abnormal labor

1. By
Gelaye Mandefro
Ambo University
Department of Medicine
September 2016
seminar on
Management of abnormal
labor and partograph
09/04/16 1

2. Outline of presentation
 Introduction
 Section I: Etiologies & management of abnormal labor
Abnormal patterns of labor
 Abnormalities of the passage
 Abnormalities of the passenger
 Abnormalities of the power
 Section II: Partograph
09/04/16 2

3. Introduction
 Normal Labor is a sequence of uterine contractions that results in
effacement and dilatation of the cervix and voluntary bearing-down
efforts leading to the expulsion per vagina of the products of conception
 Abnormal labor is labor that deviates from the course of normal labor
 several labor abnormalities that may interfere with the orderly
progression to spontaneous delivery=>dystocia
 Without timely intervention, abnormal labor usually leads to prolonged
labor
 Maternal and neonatal complications are increased with increasing
duration of labor
 One of the main objectives of monitoring labor is to detect abnormal
progress of labor before it is prolonged
09/04/16 3

4. Incidence of labor abnormalities
 Difficult to determine the exact incidence.
 In nulliparous patients, the incidence of labor disorders is ≈
25%
 Dystocia is currently the most common (50 - 60%) indication
for 1˚ C/S, ≈ 3X more common than either NRFHRP or
malpresentation.
409/04/16

5. Etiologies
 The causes of abnormal labor are generally fall in to the
following:
A. Abnormal patterns of labor
B. Abnormalities of the passage
C. Abnormalities of the passenger
D. Abnormalities of the power
09/04/16 5

6. Abnormal Patterns of Labor
 Friedman described four abnormal patterns of labor
1. prolonged latent phase
2. protraction disorders (protracted active-phase dilatation and protracted descent)
3. arrest disorders (arrest of dilatation, arrest of descent, and failure of descent), and
4. precipitate labor disorders.
09/04/16 6

7. Disorders of latent phase
1. Prolonged latent phase
 From the onset of regular uterine contractions to the beginning of the
active phase of cervical dilatation
 The latent phase is abnormally prolonged if it lasts:
 more than 20 hours in nulliparas or
 more than 14 hours in multiparas
 Causes of prolonged latent phase include:
 use of general anesthesia before labor enters the active phase,
 labor beginning with an unfavorable cervix,
 irregular, uncoordinated, and ineffective uterine contractions, and
 fetopelvic disproportion
09/04/16 7

8. Prolonged latent phase…
Treatment options
 primarily consist of therapeutic rest regimens or active management of
labor
 Adequate rest
 Rehydration
 Oxytocin stimulation OR cesarean delivery for urgent problems.
 If immediate delivery is required for clinical reasons (eg, severe
preeclampsia or amnionitis), oxytocin infusion is the treatment of
choice.
09/04/16 8

9. Diagnosis and management of prolonged latent phase of labor
9
Augmentation +
ARM
Note: If there is rupture of fetal
membranes and contractions
cease, manage her as PROM09/04/16

10. Disorders of the Active Phase…
2. Protraction Disorders
 May be divided into:
 protracted active-phase dilatation and
 protracted descent
 Protracted active-phase dilatation:
 characterized by an abnormally slow rate of dilatation in the active
phase,
 less than 1.2 cm/h in nulliparas or less than 1.5 cm/h in multiparas.
 Protracted descent of the fetus:
 Characterized by a rate of descent;
 less than 1 cm/h in nulliparas or
 less than 2 cm/h in multiparas.
 The second stage of labor is protracted when the stage exceeds:
 2 hours in nulliparas or 1 hour in multiparas, or
 3 and 2 hours, respectively, in the presence of conduction anesthesia.09/04/16 10

11. Protraction Disorders…
 Cause of a protraction disorder:
 Is probably multifactorial
 Inadequate uterine activity(the most common)
 Fetopelvic disproportion
 Abnormal positioning of the fetal presenting part
 improperly administered conduction anesthesia
 excessive sedation and,
 pelvic tumors obstructing the birth canal
09/04/16 11

