Labour dystocia

2. Definition of labour
• presence of strong regular painful
• contractions resulting in progressive cervical
change.
 Diagnosis of labour
• suspected when awoman presents with
contraction-like pains
• vaginal examination that reveals effacement and
dilatation of the cervix.
• Loss of a ‘show’ (a blood-stained plug of mucus
passed from the cervix

3. Stages of labour
• First stage
• Latent first stage of labour
• when there are painful contractions, and some
cervical change, including cervical effacement
and dilatation up to 4 cm.
• Active first stage of labour :
• when there are regular painful contractions, and
there is progressive cervical dilatation from 4 cm
• •also New definition: 6 cm of dilation

4. Duration of the first stage
• Primi 1cm/h last on average 8-10 hours and
considered delay if less than 2/4h. unlikely to
last over 18 hours.
• Multi 2cm/h last on average 5 hours and
considered delay if less than2/4h. unlikely to last
over 12 hours.

5. Management of normal labour
• history
• Previous births and size of previous babies.
• Previous caesarean section.
• Onset, frequency, duration and perception of strength of the contractions.
• Whether membranes have ruptured and, if so, colour and amount of
amniotic
• fluid lost.
• Presence of abnormal vaginal discharge or bleeding.
• Recent activity of the fetus (fetal movement).
• Medical or obstetric issues of note (e.g. diabetes, hypertension, fetal growth
• restriction [FGR]).
• Any special requirements (e.g. an interpreter or particular
• emotional/psychological needs).
• Maternal expectations of labour and delivery?

6. • General examina The temperature, pulse and
blood pressure
• Abdominal examination it is important to
determen
• fundal height, lie, presentation, position and station
• , liquor, engagement
• also includes an assessment of the contractions;
• Vaginal examination for position, length and
effacement,
• consistency, dilatation of the cervix and position
station of the presenting part. The condition of the
membranes

7. Fetal assessment options in labour
• Inspection of amniotic fluid – fresh meconium
staining, absence of fluid, and heavy blood-stained
fluid or bleeding are markers of potential fetal
compromise.
• Intermittent auscultation of the fetal heart using a
Pinard stethoscope or a handheld Doppler
ultrasound.
• Continuous external electronic fetal monitoring
(EFM) using CTG.
• Continuous internal electronic fetal monitoring
using a fetal scalp electrode (FSE) and CTG.
• Fetal scalp blood sampling (FBS).

8. • women having pain without cervical change
are not in labour Offer them support and
occasionally analgesia, and encouraged to return
home.
•

9. Observations during the active first
stage
• Use partogram with 4-hour action line once labour is
established.
• Observations during the first stage of labour include:
• 4-hourly temperature and blood pressure
• hourly pulse
• half-hourly documentation of frequency of contractions
frequency of emptying the bladder
• vaginal examination 4-hourly, or where there is concern
about progress and after vaginal loss.
• Intermittent auscultation of the fetal heart every 15
minutes.
• Encourage women to communicate their need for
analgesia at any point during labour.

10. Possible routine interventions in the
first stage
• active management of labour (one-to-one
continuous support; early routine amniotomy;
routine 2-hourly vaginal examination; oxytocin
if labour becomes slow) should not be offered
routinely.
• In normally progressing labour, amniotomy
should not be performed routinely.
• Combined early amniotomy and oxytocin
should not be used routinely.

11. Fetal heart assessment and reasons
for transfer to continuous EFM
•
Intermittent auscultation of the FHR is recommended for
low-risk women in established labour
• Indications for continuous EFM
• Significant meconium staining of the amniotic fluid.
• Abnormal FHR detected by intermittent auscultation.
• Maternal pyrexia (temperature ≥38.0°C or ≥37.5°C on
two occasions).
• Fresh vaginal bleeding.
• Augmentation of contractions with an oxytocin infusion.
• Maternal request.

12. Management during first stage
• .
• One-to-one midwifery care should be provided.
• Additional emotional support from a birth partner should be
encouraged.
• Obstetric and anaesthetic care should be available as required.
• Maternal and fetal wellbeing should be monitored.
• Vaginal examinations are performed 4 hourly or as clinically
indicated.
• Progress of labour is monitored using a partogram with timely
intervention if abnormal.
• Appropriate pain relief should be provided consistent with the
woman’s wishes.
• Ensure adequate hydration and light diet to prevent ketosis.
• .

13. First-Stage Arrest
• Six centimeters or greater dilation with
membrane rupture and no cervical change for 4
hours or more of adequate contractions (eg,
>200 Montevideo units) or 6 hours or more of
oxytocin administration if contractions are
inadequate

14. Risk Factors for Labor Dystocia
• Induction of labor
• Chorioamnionitis
• Maternal obesity
• Epidural anesthesia
• Fetal malposition
• Fetal malpresentation
• Cephalopelvic
disproportion
Contracted pelvis
Fetal macrosomia

15. To diagnosis, the clinician needs to address the
following questions, using the Six Ps mnemonic as a
guide:
• Passenger: Is there a malposition or
malpresentation or suspected macrosomia?
• Power: Are contractions adequate in
frequency, duration, and strength?
• Pelvis: Is there cephalopelvic disproportion
because of a contracted pelvis?
• Patient: Are there other coexisting clinical
issues such as chorioamnionitis or
nonreassuring fetal monitoring that affect the
treatment choices?
• Psyche: How are the woman and her support

