture avoid frequent vaginal examination
because danger of infection.
Procedure
Finger in inserted in to the cervix by holding
amniotomy forceps or kocher’s and then ruptures
the fore waters.

30. 2. Augmentation of labor
Defn - correction of dystocia due to inefficient uterine
contraction (power) by the use of oxytocin
Indication
Poor progress of labor due to inefficient uterine
contractions.

31. Contra indications
Breech presentation
CPD
Malpositions
Invasive cervical Ca
Active genital herpes infection
Outlet and mid pelvis contracture
None – reassuring FHB pattern and fetal
macrosomia

32. Conditions to be fulfilled
Proper evaluation of the fetus and mother to rule out
contra indications
Maternal dehydration, positioning
The capacity to do emergency c/s
Get an informed consent

33. Procedure
Do ARM aseptically if membrane is intact
Start oxytocin infusion
 Add 1 IU of oxytocin to 1000 ml of RL
 Start with 0.5 mu/min for multipara and 1 mu/min for
primigravida
 The rate of increment should be 1 mu/min every 30min up
to maximum dose of 20 mu/min
NB: Dose of oxytocin is half of the dose for induction
otherwise similar procedure

34. Prolonged labor

35. Prolonged Labour
Defn
Traditionally labour is prolonged if it exceeds 24
hours. When labour is actively managed it is
termed prolonged if delivery is not imminent after
12 hours of established labour.
NB - Transfer a patient to hospital from health
center
Primigravida at 18 hours
Multigravida at 12 hours
Or transfer the woman to hospital when the
progress crosses alert line on the pantograph.

36. Causes of prolonged labour (4 P’s are the
main causes)
1. Passenger (The fetus) like
Big baby
Mal position (OPP)
Mal presentation
Congenital abnormalities (Hydrocephaly)
CPD

37. 2. Passages (The pelvic)
Abnormality of size, shape, of pelvis (Android)
Disease or injury of pelvis (Rickets)
Congenital abnormality pelvis
CPD

38. 3. Powers (uterine contractions)
 Inefficient uterine contractions (Hypotonic uterine action).
This is the most common causes of prolonged labour.
4. Psychological causes
 Abnormally tense or apprehensive women tend to have
prolonged labour. This phenomenon affects primigravida more
often than multigravida.

39. Causes of a prolonged second stage of labour
1. Hypotonic contraction
- Secondary hypotonic contraction may cause delay
2. In effective maternal effort
Fear exhaustion or lack of sensation may inhibit a
woman’s ability to push and cause delay especially
in a primigravida.
3. A rigid perineum
May prevent the advance of the fetus during the
perineal phase. If this is evident an episiotomy is
performed

40. 4. Reduced pelvic outlet
Android pelvis is the most likely cause of obstruction
at the outlet due to it’s prominent ischial spines and
narrow sub pubic arch. A forceps delivery is
performed.
5. A large fetus
6. OPP

41. Management of prolonged labor
With the principle of” The sun should not set twice
in woman in labor”
1. Acceleration of labour
Doctor may order oxytocic drug in Iv drip and rupture
membranes provided there is no disproportion.
2. C/S may be decided on depending the finding like if
Any disproportion
Condition of the mother and fetus
The history of the pt will play a part in the decision
3. Enema may be repeated provided head descending
4. Instrumental delivery

42. Nursing care during labour is prolonged
1. Be kind to mother, reassure her, encourage here and
explain to her what is happening if you do this the
mother will be co – operative with you
2. Keep her as clean and dry as possible
3. Keep her bladder empty. Test urine for albumin and
ketones
4. Don’t allow the woman to become dehydrated or
prevent ketoacidosis

43. 5. Observe the following
Dilatation of Cx
Descent of the head
Contractions
General condition of the pt
B/p every 4 hrs
FHB and maternal pulse every 15 min