12. Protraction Disorders…
 Treatment of protraction disorders:
 Depends on the presence or absence of fetopelvic disproportion, and
 The adequacy of uterine contractions,
 Cesarean section is indicated in the presence of confirmed fetopelvic
disproportion
 In the absence of fetopelvic disproportion,
 conservative management:
 consisting of support and close observation, and
 therapy with oxytocin augmentation
 both carry a good prognosis for vaginal delivery (approximately
two-thirds of patients)
09/04/16 12

13. 3. Arrest Disorders
 The two patterns of arrest in labor can be characterized as follows:
 secondary arrest of dilatation
 with no progressive cervical dilatation in the active phase of labor for 2
hours or more and
 Arrest of descent
with descent failing to progress for 1 hour or more.
 Causative factors:
fetopelvic disproportion(in approximately 50%)
fetal malpositions,
inappropriately administered anesthesia, and
excessive sedation.
 Arrest disorders in the presence of adequate uterine contractions carry a poor
prognosis for vaginal delivery.
 If allowed to continue, arrest disorders are associated with increased perinatal
morbidity.
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14. Management of abnormal active phase 1st stage of labor
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15. The diagnostic criteria of abnormal labor
1509/04/16

16. 4. Precipitate labor and delivery
 Expulsion of the fetus in less than 3 hours
cervical dilation ≥ 5cm /hr in a primigravida
 ≥ 10cm /hr in a multipara.
 Causes
abnormally low birth canal resistance
extremely strong uterine contractions
The absence of painful sensations
1609/04/16

17.  Complications
 Maternal
 uterine rupture
 extensive lacerations of the cervix, vagina, vulva, or perineum
 PPH from uterine atony
 Fetal
 Perinatal mortality and morbidity
 intracranial hemorrhage
 risks associated with unattended delivery
 Management
 stop any oxytocin if being administered
 no significant use of analgesia
 terbutaline or ritodrine intravenously
 Physical attempts to retard delivery are absolutely contraindicated
1709/04/16

18. Abnormalities of birth canal (passage)
 involve aberrations of pelvic structure and its relationship to the
presenting part
 The abnormalities may be related to:
 size or configurational alterations
 soft-tissue abnormalities
 reproductive tract masses
 aberrant placental location.
Mechanism
 For Contracted pelvis , the fetus has difficulty in passing through birth
canal.
 The labor is protracted or arrested.
 Secondary uterine inertia occurs.
1809/04/16

19. Assessment of the passages
 Bony pelvis – clinical pelvimetry
 Soft tissue dystocia – vaginal exam
 Contracted pelvis:
 Contracted Pelvic inlet
 obstetric conjugate <10cm
 diagonal conjugate<11.5cm
 greatest transverse diameter
is < 12 cm
1909/04/16

20. Assessment of the passages….
 Contracted midpelvis:
convergence of side walls
prominence of ischial spines
Narrow interspinous
diameter.(normally 10cm)
Normally AP diameter =11.5
2009/04/16

21. Assessment of the passages…
 Contacted Pelvic out let:
Intertuberous diameter < 8 cm
 narrow subpubic arch
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22. Diagnostic approach and risk assessment
 Suspect CPD
 Previous prolonged labor with bad
obstetric history or operative delivery
 Primigravida especially if age < 16yrs
 True conjugate of 8 – 10 cm (borderline
CPD)
 Prominent ischial spines, flat sacrum etc
 Gross CPD
 Estimated fetal wt ≥ 4kg
 Hydrocephalus
 Gross traumatic or congenital
pelvic abnormality
 True conjugate and/or
bituberous diameter <8cm
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23. Abnormalities of birth canal…
Treatment plan
 CS for gross CPD with normal fetus
 Hydrocephalus is managed by craniocentesis
 If gross CPD with normal fetus is dxed, elective CS –apro.
 Suspected CPD:
 Plan place of delivery at a hospital
Conduct trial of labor using partograph
Emergency CS is done when CPD is diagnosed after trial of labor
N.B. Absolute CI of vaginal delivery after clinical or x-ray estimation
contracted pelvis is out dated, so trial of labor is necessary
2309/04/16

24. Abnormalities of fetus (passenger)
 Abnormalities of fetal:
position,
presentation,
lie,
attitude
 Macrosomia
 Fetal malformation(hydrocephaly)
2409/04/16

