This document discusses abnormal labor, which includes any deviations from normal spontaneous labor of a singleton fetus in cephalic presentation at term. Abnormal labor can occur due to poor progress, fetal compromise, malpresentation, multiple gestation, uterine scar, or induction of labor. Poor progress is defined as less than 2 cm dilation in 4 hours and can be caused by dysfunctional uterine contractions, cephalic-pelvic disproportion, or malpresentation. Malpresentations include abnormal lie, face/brow presentations, breech presentation, and compound presentations. Management depends on identifying the underlying cause based on the 3 Ps - powers (uterine contractions), passages (maternal pelvis), and passenger (fetus).

1. Abnormal labor

2. Abnormal labor
 Is any deviation from the normal
 Normal labor should be spontaneous labor, singleton fetus, cephalic vertex presentation
with no intervention , term
Abnormal if :
 poor progress
 Fetal compromise
 fetal malpresentation
 a multiple pregnancy
 a uterine scar
 induced labor
 Progress in labour is dependent on the ‘3 Ps’ as described previously (powers, passages,
passenger)

3. abnormal progress in labour

4. Prolonged latent phase
 Prolonged latent phase occurs when the latent phase is longer than the arbitrary
time limits of the normal
 more common in primiparous women
 best managed away from the labour suite with simple analgesics,
mobilization and reassurance
 intervention in the form of artificial rupture of membranes (ARM) or oxytocin
infusion will increase the likelihood of poor progress later in the labour and the
need for caesarean birth

5. Primary arrest
 poor progress in the active first stage of labour (<2 cm cervical dilatation/4 hours)
 More in primiparous
Causes :
 inefficient uterine (most common )
 CPD
 Malspresentation

6. Secondary arrest
 progress in the active first stage is initially good but then slows or stops
 Same causes of primary arrest

7. Arrest of second stage of labor
 when delivery is not imminent after the usual interval of pushing in the second
stage of labour
Causes :
 inefficient uterine activity
 malposition
 malpresentation
 CPD
 resistant perineum

8. Poor progress in the first stage of
labour
 defined as cervical dilatation of less than 2 cm in 4 hours,
usually associated with failure of descent and rotation of the fetal
head
 Management depends on the cause …3p’s
Dysfunctional uterine activity (‘powers’)
Cephalopelvic disproportion (‘passages’ and ‘passenger’)
Malpresentation (the ‘passenger’)

9. Portogram to assess labor progress
Should be used starting from the
active phase of first stage of labor;
if to be used

10. Dysfunctional uterine activity (‘powers’)
 weak, irregular and infrequent contractions
 A frequency of four to five contractions per 10 minutes is usually considered
ideal
 the most common cause of poor progress in labour
 more common in primigravidae and in older women
 Management : if confirmed delayed after 4 hours; ARM should be done first and
vaginal examination 2 hours later , if still delayed; consider augmentation of
contractions by oxytocin infusion
 If progress fails to occur despite 4–6 hours of augmentation with oxytocin, a
caesarean section will usually be recommended

11. Augmentation should be used with caution in multiparous women*
Risk of rupture uterus , PPH and other causes to be involved in the delay as
malpresentation
Augmentation with oxytocin is contraindicated if there are concerns regarding the
condition of the fetus
Use continuous EFM if augmentation started

12. Cephalopelvic disproportion
 CPD implies anatomical disproportion between the fetal head and maternal pelvis.
 Causes : small pelvis in relation to fetal size
large fetus
fetal neck masses , thyroid goiter
macrocephaly , hydrocephaly
malposition (relative CPD )
Retrospective diagnosis (failure of vaginal delivery )

13. Findings suggestive of CPD
 Fetal head is not engaged.
 Progress is slow or arrests despite efficient uterine contractions.
 Vaginal examination shows severe moulding and caput formation.
 Head is poorly applied to the cervix.
 Haematuria.