44. Complications of prolonged labour
1. Maternal
Intera – uterine infection
Acidosis and dehydration
Vesico vaginal fistula
Ruptured uterus
PPH
Cystocele, rectocele, and prolapse of uterus ( comes
due to over stretching of uterus)

45. 2. Fetal
Intera – uterine hypoxia
IUFD
Intra – uterine infection
Intra cranial hemorrhage

46. Prolonged 1st stage labour classified in to two
1. Prolonged latent phase
The cervix effaces and dilatation occurs
The average duration of the latent phase in
nulliparous women was 8.6 hours and if it lasted
20 hours or more it should be considered as
prolonged.
The latent phase of labor is still poorly understood
and it’s duration difficult to define.

47. 2. Prolonged active phase
A rate of 1cm per hour is most commonly used. A
prolonged active phase is caused by a combination of
factors including the Cx, uterus, fetus and the
mother’s pelvis.

48. Obstructed Labor

49. Obstructed Labor
Defn - Where there is no advance of the presenting
part in spite of good uterine contractions. It is the
fault of the passages or passenger but not the
power.
Obstructed labour should not occur and does not
occur when competent obstetric supervision and
service is available

50. Causes of obstructed labour
Contracted pelvis
Big baby
Major CPD
OPP (Deep transverse arrest)
Malpresentation (Brow, face, shoulder)
Malformation (Hydrocephalus)
Pelvic tumors
Locked and conjoined twins

51. Signs and symptoms of obstructed labour
1. Early signs
The presenting part does not enter the brim in
spite of good uterine contractions (about 6 – 8 hrs)
The cervix dilates slowly and is edematous (thick)
and hangs loosely like an empty sleeve.
Cervix is badly applied to the presenting part
Membranes rupture early

52. NB - The midwife must be able to recognize at this
stage. And she should sedate her and transfer her as
soon as possible.

53. 2. Late signs
A. Maternal condition
Signs of dehydration and ketosis develop
Raised pulse and temperature
Vomiting and restlessness
Oligouria
B. Fetal condition
Change in the fetal heart rate and rhythm
Meconium is passed in a vertex presentation
Excessive fetal movement
Excessive caput and moulding

54. C. Abdominal examination
The abdomen is tense. Tender, and hard to palpate
The contractions are long, strong with little or no
relaxation between them. Some times the
contraction stop as the uterus exhausted.
Bandl’s ring is seen rising to the level of the
umbilicus showing that the lower uterine segment is
very thin and ready to rupture.

55. D. Vaginal examination
The presenting part is wedged (stuck) usually in
the pelvic brim and there will be excessive caput
and Moulding felt
Cervix is loose and edematous and hangs like an
empty sleeve
The vagina is hot and dry
There will be meconium stained liquor and
meconium on the finger
Edematous vulva and cervix (Kanula syndrome)

56. Dangers of Obstructed Labour
A. Mather
Rupture of the uterus
Hemorrhage
Shock
Death
Vesico vaginal fistula
B. Fetal
Meconium aspiration
Still birth
Neonatal death
Asphyxia
Infection (Ascending)

57. Management of obstructed labour
Caesarean section if baby is a live
Intra venous fluid
Blood group and cross matching
Pass a catheter
Reassurance
Antibiotics
Craniotomy if fetus is dead
Decapitation if shoulder presentation & dead

58. Prevention of obstructed labour
A. During pregnancy
Select high risk patient for hospital delivery
Pelvic assessment at 36 wks for all primigravida
Careful antenatal follow up

59. B. During labor
Careful observations on all women in labor noting
how the head is descending how the cervix is dilating
and it’s state. Beware of any woman who has had a
previous still birth or instrumental delivery if you get
mother in such condition refer her as soon as
possible after you do the following:

60. IV infusion must be commenced
Start antibiotics
Send blood donors
Check uterus is not ruptured
Bladder drainage (Folly catheter for about 10-14 days
to prevent VVF)
Antipain or sedative

61. Obstetric Anesthesia
BY GT BSC MW

62. Obstetric anesthesia
Obstetrical anesthesia presents unique challenges.
Labor begins without warning, and anesthesia may
be required within minutes of a full meal. Vomiting
with aspiration of gastric contents is a constant
threat.
The usual physiological adaptations of pregnancy
require special consideration, especially with
disorders such as preeclampsia, placental abruption,
or sepsis syndrome.