25. Predisposing factors
 Maternal:
 Contracted pelvis
 Pendulous abdomen
 Pelvic tumors: fibromyomas,
 Uterine anomalies: bicornuate
uterus, uterine septum etc.
 Fetal:
 Prematurity
 Fetal attitude
 Fetal anomaly
 Poly/oligohydramnious
 Multiple pregnancy
 Placental & membranes:
 Placenta previa
 PROM
2509/04/16

26. Abnormalities of fetus (passenger)…
Diagnostic approach
 Clinical assessment is usually diagnostic especially in labor with dilated
cervix through which Vaginal Exam. provides adequate information.
 Ultrasound is mainly used to:
 investigate predisposing factors (e.g., placenta previa, fetal goiter)
 assess fetal condition
 assess attitude of the fetus especially in breech
 confirm clinical diagnosis etc
2609/04/16

27. Malposition and Malpresentation
Occiput posterior
The occiput is posterior in relation to the maternal pelvis
(contracted anthropoid or android)
Diagnosis:
Abdominal findings
 Anteriorly palpable fetal limbs
 Fetal heart heard in the flank
Vaginal findings
 Posterior fontanelle towards the sacrum
 Anterior fontanelle felt anteriorly if neck is flexed
2709/04/16

28. Occiput posterior…
Management plan
 Gross CPD or any other indication for CS CS⇒
 No gross CPD, follow labor closely:
Anterior rotation to OA expect vaginal delivery as OA⇒
Posterior rotation and if:
 borderline CPD suspected, perform CS
 Grossly adequate pelvic, expect vaginal delivery and manage labor
as OA including augmentation of labor if there are inadequate
uterine contractions.
 The use of instrumental vaginal deliveries is also as in vertex
Anterior Position.
2809/04/16

29. Malposition and Malpresentation…
Persistent occiput transverse
 No rotation of the OT position for 2 or more hours.
platypelloid or android pelvis
pelvic dystocia, uterine dystocia
Management: C/S
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30. Brow presentation
 Partial extension of the fetal neck making the sinciput lower than the
occiput
 rarest , o.o6% of all deliveries
 Engagement can’t take place _ unless head is small or pelvis is very large
 Diagnosis
 Abdominal findings
 Occiput felt above sinciput
 Vaginal findings
 Anterior fontanelle and orbit are felt
 Mgt:-Cesarean delivery if:
 Suspected CPD or any other indication for CS
 Flexion to OP or extension to MP
 Persistent brow
 Grossly adequate pelvis with:
 Flexion/ extension to occiput posterior/MA expect vaginal delivery⇒
3009/04/16

31. Face presentation (0.2% of all deliveries)
 Hyperextension of the neck with the face being the
leading part
 The widest diameter of the fetal head negotiating
the pelvis in face presentation is the
tracheobregmatic or submentobregmatic diameter
 Associated risk factors: grand multiparity, advanced
maternal age, pelvic masses, multiple gestation,
polyhydramnios, macrosomia, congenital anomalies
 Diagnosis
 Abdominal findings
 Groove may be felt between the occiput and
the back
09/04/16 31

32. Face presentation…
 Vaginal findings
 Face palpated and the finger may get
into the mouth
 The mouth with the two malar bone
prominences make a triangle (unlike in
breech where the anal orifice with two
trochanteric eminences are in a line)
 MA: Chin anterior position
 MP: Chin posterior
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33. Landmarks of fetal skull for determination of fetal position
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34. Management of Face presentation
 Suspected CPD or any other indication for CS CS⇒
 MA:− Grossly adequate pelvis, manage labor as vertex anterior.
 Augmentation and
 forceps delivery can also be used when the indications arise.
 Vacuum delivery is CI.
 MP :− Cesarean delivery if:
 Suspected CPD or any other indication for CS
 Persistent brow (no rotation or late admission)
− Early admission with rotation to MA expect vaginal delivery⇒
3409/04/16

35.  Abnormal fetal lies (0.33% of all deliveries )
 Transverse or oblique
 Causative factors: grand multiparity, prematurity(6 times more
frequently ), pelvic contraction, and abnormal placental implantation
 Management option:
 ECV to undergo vaginal delivery(3rd
Tx ,)
 Cesarean section(mandatory with onset of labor or membrane
rupture)
09/04/16 35

