ABNORMAL LABOUR
INTRODUCTION:-
NORMAL LABOUR
Normal labor is defined as regular uterine contractions that cause cervical change.
The onset of painful, regular uterine contractions that lead to effacement and dilatation of the
cervix with descent of the fetus in a vertex presentation High risk pregnancy
ABNORMAL LABOUR
Abnormal labor may be referred to as 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.
A few examples of abnormal labor patterns may help you understand how the condition is
diagnosed:
An example of an “arrest of dilation” is when the cervix is 6 centimetres dilated during the first
and second examinations, which your doctor performs one to two hours apart. This means that
the cervix hasn’t dilated at all over the course of two hours, indicating labor has stopped.
In an “arrest of descent”, the head of the fetus is in the same place in the birth canal during the
first and second examinations, which your doctor performs one hour apart. This signifies that the
baby hasn’t moved farther down the birth canal within the last hour. Arrest of descent is a
diagnosis made in the second stage, after the cervix is completely dilated.
Failure to meet defined milestones & time limits for normal labour
Another name is dystocia.
Assessment of progress in labour
a) Progressive dilatation of cervix
1 cm / hr in primigravida
1.5 – 2 cm / hr in multigravida
b) Progressive descent of head
DEFINITION:-
NORMAL LABOR-
Normal labor is defined as regular uterine contractions that cause cervical change. Abnormal
labor patterns are characterized as abnormalities of the first, second, or third stage of labor.
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ABNORMAL LABOR-
Abnormal labor is defined as the abnormal onset of labor - either too early or too late in the
pregnancy - or abnormal duration of the stages of labor.
“No change or minimal change in cervical dilatation in a 2-hour period during the latent or the
active phase of labour, or no change or minimal change in descent of the presenting part during
one hour during the second stage of labour” high risk pregnancy
DISORDERS OF LABOR:-
Prolonged latent phase
Primary dysfunctional labour
Secondary arrest
TYPES OF LABOUR ABNORMALITIES ;-
Slow Progress “Protraction disorders”: refer to slower-than-normal labour progress.
Arrest of Progress “arrest disorders”: refer to complete cessation of progress.
Protraction and arrest disorders may occur in both the first and second stage of labour
Precipitate Labour: Complete Delivery within ≤3 hour
DETERMINANTS OF LABOR:-
Power
P Passages
Passenger
Plotting the findings of serial vaginal examinations on partogram
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ABNORMALITY OF POWER (uterine contractions)
Inefficient uterine action is characterized by weak, infrequent and irregular contractions
and is the most common cause of poor progress in labour
3-4 contractions every 10 minutes, each one lasting for minimum of 40 seconds
In 2nd stage uterine work is complemented by maternal expulsive efforts
ASSESSMENT OF UTERINE CONTRACTIONS
Clinical examination
External uterine tocography
Intrauterine pressure catheter:
expressed in Montevideo units
3 contractions in 10 minutes will produce approx. 100-200MVU
Common causes are:
o Primigravida
o Advanced maternal age
o Diabetic mother
o Multiple pregnancy etc.
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CLASSIFICATIONS:-
Hypertonic uterine dysfunction:
frequent, intense and painful contractions having no effect on cervical dilatation and
effacement
Subtypes are:
a) Uterine tachysystole: increase in frequency of uterine contractions more than 5 every 10
minutes with little or no relaxation
b) Hyper stimulation: tachysystole associated with FHR abnormalities
Hypotonic uterine dysfunction: another name Uterine inertia
Decrease in frequency and intensity of uterine contractions
a) primary due to intrinsic failure of uterine muscle
b) secondary to pharmacological interventions
ABNORMALITY OF PASSAGE:-
The passage relates to the uterus, cervix and the bony components of the pelvis
CAUSES:
Malnourishment
previous fracture or metabolic bone diseases
Woman with paraplegia or spina bifida
Space occupying viscera in the pelvis
Impacted rectum
Full bladder
Cervical fibroid
Ovarian cysts
Cervical dystocia: noncompliant cervix which effaces but fails to dilate because of
severe scarring which may be as a result of previous cone biopsy and also because of
malpresentation and malposition
CPD cephalopelvic disproportion
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CEPHALOPELVIC DISPROPORTION
Contracted pelvis
Contracted inlet plane
Contracted midpelvis
Contracted outlet plane
Pelvic malformation
MECHANISM
For Contracted pelvis, the fetus has difficulty in passing through birth canal.
