This document discusses abnormal labor and provides definitions and classifications of abnormal labor. It covers the four major etiologic categories that can cause abnormal labor: the passage (pelvis), the passenger (fetus), the powers (uterine action and cervical resistance), and the patient/provider. For each category it provides examples of specific conditions that can cause dystocia or difficult labor. It also discusses the importance of communication between providers and patients to prevent trauma and post-traumatic stress disorder from difficult labor experiences.

1. ABNORMAL LABOUR
Rachael annor
January 2022

2. Course Objectives
By the end of the course, the student will be
able to:
 Identify risk factors for intrapartum
complications
 Identify intrapartum disorders and deviations
from normal
 Work with the individual woman and use your
understanding of the big picture to help
maintain your focus and maximize your
impact

3. Course Objectives
 Synthesize information and develop
appropriate management plans for high
risk conditions
 Demonstrate competency in executing
emergency obstetric interventions
 Demonstrate an understanding of
consultation, collaborative management
and transfer to medical management

4. DEFINITION OF TERMS
 Abnormal labor-dysfunctional labor, which simply
means difficult labor or childbirth.
 When labor slows down, it’s called protraction of
labor.
 When labor stops altogether, it’s called arrest of
labor.
 Dystocia of labor is defined as 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).

5. DIAGNOSIS OF ABNORMAL
LABOUR
 The diagnosis of abnormal labor (dystocia) has
four major etiologic categories:
 the “passage,” or pelvic architecture; the
conditions relating to pelvis
 the “passenger,” or fetal size, presentation, and
position; the conditions relating to the fetus
 the “powers,” or uterine action and cervical
resistance; the conditions relating to the
reproductive system
 the “patient” and “provider.” Faults arising as a
result of sickness or omission

6. PASSAGE—THE OBSTETRIC
PELVIS
 During labor, the fetus assumes positions and
attitudes that are determined in part by the
configuration of the mother’s pelvis.
 The type of pelvis the individual has play a
significant role in the outcome of labour
 Of the four types of pelvis, gynecoid, android,
anthropoid, and platypelloid, the gynecoid
pelvis is most optimal for normal delivery.

7. Other abnormalities also may
affect the bony pelvis such as:
 Kyphosis, if it involves the lumbar area, may be
typically funnel-shaped pelvis, which leads to late
arrest of labor
 Scoliosis, which involves the lower region of the
spine, may produce an irregular inlet, leading to
obstructed labor
 Lameness: not contracted in cases of unilateral
lameness.
 In bilateral lameness, the pelvis is wide and short, but
most women are able to deliver vaginally
 In poliomyelitis, now extremely rare, the pelvis
may be asymmetric, but most patients can deliver
vaginally

8.  In dwarfism, cesarean delivery is generally
the rule because of marked fetopelvic
disproportion
 Cesarean sections occur more frequently in
women with a history of a pelvic fracture,
especially bilateral fracture of the pubic rami,
before pregnancy

9. Soft tissue abnormalities
 in the pelvis occasionally can result in
dystocia.
 Uterine myomas are the most common pelvic
masses associated with dystocia- it can
obstruct the birth canal or cause
Malpresentations of the fetus.
 Others: upper genital tract dystocia-ovarian
tumors, bladder distention, excess adipose
tissue, uterine malposition

10. PASSENGER—THE FETUS
 The size,
 presentation,
 and position of the fetus are important factors
in the conduct of labor.
 Pelvic size and excessive soft tissue may
influence the fetal position and presentation.

11. POWERS—UTERINE
CONTRACTILITY
 Functional dystocia has been associated with
two different types of abnormal contraction
patterns.
 Hypertonic
 This pattern is seen more often with fetal
Malpresentations and uterine over distention.
 Hypotonic uterine dysfunction is more
common and frequently responds to oxytocin.

12. PROVIDER/PATIENT
 physician factor is significant in the diagnosis of
dystocia.
 Physicians may be influenced by the patient’s attitude,
the time of day, anesthesia support, the medicolegal
climate, and their own training and experience.
 The patient’s level of anxiety and pain tolerance also
may influence the character and duration of labor.
 Medications given during labor may alter uterine
contractility. Example:
 β-Mimetics, calcium channel blockers, magnesium
sulfate, and antiprostaglandins have been used to
inhibit labor.
 Ethanol has a direct depressant effect on smooth
muscle and inhibits oxytocin release.
 Theophylline and caffeine may lead to longer labors.