36. Breech presentation (3–4% of all deliveries)
 a longitudinal lie with the fetal head occupying the
fundus
 Occurs more frequently in second and early third
trimesters
 Subtypes:
 frank breech:a breech presentation with flexed
hips and extended knees
 complete breech :flexion at both hips and knees
 incomplete (footling) breech :extension of one or
both hips
 Conditions that are associated with breech
presentation:
Multiple gestation
Polyhydramnios
Anencephaly
Uterine anomalies
previous breech presentation
09/04/16 36

37. Diagnosed: with Leopold maneuvers, pelvic
examination, U/S
Management of Breech Presentation
 External cephalic version – applying pressure to
abdomen to turn fetus in a forward or backward
• Successful 50% of the time
 Selection Criteria
• Preferred candidates have completed 37
weeks gestation
 Risks
• Rupture of membranes
• Placental abruption
• Uterine rupture
 Procedure
• Tocolysis with terbutaline
 Cesarean delivery
 Vaginal delivery
09/04/16 37

38.  Fetal Malformation
 hydrocephalus, with an incidence of 0.05%
 distended bladder, ascites, or abdominal neoplasms; or other fetal masses
 Shoulder dystocia
 difficult delivery of the shoulders after delivery of the fetal head
 0.6–1.4% of all vaginal deliveries
 R/F:
 estimated fetal weights >4500 g in nondiabetic patients and >4250 g in diabetic
patients
 Other fetal causes of dystocia: Hydrocephalus, distended bladder, ascites,
enlarged kidneys or liver
3809/04/16

39. Shoulder dystocia…
Diagnosis
 Shoulder dystocia is a subjective clinical diagnosis.
 It should be suspected when the fetal head retracts into the
perineum (ie, turtle sign) after expulsion due to reverse
traction from the shoulders being impacted in the pelvic inlet.
 The diagnosis can be made when the routine practice of gentle,
downward traction of the fetal head fails to accomplish
delivery of the anterior shoulder.
09/04/16 39

40. Shoulder dystocia…
 Maternal consequences
PPH- atony, laceration
 Fetal consequences
 fetal morbidity and mortality
Brachial plexus injury due to down ward traction on the
brachial plexus during delivery of the ant shoulder
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41. Shoulder dystocia…
MX of shoulder dystocia
 Techniques used to free the ant shoulder
from its impacted position
 Moderate suprapubic pressure with
down ward traction to the fetal head
 The MC Roberts maneuver
 hyperflexion of maternal legs upon
to the abdomen
• Cause straightening of the sacrum
relative to the lumbar vertebrae
09/04/16 41

42. Shoulder dystocia…
 Rubin
 The fetal shoulders are rocked from
side to side by applying force to the
maternal abdomen
 The pelvic hand pushes accessible
fetal shoulder toward the ant. surface
of the chest
 results in abduction of both
shoulders
 produce smaller shoulder to
shoulder diameter
 Fracture of the clavicle
 by pressing the ant clavicle against
the ramus of the pubis
 to free the shoulder impaction
 Zavanelli maneuver
 cephalic replacement into the pelvis
and then c/ delivery
09/04/16 42

43. Compound presentation(complicates 0.1% of deliveries)
 A prolapsed extremity alongside the
presenting part
 Hand with head.
 Hand with breach
 Leg with head
Mgt:-If suspected CPD or any other indication
for CS
⇒CS
 Closely monitor labor or put the woman in
the knee-chest position; push the arm above
the pelvic brim; and hold it there till a
contraction pushes the head into the pelvis:
If procedure succeeds, expect
vaginal delivery
If procedure fails or complication
arise (cord prolapse), deliver by CS
09/04/16 43

44. Abnormalities of the powers
 it is the most important expulsive force.
 Bring about dilation of cervix and expulsion of fetus and
placenta.
 Common causes:
 1° uterine inertia – abnormal uterine contraction frequency,
duration and intensity that is due to inherent myometrial
dysfunction
Mainly affects primigravid labors without other additional
factors
4409/04/16

45. Etiologies….
 2° uterine inertia – causes
Prolonged labor
Malpresentations/ malpositions
Epidural analgesia
 Uterine myomata
Fetopelvic disproportion
Abruptio placentae
4509/04/16

