This document discusses abnormal labor and dystocia. It defines abnormal labor as difficult labor characterized by abnormal slow progression due to problems with the passenger (fetus size/position), pelvis (size/shape), or power (uterine contractility). Specific causes of abnormal labor discussed include cephalopelvic disproportion (CPD), obstructed labor, shoulder dystocia, breech presentation, and fetal malpositions. The signs, risks, and management of these complications are described. Obstructed labor is defined as cessation of labor progression despite adequate contractions due to mechanical obstruction, and can lead to maternal death if not properly managed.

1. ABNORMAL LABOUR

2. objectives
• what is abnormal labor or dystocia?
• Etiologies of abnormal labor
• what is CPD?
• What is obstructed labor?

3. Abnormal
labor/dystocia/dysfunction
 Is difficult labor characterized by abnormaly slow
progresion of labor
 Most common cause for primary CPD
 More common for primi (25-30%), multipara (10-15%)

4. Definition
 In general, abnormal labor is the result of problems with
one of the following three P’ s:-
 Passenger (infant size, fetal presentation [occiput anterior,
posterior, or transverse])
 Pelvis or passage (size, shape, and adequacy of the pelvis)
 Power (uterine contractility)

5. Etiologies of abnormal labor
1)Abnormalities of essential labor forces
 1. Power -poor uterine contraction ,poor maternal effert
 2. Passanger-large baby, malpresentation
 3. Passage(birth canal)-contracted pelvis, soft tissue
abnormalities(myoma, cervical ca ..)
 4.Placents –position,time,and mode of expulsion
 5.Psyche –emotional response of the woman to labor

6. Types of abnormal uterine
contraction
1. hypotonic uterine dysfunction
• more common
• low basal ton
• treatment-augimentation by oxytocin
2.hypertonic/uncordinated uterine dysfunction
• basal tone is elevated
• contraction has no coordination (asynchronous) or pressure
gradient is distorted
• treatment-sedation

7. Reported Causes Of Uterine
Dysfunction
• Epidural anelgesia -results in prolongation of both 1ST &2nd
stage of labor
• choramnionitis (infection)

8. 3.Prolonged latent phase-
• A latent phase lasting longer than 20 hours for nulliparas and
14 hours or longer for multiparas or more than 8 hrs in
partograph labor management protocol

9. ACTIVE-PHASE DISORDERS
Classification based cervical diltation
• Protracted diltation Disorder (slower than normal) -primi
<1.2cm/1hr multigravida<1.5cm/hr
• Arrested diltation Disorder (complete cessation of progress)
• causes for both- CPD &poor uterine contraction

10. CRITERIA FOR DIAGNOSIS OF ABNORMAL
LABOR DUE TO ARREST OR PROTRACTION
DISORDERS
Labor Pattern Nullipara Multipara
Dilatation < 1.2 cm/hr < 1.5 cm/hr
Descent < 1.0 cm/hr < 2.0 cm/hr

11. 4.Prolonged Second-stage
• incorporates many of the cardinal movements necessary for
the fetus to negotiate the birth canal
• disproportion of the fetus and pelvis frequently becomes
apparent

12. 5. Protraction Disorders
 (slow rate of cervical dilatation or fetal decent)
 May occur due to CPD,ineffective urterine contractions or
unknown reasons
 Protraction active phase dilatation <1.2 to 1.5 CM/hour
 Protraction descent –descent <2 cm /hour.

13. DURATION OF 2ND STAGE
Nulliparas - 2 hours
• extended to 3 hours with regional analgesia
Multiparas - 1 hour
• extended to 2 hours with regional analgesia

14. 6. Arrest disorders
Complete cessation of cervical dilatation or fetal descent .May
occur due to excessive sedation ,fetal malpresentation
,anesthesia administration early in the labor process, meternal
exhaustion and anxity.
 Arrest dilatation : No active dilatation for over two hours.
 Arrest descent: failure of the fetus to descent for over one
hour .