17. Treatment for Labor Dystocia
• • Hydration
• • Position changes
• • Amniotomy
• • Oxytocin

18. Oxytocin Augmentation:
• Sample Protocols
• • Routine
• Start at 1 to 2 mU/min
• Increase by 1 to 2 mU/min
• every 30 min
• Maximum dose: 36 mU/min
• • High‐dose
• Start at 2 to 4 mU/min
• Increase by 2 to 4 mU/min
• every 15 min
• Maximum dose: 36 mU/min
• May shorten length of labor,
• but caution with uterine
• tachysystole

19. Assessing Uterine Contractions
• • When expected cervical change is not occurring
• Palpate abdomen for strength of contractions
• Place intrauterine pressure catheter (IUPC)

20. • If no cervical change deaspite adequate
contractios for at least 4 hours consider c/s
if inadequate contractions and no cervical
change for at least 6 hours cosider c/s

22. • Benefit of Watchful Waiting
• • 80% percent of those not progressing after 2
hours of
• adequate contractions had a vaginal delivery
when
• allowed to labor for 4 hours with adequate
contractions
• • Recommend waiting at least 4 hours after
adequate contractions with no progress (instead
of 2 hours) before making the decision for
cesarean delivery, as long as FHR tracing remains
normal.

23. Definition of the second stage
• Passive 2nd stage of labour: at full dilatation of
the cervix with absence of involuntary expulsive
contractions.
• active 2nd stage of labour: at full dilatation of
the cervix with involuntary expulsive
contractions

24. Duration and definition of delay in the second
stage
• Nulliparous women: Birth expected within
(2hrs, 3hrs with epidural) of the start of the
active 2nd stage.
• Parous women: Birth expected within (1hrs,
2hrs with epidural) of the start of the active 2nd
stage.

25. Observations during the second stage
• All observations should be documented on the partogram:
• half-hourly frequency of contractions frequency of emptying the
bladder
• assessment of woman's emotional and psychological needs.
• maternal behaviour, effectiveness of pushing and fetal wellbeing,.
• Intermittent auscultation of the fetal heart should occur after a
contraction for at least 1 minute, at least every 5 minutes.
• hourly BP and pulse, temperature and vaginal examination
• consideration should be given to the woman's position,
hydration, coping strategies and pain relief throughout the second
stage

26. Women's position and pushing in the
second stage
• discouraged lying supine or semi-supine in
the second stage of labour.
• Inform Women that in the 2nd stage they
should be guided by their urge to push.
• If pushing is ineffective strategies to assist
birth can be used: support, change of position,
emptying of the bladder and encouragement

28. Second Stage Labor Dystocia
• New definitions for second stage arrest of labor:
• • No progress (descent or rotation) with
epidural
• Four hours or more for a nulliparous woman
• Three hours or more for multiparous woman
• • No progress (descent or rotation) without
epidural
• Three hours or more for a nulliparous woman
• Two hours or more for a multiparous woman

29. • Second stage labor dystocia may occur
secondary
• , inadequate contractions
• , maternal exhaustion
• , or cephalopelvic disproportion
• . Each of these etiologies has potential
management options

30. • • For fetal malposition
• Consider manual rotation
• Maternal position change and movement
• • For inadequate contractions in the second stage
• Consider augmenting with oxytocin
• • Allow pushing in an upright, lateral, or hands‐knees
position
• • Pushing in an upright position increases the risk of:
• Second degree perineal tears
• Postpartum hemorrhage

31. • Passive Second Stage Management
• • If epidural, may delay active pushing after
complete
• dilation (60 to 90 minute delay)
• • Allow patient to labor down to a lower station or
• until she develops the urge to push
• Less time pushing may decrease maternal
exhaustion
• No decrease in cesarean or assisted vaginal
delivery rates
• No effect on neonatal outcomes

32. • Second Stage Labor Dystocia: Cautions
• • In prolonged second stage
• Assess fetal tolerance of ongoing labor and
active pushing
• Avoid prolonged dorsal lithotomy position
• Allow rest between pushing
• • Expedite delivery for concerning fetal
monitoring
• Assisted vaginal delivery if station +2 or
greater
• Perform cesarean delivery

34. Prevention
• Maternity care providers can attempt to
decrease the risk of dystocia with the following
antepartum and intrapartum strategies:
undertaking prenatal interventions to decrease
the incidence of fetal macrosomia, providing
labor support and hydration, avoiding elective
labor induction with an unripe cervix, using
epidural analgesia judiciously, and preventing
chorioamnionitis.

35. • Active management of the third stage
• Active management of the third stage involves
3 components:
• 1. uterotonic drugs(oxytocin10 IU by
intramuscular injection)
• 2. early clamping and cutting of the cord
• 3. controlled cord traction

36. • Physiological management of the third
stage
• Physiological management involves 3
components:
• 1. no uterotonic drugs
• 2. no clamping of the cord until pulsation has
ceased
• 3. delivery of the placenta by maternal effort.

37. Prolonged third stage
• if not completed within 30 minutes of the
birth of the baby with active management and
60 minutes with physiological management

38. • Observations in the third stage
• 4. general physical condition,
• 1. report of how she feels
• 2. vaginal blood loss.
• 3. in the presence of haemorrhage, retained
placenta or maternal collapse, frequent
observations to assess the need for resuscitation
are required

39. • Changing from physiological management to
active management of the third stage is
indicated in the case of:
• haemorrhage
• failure to deliver the placenta within 1 hour
• the woman's desire to shorten the third stage.
• Pulling the cord or palpating the uterus
should only be carried after oxytocin.
• Don‟t use routinely umbilical oxytocin
infusion nor prostaglandin