13. The Context
 Maternal Mortality Ratio: number of
women who die out of every 100,000
births.
US 19, UK-9 (Word bank, 2017)
Ghana 875-2018 and 838 in 2019.
776 in 2020 despite the increase in total
deliveries
 while institutional maternal mortality
ratio reduced from 117 in 2019 to 106 in
2020 (GHS 2021)

14. The Context
 Neonatal Mortality Rate: number of babies
who die within the first month out of every
1,000 live births.
 US 4 (Unicef 2010)
 Ghana 50 (Ghana Demographic Health Survey
2008)

15. The Context
 Percentage of births attended by a skilled
attendant.
 57% (Unicef 2010)

17. For Discussion
 Evidence based practice vs. Standards of care
 Are these the same? Different? Where does
evidence come from?
 Critical thinking
 What does it mean? What does it involve?
 Role of the midwife
 What is our focus? What are our limitations?
What is our relationship with physicians? . . .

18. How do we identify deviations from
normal and determine urgency?
 Maternal vital signs
 Maternal labs
 Partograph: contractions, dilation, descent
 Fetal Heart Tone (FHT) monitoring

19. case
A primigravida reports to the labour ward
complaining of contractions.
She states that she has been contracting off and
on for three days but now the pain is “too much.”
She is 4 centimetres and so you admit her to
L&D. After 3 hours you re-examine her and find
that she is still 4 centimetres.

20. PATIENT COMMUNICATION &
PSYCHOLOGICAL EFFECTS
OF BIRTH

21. Learning Objectives
 Know communication goals in patient –
clinician relationship
 Know risk associated with traumatic birth
experiences
 Know warning signs/risk factors for potential
PTSD
 Know appropriate interventions to prevent
PTSD.

22. Communication Goals
 Patient actively participates in care
 Patient understands and able to carry out
tasks of self care
 Patient comfortable asking questions
 Patient’s needs are met
 Patient understands their condition
 Patient feels confident that they are
receiving excellent care

23. Communication Goals
 Patient understands the processes involved in
their care
 Patient feels respected
 We (clinical staff) understand the patient (i.e.
problems, needs, challenges to their health
maintenance)
 Members of the health care team work
together with a common goal

24. Achievement of the best
outcome demands
excellent communication.

25. Communication Failures
Communication failures compromise
care.
A common indicator of
communication failure is the phrase:
“the patient is non-compliant” this
phrase usually means:
The patient does not understand our
instruction

26. PTSD & Maternal Morbidity
 Review of 11 studies (2018) by
Furuta & colleagues found that child-
birth can be a cause of post-traumatic
stress syndrome (PTSD); especially
among women who experience
severe morbidity

27. Psychological Effects & Maternal
Morbidity
 2018 study in Tanzania on women with fistula
by Mselle and colleagues found fistula
associated with deep sense of loss;
 Women reported loss of body control, loss of
the social roles as women and wives, loss of
integration in social life, and loss of dignity and
self-worth were located at the core of these
experiences.

28. Warning signs of traumatic birth
and potential PTSD
Include the following behaviors:
 feeling angry (blaming others);
 feeling alone, unsupported, helpless,
overwhelmed, or out of control;
 panicking;
 dissociating; giving up;
 feeling hopeless and as if she cannot go on
(“mental defeat”); and
 experiencing physical damage and a poor
outcome.

29. Interventions to Prevent PTSD
 Remain close to her;
 Offer reassurance
 Explain what is happening and why;
 Physical touch
 Eye contact;
 Talk to her in a kind, firm, confident tone of voice.
Help her maintain some sense that she is not totally
alone, out of control, and overwhelmed (Simkin,
2011)

30. Pain vs Suffering
 Suffering, “ Perceived threat to body and/or
psyche, helplessness and loss of control, distress,
inability to cope with the distressing situation, and
fear of death of mother or baby (Lowe 2012)
 Pain is possible without suffering.
 “Strategize a course of care that maximizes the
woman’s feelings of being supported, listened to,
and in control of what is done to her, and that
minimizes the likelihood of loneliness, disrespect,
and excessive pain” (Simkin 2017).

31. Factors that influence the
perception of pain in labour
 Parturient perception and response to labour
pain depends on:
 the intensity of pain,
 psychological factors,
 cultural beliefs,
 previously painful experiences,
 history of pregnancy,
 social and marital status .
 mental preparation,

32. Birth Experience & Care
 The most influential element in
women’s satisfaction (high or low)
with their birth experience, as
recalled 15 to 20 years later, is
how they remember being cared
for by their clinical care providers
(Simkin 1991)

33. Individuals caring for laboring women should
remind themselves that the birth experience is a
long-term memory that can be devastating,
negative, depressing, acceptable, positive,
empowering, ecstatic, or orgasmic. The
difference between negative and positive
memories of the birth experience depends not
only on a healthy outcome but also on a process
in which the woman was respected, nurtured,
and aided (Waldenström & Irestedt, 2016).