63. Cont…
Anesthesia complications caused 1.6 percent of
pregnancy-related maternal deaths in the United
States from 1991 through 1997.

64. Role of obstetricians
Every obstetrician should be proficient in local and
pudendal analgesia that may be administered in
appropriately selected circumstances.
In general, however, it is preferable for an
anesthesiologist or anesthetist to provide pain relief
so that the obstetrician can focus attention on the
laboring woman and her fetus.
General anesthesia should be administered only by
those with special training.

65. Principles of Pain Relief
The experience of labor pain is a highly individual
reflection of variable stimuli that are uniquely
received and interpreted by each woman.
These stimuli are modified by emotional,
motivational, cognitive, social, and cultural
circumstances.

66. Cont…
The complexity and individuality of the experience
suggest that a woman and her caregivers may have a
limited ability to anticipate her pain experience prior
to labor.
Thus, choice among a variety of methods of pain
relief is desirable

67. NONPHARMACOLOGICAL METHODS OF
PAIN CONTROL
Fear and the unknown potentiate pain.
A woman who is free from fear, and who has
confidence in the obstetrical staff that cares for her,
usually requires smaller amounts of analgesia.
The intensity of pain during labor is related in large
measure to emotional tension.

68. Cont…
The urged that women be well informed about the
physiology of parturition and the various hospital
procedures they may experience during labor and
delivery.
Pain often can be lessened by teaching pregnant
women relaxed breathing and their labor partners
psychological support techniques.
These concepts have considerably reduced the use of
potent analgesic, sedative, and amnesic drugs during
labor and delivery.

69. cont…
When motivated women have been prepared for
childbirth, pain and anxiety during labor have been
found to be diminished significantly, and labors are
even shorter.
In addition, the presence of a supportive spouse or
other family member, of conscientious labor
attendants, and of a considerate obstetrician who
instills confidence have all been found to be of
considerable benefit.

70. Pharmacological therapy
Meperidine 25–50 mg (IV) every 2–4 hr 5 min
onset of action (IV) or 50–100 mg (IM) every 1–2 hr
have onset of action 30–45 min (IM)
Fentanyl 50–100 g (IV) every 1 hr onset of action
after 1 min
Nalbuphine 10 mg (IV or IM) every 3 hr onset of
action after 2–3 min (IV) or after 15 min (IM)
Butorphanol 1–2 mg (IV or IM) every 4 hr

71. Obstetric Anesthesia Cont…
1. General Anesthesia
Defn - When a state of unconsciousness is induced but
which may also involve giving some analgesia.
Agents used in general anesthesia
A. In halation anesthesia
Gas anesthetics (Nitrous oxide) may be used to
provide pain relief during labor as well as at delivery. The
agents produce analgesia and altered consciousness.
The gases are connected to a breathing circuit through a
valve that opens only when the patient inspires.
Volatile anesthetics (halothane)

72. Cont…
B. Intravenous drugs during anesthesia
Thiopental:- given IV and widely used in conjunction
with other agents for general anesthesia
Ketamine:- given IV in low doses of 0.2 to 0.3 mg/kg
this drug is used to produce analgesia and sedation
just prior to delivery.

73. Cont…
Mendelson’s syndrome
This is when general anesthesia is induced silent
regurgitation may easily occur unnoticed and if acid
stomach contents are then aspirated in to the lungs a
condition known as Mendelson’s syndrome. (When
acid gastric juice is inhaled during general
anesthesia).