14. Clinical pelvimetry
 Clinical pelvimetry Has less role in assessing for CPD than in the past
 X ray had a role (radiological pelvimetry )
 CPD is considered a retrospective diagnosis after a failure in trial of vaginal
delivery

15. Clinical pelvimetry

18. Malpresentation
 Near term or during labor the fetus normally assumes a vertical orientation and
cephalic presentation, with the flexed fetal vertex presenting to the pelvis (95 %)
 In about 5% of these cases, deviation occurs from this normal presentation called
malpresentation
 Malposition : subtype of malpresentation with cephalic but not vertex presentation
as in occipitoposterior
 Malpresentation suggests the possibilities of adverse consequences and increases
the risk for both the mother and fetus

19. Causes and risk factors for
malpresentation
 Diminished vertical polarity of the uterine cavity
 Increased or decreased fetal mobility
 Obstructed pelvic inlet, cephalo-pelvic disproportion
 Polyhydramnios
 Oligohydramnios
 Fetal malformation
 Abnormal placentation
 Uterine myoma and uterine synechiae
 Multiparous
 Idiopathic

20. Abnormal Lie
 Lie: orientation of the fetal spine relative to the
mother’s spine
 Transverse
 Oblique
 Usually transient but if persistent; transverse lie
needs cesarean section
 Occur in 0.3 %
 Risk factors as : grand-multiparity ,Prematurity,
Contraction and deformity of maternal pelvis
,Abnormal placentation

21. Face presentation
 Is longitudinal lie, full extension of the fetal head on the neck and the occiput against the
upper back
 Anencephaly is found in one third of cases
 Fetal goiter and neck soft tissue tumors also cause deflection
 Contracted pelvis or CPD is found in 10-40% of cases

22. Face presentation
 Dominator is mentum
 Submento bragmatic is the engagement diameter
 Mentoanterior : vaginal deliveryand Delivers by flexion (mento-anterior)
 Mento posterior : CS

23. Brow presentation
 Is longitudinal axis with partially deflexed cephalic attitude, midway between full flexion
and full extension
 The frontal bones are the point of designation
 The engagement diameter is the mento-vertical 13.5 cm
 the incidence is 1 to 1500 deliverers
 It is more detected in early labor before flexion occurs to normal attitude. Less
frequently, further extension results in face presentation
 Transient; most convert spontaneously by flexion or extension to either vertex or face
presentation and are managed accordingly
 If persist : CS

25. Compound presentation
 an extremity is found prolapsed beside the main presenting part
 The combination of an upper extremity and vertex presentation is the most
common
 Prematurity is the most consistent clinical finding
 fetal risk is associated with birth trauma and cord prolapse

26.  the prolapsed extremity should not be manipulated, as it may retract as the
major presenting part descends
 75% of vertex/upper extremity combinations deliver spontaneously; occult
or undetected cord prolapse is possible, therefore continuous CTG is
recommended
Persistent compound presentation with parts other than vertex and hand in
combination in a term-sized infant has poor prognosis for safe vaginal
delivery and cesarean section is necessary

27. Breech presentation
 When the buttocks of the fetus enter the pelvis before the head the presentation is
breech
 Its more common in preterm fetuses because the bulk of each pole is more or less
similar
 Types :
1)Frank breech:
the lower extremities are flexed at the hips and extended at the knees.
2)complete breech:
the lower extremities are flexed at the hips and one or both knees are flexed.
3)incomplete breech:
one or both hips are not flexed and one or both feet are below the breech(footling)

29. Risk factors for breech
 Gestational age
 Hydramnios
 Uterine relaxation
 Multiple fetuses
 Oligohydramnios
 Hydrocephaly, anencephaly
 Previous breech delivery
 Uterine anomalies and pelvic tumor

30. Breech delivery
Cesarean delivery is commonly but not exclusively used in the following
circumstances
 A large fetus
 Any degree of contraction or unfavorable shape of the pelvis
 Hyperextended head
 When delivery is indicated in the absence of spontaneous labor
Methods of delivery ; CS , assisted vaginal delivery , spontaneous vaginal
delivery and complete breech extraction in CS or second twin

31. Poor progress in the second stage of
labour
 Delay is diagnosed if delivery is not imminent after 2 hours of pushing in a
nulliparous labour and 1 hour for a parous woman
 Secondary dysfunctional uterine activity (‘powers’) is a common cause of second
stage delay
 Epidural analgesia may delay second stage progress for one hour
 Operative vaginal delivery maybe done if suitable
 Oxytocin shouldn’t be started in this stage

32. Vaginal delivery with previous uterine scar
VBAC
 Risk of rupture in previous lower segment cs 1:200
 Risk of rupture in previous upper segment cs 2-3 % (classical )
 Success rate : 70-80 % and more if previously delivered vaginally
 Continuous CTG with close observation for signs of rupture uterus
Relative contraindications to VBAC
 Two or more previous caesarean section scars.
 Need for induction of labour (IOL).
 Previous labour outcome suggestive of CPD.
 Previous classical caesarean section is an absolute contraindication.