46. Abnormalities of the powers…
 2 categories
 Hypotonic
 insufficient force, irregular or infrequent rhythm
 Cause: Sedation, over distension of the uterus, early
administration of anesthesia
 Rx: -augmentation(ARM or oxytocin)
-general labor support mgt
4609/04/16

47. Abnormalities of the powers …
Hypertonic
Uncoordinated and frequent intense uterine contractions
Midsegment of uterus has more pressure power than the
fundus
Cause: over use of oxytocin,
Rx:tocolysis, decrease in oxytocin infusion, or C/S
4709/04/16

48. Abnormalities of the powers …
Assessment of powers of labor
 3 ways:
 Palpation of uterine contractions
 External tocodynamometer
 Intrauterine pressure catheter monitoring
Clinical presentation
 Abdominal palpation: uterine contraction is weak, and intervals is
prolonged.
 Abnormal labor course: the most important clinical presentation.
4809/04/16

49. Abnormalities of the powers …
Management
The Vaginal examination: r/o CPD
To determine fetal presentation, position and station.
To assess the cephalopelvic relation.
To consider the route of delivery.
The supportive management
Sufficient rest
To relieve anxiety and fear.
Fluid and food intake.
4909/04/16

50. Abnormalities of the powers …
Augmentation
 Increase the frequency and force of the existing uterine contractions.
 Methods:
 Amniotomy
 oxytocin administration
Amniotomy :
 If the fetal head is engaged, amniotomy is a choice to facilitate the uterine
activity.
 After amniotomy the fetal head descends , pressing directly on cervix to
enforce uterine contraction⇒ accelerating labor.
5009/04/16

51. Abnormalities of the powers …
Oxytocin
 uterine contraction
 CI:
CPD,
severe fetal malposition.
 placenta previa, brow presentation, face with MP, twin pregnancy,
extensive genital wart, cervical cancer, uterine scar, NRFHR
Secondary powers failure – Instrumental assistance
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52. Partogram and detection of fetal condition in labor
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53. Outline
 Introduction
 Partograph &its use
 Observations charted on the Partograph
 Abnormal Progress of Labor
 Management of Labor
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54. Partograph
 Graphic recording of the progress of labor
 Recording of salient conditions of the mother and fetus
 Early warning system
Uses
 To detect abnormal labor
 To indicate when augmentation of labor is appropriate
 To recognize CPD
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55. WHO Partograph: Results of Study
All WomenAll Women BeforeBefore
ImplementationImplementation
AfterAfter
ImplementationImplementation
pp
Total deliveriesTotal deliveries 1825418254 1723017230
Labor > 18 hoursLabor > 18 hours 6.4%6.4% 3.4%3.4% 0.0020.002
Labor augmentedLabor augmented 20.7%20.7% 9.1%9.1% 0.0230.023
Postpartum sepsisPostpartum sepsis 0.70%0.70% 0.21%0.21% 0.0280.028
Normal WomenNormal Women
Mode of deliveryMode of delivery
SpontaneousSpontaneous
cephaliccephalic
ForcepsForceps
8428 (83.9%)8428 (83.9%)
341 (3.4%)341 (3.4%)
7869 (86.3%)7869 (86.3%)
227 (2.5%)227 (2.5%)
<0.001<0.001
0.0050.005
WHO 1994.
09/04/16 55

56. WHO’s partogram
Identification
Fetal condition
Progress of labor
Maternal condition
09/04/16 56

57. Observations charted on the Partograph
 Progress of labor
 Cervical dilatation
 Descent of fetal head
 Uterine contractions –duration, frequency
 Fetal condition
 Fetal heart rate
 Membranes and liquor
 Moulding of the fetal skull
 Maternal condition
 Pulse/ BP / Temp
 Urine –volume, acetone, protein
 Drugs & IV Fluids
 Oxytocin regime
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58. Conditions that does not need the use of partograph
Antepartum hemorrhage
Severe pre-eclampsia and eclampsia
Fetal distress
Previous cesarean section
Malpresentation
09/04/16 58

59. Starting a Partograph
 A partograph should be started only when a woman is in active
phase of labour
 Contractions must be 1 or more in 10mins, each lasting for
20secs or more
 Cervical dilatation ≥ 4cms
5909/04/16