74. Cont…
Sign and symptoms of Mendelson’s Syndrome
Patient become restless
Dyspnoea
Bronchospasm
Cyanosis
Tachycardia
Hypotension
Pulmonary edema
Death

75. Cont…
Prevention
NPO if patient is high risk
Give antacid if patient going for general anesthesia
Empty a full stomach/ NG tube in place
Cricoid pressure:- pressure on the one complete ring
of tracheal cartilage to occlude the esophagus so
preventing acid reflex

76. Cont….
Management
1. Obstetric emergency
Head down
Aspirate secretion
Artificial respiration
Oxygen
2. Antibiotics
For chemical pneumonia
3. Steroids
To inhibit inflammatory reaction

77. Cont…
B. Failed intubations
This may occur when there may be some laryngeal
edema, poor mouth opening and a fat or stiff neck or
large breasts may also contribute to difficulty with
intubations.
Prevention
Pre oxygenate every pregnant woman prior to
induction of anesthesia

78. Cont…
C. Supine hypertensive syndrome (aortacaval
occlusing)
This occur when the weight of the gravid uterus
occluding the inferior vanacava with supine position.
Prevention
Ensure that she is tilted laterally either by means of a
small rubber wedge under the mattress or by placing
a folded blanket under one buttock.

79. Cont…
Regional anesthesia
Defn - When a group of nerve is anaesthetized, so giving
an area of anesthesia. Various nerve blocks have been
developed over the years to provide pain relief during
labor and delivery.
They are correctly referred to as regional analgesics.
Types of regional anesthesia
1. Epidural anesthesia
This is the commonest type of approach and there are
different techniques when may be used.
The anesthetic is introduced between lumbar vertebrae
3 and 4 or 2 and 3.

80. Cont…
Indication
Maternal request
Malposition
Malpresentation
PIH
Multiple pregnancy

81. Cont…
Spinal anesthesia
Is a technique by which local anesthetic solution is
injected in to the subarachnoid space that is in to the
CSF.
Advantages include a short procedure time, rapid
onset of blockade, and high success rate.
Indication
Caesarean section
Forceps or vacuum delivery

82. Vaginal delivery
Vaginal Delivery Low spinal block can be used for
forceps or vacuum delivery.
The level of analgesia should extend to the T10
dermatome, which corresponds to the level of the
umbilicus.
Blockade to this level provides excellent relief from
the pain of uterine contractions

83. Cesarean Delivery
A level of sensory blockade extending to the T4
dermatome is desired for cesarean delivery
Depending on maternal size, 10 to 12 mg of
bupivacaine in a hyperbaric solution or 50 to 75 mg
of lidocaine hyperbaric solution are administered.
The addition of 20 to 25 mg of fentanyl increases the
rapidity of blockade onset and reduces shivering.
The addition of 0.2 mg of morphine improves pain
control during delivery and postoperatively.

84. Cont…
3
3 Pudendal block
This is a technique used to anaesthetize the specific area
served by the pudendal nerve.
Local anesthetic solution is injected adjacent to the
pudendal nerves as they pass close to the ischial spine.
Within 3 to 4 minutes of injection, the successful
pudendal block will allow pinching of the lower vagina
and posterior vulva bilaterally without pain.
4

85. Cont…
If delivery occurs before the pudendal block
becomes effective and an episiotomy is indicated,
then the fourchette, perineum, and adjacent vagina
can be in- filtrated with 5 to 10 mL of 1-percent
lidocaine solution directly at the site where the
episiotomy is to be made.
By the time of the repair, the pudendal block
usually has become effective

86. cont…
4 Paracervical block
In this technique the paracervical plexuses are
blocked.
This gives pain relief for the first stage of labor.
The local anesthetic solution is injected to 3 or 9 a
clock on the cervix.
Because the pudendal nerves are not blocked,
however, additional analgesia is required for
delivery.

87. Cont…
Local anesthesia
Defn - When a small specific area is anaesthetized.
This is the most common instance of use of local
anesthesia for the midwife, who may undertake it
herself prior to performing or repairing an
episiotomy
The drug in most common use is
lignocaine/Lidocaine/.