15. Disorders in
labour
CPD
Malpostion
Malpostion
presentation
Abnormal
uterine
contraction
Precipitate labor
Excessive uterine
contraction
Hypotonic &
hypertonic
inertia
Contraction ring

16. FETOPELVIC DISPROPORTION

17. CPD May due to:-
 diminished pelvic capacity, excessive fetal size, or
malpresentation
Two Types-
 Absolut CPD --Contracted pelvis, macrosomia
 Relative CPD--malpresentation, tight pernium

18. FETOPELVIC DISPROPORTION
are
 CONTRACTED MIDPELVIS
• more common than inlet contraction
• causes transverse arrest of the fetal head
• interischial spinous diameter is < 8cm
• spines are prominent
• pelvic sidewalls converge
• narrow sacrosciatic notch

19. Cont…
 AVERAGE MIDPELVIS MEASUREMENTS
• transverse or interspinous = 10.5 cm
• anteroposterior (from the lower border of the symphysis
pubis to the junction of S4–S5) = 11.5 cm
• posterior sagittal (from the midpoint of the interspinous line
to the same point on the sacrum) = 5 cm

20. Female pelvis – Superior/Anterior
view

21. Cont…
CONTRACTED PELVIC INLET
 shortest anteroposterior diameter is less than 10 cm or
 greatest transverse diameter is less than 12 cm or
 diagonal conjugate of less than 11.5 cm

22. Cont…
 CONTRACTED PELVIC OUTLET
 interischial tuberous diameter of 8 cm or less.

23. Cont…
 Soft tissue dystocia
 • pelvic masses
 • Ca of the cx
 • Myoma (LUs)
 • Distended bladder
 • Ovarian tumor
 • low lying placenta
 • marginal or low lying placenta may prevent fetal descent

24. Fetal dystocia
 Abnormality of the passenger (Fetal dystocia) Is abnormal
labor caused by mal position or mal presentation , excessive
size of the fetus or fetal mal formation
 Mal position or mal presentation

25. The most common cause of fetal
dystocia
 Face presentation--The head is hyperextended occiput is in
contact with the fetal back and the chin (mentum ) is
presenting
Presenting
 submentobregmatic _ 10.2 cm
 Brow presentation- portion of fetal head between orbital
ridge and the ant. fontanel presents at the pelvic inlet
 unstable commonly often coverts to face or occiput
presentation.

26. Cont….
 Transverse lie-- the long axis of the fetus is perpendicular
to that of the mother
 incidence 0.3%
 The shoulder is over the pelvic inlet (shoulder presentation)
 The side of the mother on which the acromion rests
determines the designation of the lie as Rt or Lt acromial

27. Etiology
 abdominal wall relaxation from high parity
 uterus fall forward, deflect the long axis of the fetus away
from the axis of birth canal
 preterm fetus
 placenta previa
 abnormal Ux anatomy
 excessive amniotic fluid
 contracted pelvis

28. Compound presentation
 an extremity prolapses along side the presenting part with
both presenting in the pelvis simultaneously
 Cause – Condition that prevents complet occlusion of the
pelvic inlet by the fetal head

29. Persistent occiput posterior
position
 most op rotate to OA
 may be normal in early labor Cause- precise reason not
known .Transverse narrowing of the mid pelvis
 When it persists it may cause dystocia
 2/3 of OP deliveries occurs with fetuses Who were OA at
the beginning of labor
 Cause of CPD_ partial deflexion of the fetal head

30. Cont…
 Persistent occiput transverse position
 In absence of pelvic abnormality frequently a transient
position
 Tends to rotate to OA
 Cause
• pelvic dystocia
• Ux dystocia
• Platypelloid or android pelvis

31. Shoulder Dystocia
 When maneuvers were required to deliver the shoulders
 A head to body delivery time exceeding 60seconds (N.24
sec)
 failure of the shoulders to spontaneously traverse the pelvis
after delivery of the fetal head
 Most cases can’t be accurately predicted or prevented

32. Risk factors for shoulder
dystocia
Maternal
 obesity
 multiparity
 diabetes
 posterm __ because of ↑ed birth wt
 prior shoulder dystocia _17%
 Macrosomia
 Prolonged 2nd stage

33. Breech presentation
 Definition - When the fetus assumes a longitudinal lie with
the Cephalic pole in the Ux fundus and caudal pole at the
pelvic brim.
 When the buttocks of the fetus enters the pelvic first.