60. 1.Progress of labour
In the centre of Partograph , along the left side are
numbers 0 -10 against squares ; each square represents
1cm dilatation.
The dilatation of Cx is plotted with an “X . Vaginal‟
examinations are done at admission and once in 4 hours
Along the bottom of the graph are numbers 0-24;each
square represents 1hour
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61. Example
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62. Descent of fetal head
 It is measured in terms of fifths above the pelvic brim
 The width of the 5 fingers is a guide to the expression in fifths
of the head above the brim
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63. Descent of fetal head
2/5 = engaged 5/5=floating head
09/04/16 63

64. Descent of fetal head….
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65. Plotting the Descent of the Head
 On the left hand side of the graph is the word “descent’ with
lines going from 5 –0
 Descent is plotted with an “O’ on the Partograph
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66. Example 1
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67. Uterine Contractions
 Observations are every half hour in active phase
 Frequency -Number of contractions in a 10 minutes period
 Duration –Measured in seconds from the time the contraction
sets in to the time the contraction passes off
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68. Recording Uterine Contractions
 On the Partograph below the time line,
there are 5 blank squares going across
the length of the graph.
 Each square represents 1 contraction
09/04/16 68

69. Example 2
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70. 2.Fetal condition
Fetal Heart Rate
 Listen
 Patient in left lateral position
 Just after the contraction has passed its
strongest phase
 For 1 full minute, if abnormal every 15mins
 If abnormal over 3 observations, take action
 Record Every half hour
09/04/16 70

71. Membranes & Liquor
 State of Liquor &Record
 Membranes intact I
 Clear C
 Meconium M
 Absent A
 Blood Stained B
09/04/16 71

72. Moulding
 If bones Separate & sutures felt easily ……………….…………..O
 If bones just Touching each other not over lapping ………….+
 If bones overlapping &separate(reducible )digitally ………++
 If bones severely overlapping ( Non – reducible ) …………...+++
 Generally, summarized as “STONE”
09/04/16 72

73. Example 3
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74. 3.Maternal Condition
 Recorded at the foot of the Partograph
 Oxytocin:dosage/unit& drop/min
 Drugs:any drug & iv fliud
 Pulse: every half hour
 BP: every 4 hrs or more frequently(any problem)
 Temp: every 4 hrs or more frequently
 Urine: Protein ,Acetone ,Volume
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75. Example 4
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76. Abnormal Progress of Labor
Prolonged Active Phase
 In the active phase, plotting of cervical dilatation will remain on the left of
or on the alert line
 If it moves to the right of the alert line, labour may be prolonged
 Transfer if facility for emergencies is not available
 Carful reassessment of labour and decision on further management made
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77. Example 5
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78. At the Action Line
 It is 4 hours to the right of Alert line
 Assess the cause of slow progress and take action
 Action may include; termination of preg, augmentation,
observation with supportive therapy
Remember
 Reaching the action line means
 POSSIBLE DANGER
 Think possible cause manage accordingly
7809/04/16

79. Management of Labor
Normal Latent and Active Phases
Not intervene unless complications develop
ARM may be done at any time in the active phase
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80. Between Alert and Action lines
• In a Health Centre:
Transfer to hospital with facilities for Cesarean section, unless
Cervix is almost fully dilated
ARM may be performed if membranes are still intact and observe
labor for a short period before transfer
• In Hospital:
Perform ARM if membranes are intact and continue routine
observations
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81. THIS INTERVAL
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82. At or Beyond Active phase Action Line
 Full medical assessment
 Consider IV infusion/bladder catheterization
 Options: Delivery if fetal distress or obstructed labor
 Oxytocin augmentation if no contraindication
 Supportive therapy (only if satisfactory progress is now established and
dilatation could be anticipated at 1cm/hr or faster)
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83. Exp.Dilatation that reaches the Action
• Cs done
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84. Example
• Inadequate uterine
contraction
corrected with
oxytocin
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85. References
 Williams obstetrics, 24th
edition
 Current Obstetric & Gynecology. 2007
 Management protocol on selected obstetric topics EFDRE-MOH, January,
2010
 Up to dates 21.
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