34. Types of breech presentation
 Frank breech 60-65% • the lower extremities are flexed at
the hips and extended at the knees.
 Incomplete breech (Footling – 25-35%) • One or both feet
felt below the breech • A foot or knee is lower most in the
birth canal
 Complete breech 5% • one or both knees are flexed • the
feet may be felt along side the buttocks 32

35. Causes
 prematurity
 fetal congenital malformation
 anencephaly
 hydrocephaly
 congenital hip dislocation
 Uterine anomalies . Bicornuate and Septate Ux

36. Cont…
 uterine over distension (Polyhydraminos, multiple
gestation)
 High parity
 Pelvic obstruction . placenta previa, myoma , other pelvic
tumors
 Previous breech delivery

37. Management
 Vaginal delivery
 Indications
• No maternal or fetal indication for c/s
• Wt < 3500gm
• Frank breech
• Adequate pelvis
• Zatuchini – Andros score > 4 • Documented lethal fetal
congenital anomalies • Presentation of mother in advanced
labor with no maternal or fetal distress

38.  1. spontaneous breech vaginal delivery
 2. partial extraction breech delivery
 3. total extraction breech delivery

39. External Cephalic Version (ECV)
 External Cephalic Version (ECV) Version is a procedure in
which the fetal presentation is altered by physical
manipulation, either substituting one pole of a longitudinal
presentation for the other or converting an oblique or
transverse lie into a longitudinal presentation. external
version- the manipulations are performed through the
abdominal wall internal version- are performed inside the
uterine cavity.

40. Obstructed labor

41. obstructed labor
 • cessation of labor progression despite adequate uterine
contraction due to mechanical obstraction
 • It is an absolute condition, further progress is impossible
with out assistance
 • It is an out come of a neglected and mismanaged labor
 • account for 8% of maternal death globally

42. Causes
 CPD – faults in the pelvis -faults in the fetus
 Mal presentation and mal position - Breech (impacted,
large breech) -Transverse lie,Brow presentation, Mp, OP
 myoma, longtudinal vaginal septum • Tight perineum esp
in primipravida

43. Clinical presentation
 prolonged labor often extending to days rather than hours
 prolonged Rom(rupture of membrane)
 painful contractions eventually might cause Ux hypotonia
or rupture
 fever ,confusion ,distress

44. Cont…
 P/E
 exhausted , tired and anxious (by sever pain , lack of sleep)
 dehydrated and acidotic- due to muscular activity in
absence of intake
 Rapid pulse & often febrile
 Hypotension or shock ( septic or unhgic due to infection or
Ux rupture)
 Distended hypoactive bowels due to electrolyte deficit

45. Hypotonic or hypertonic Ux
contractions
 Hypotonic or hypertonic Ux contractions depending on the
progress of labor
 The cause of the obstruction may be evident on abdominal
examination (abnormal lie , big baby etc..)
 In the presence of Ux rupture the abdomen will be tender,
fetal parts are easily felt, lie and presentation may be
difficult to detect as the baby has been displaced into the
peritoneal cavity
 edematous vulva(canula sign), foul smelling vaginal
discharge.

46. Management
 Resuscitation - If delivery is not imminent or likely to be so
shortly, resuscitation is the first Step before facilitating
transfer of the Pt to higher institution.
 admit the Pt straight to the delivery unit or operating
theater
 Update HCt, blood group & RH type, WBC
 definitive management depends on status of fetus ,degree
of descent.