The labour is protracted or arrested.
Secondary uterine inertia occurs.
CONTRACTED INLET PLANE
Criteria: sacral-pubic diameter<18cm
Clinical findings: fetal head palpable above the inlet plane. prolonged latent phase
CONTRACTED MIDPELVIS AND OUTLET PLANE
Bi-ischial spine diameter<10cm
Bi-ischial tubercle diameter<8cm
Clinical findings: disorders of active phase and the second stage.
ABNORMALITIES OF THE PASSENGER:-
Refers to the fetus
Fetal macrosomia
Fetal abnormalities such as hydrocephaly, fetal ascites, and fetal tumors
Abnormal fetal presentation (brow, shoulder, face) more common in high parity
Malposition (occiput posterior, occiput transverse)
Attitude (extension, asynclitism)
Fetal head diameter
Bi-parietal dimension: 9.5cm
Suboccipitobregmatic dimension: 9.5cm
Occipitofrontal dimension:11.5cm
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Occipitomental dimension: 13cm
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INTERACTION
a) Abnormalities of fetus
Abnormalities of fetal development
Abnormalities of fetal size
Abnormalities of fetal position
b) Abnormalities of birth canal
Contracted pelvis
Pelvic malformation
Abnormalities of soft tissue
c) Abnormalities of labor force
Primary inertia
Secondary inertia
PROLONGED LATENT PHASE :-
Lack of change or minimal change in cervical effacement and dilatation before the beginning
of active phase of labour i-e cervical dilatation of 4cm and effacement -80%
The mean duration of latent phase:
8.6 hours in nullipara
5.3 hours in multipara
Prolonged when duration exceeds
more than 20 hours in nullipara
more than 14 hours in multipara
ETIOLOGY-
Primipara
Unripe cervix
False labour
Ineffective, inadequate uterine contractions
Unrecognized pelvic disproportion
OUTCOME:
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Increased incidence of cesarean section
Chorio-amnionitis
Postpartum bleeding
Thick meconium
Low 5-minute Apgar score
Admission to NICU
PRIMARY DYSFUNCTIONAL LABOUR
Poor progress during the active phase of labour
26% in nullipara
8% in multipara
Protracted dilation
Primipara < 1.2 cm/h
Multipara < 1.5 cm/h
Arrest of dilation
Primipara >2 h
Multipara >2 h
ETIOLOGY:
Cephalopelvic disproportion…early
Abnormal uterine contraction…any time
Fetal malpositions …late
SECONDARY ARREST:
6% nullipara
2% multipara
Cessation of cervical dilatation following a normal period of active phase dilatation
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More likely cause is CPD
SECONDARY ARREST IN DECELERATIVE PHASE:
Between cervical dilatation of 7 and 10 cm
ASSESSMENT:
An estimate of fetal size
The degree of engagement
Position of the presenting part
Signs of obstruction (moulding)
Presence of pelvic masses
Descent of presenting part with contractions
Contraction frequency
Fetal wellbeing
Variable decelerations and a rising baseline are common in obstructed labour
If fetal scalp sampling shows normal PH then CTG changes represent obstruction rather than
fetal intolerance to labour
SECONDARY ARREST IN SECOND STAGE OF LABOUR
Protracted or no descent of the presenting part into the birth canal during 2nd stage of labour
Normal rate:
nullipara: 6.6cm/hour
multipara: 3.3cm/hour
In nullipara: Protracted descent < 1cm/hour
In multipara: protracted descent < 2.0cm/hour
Arrest or failure of descent .. no progress in the movement of fetus through the birth canal in
the second stage of labour for one hour as documented by appropriately spaced vaginal
examinations
Prolonged second stage
without epidural:
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Primipara- ----- >2 hr
Multipara------- >1 hr
With epidural:
Primipara------- >3hr
Multipara------- >2hr
ETIOLOGY:
CPD:
50% in nullipara
30% in multipara
Inadequate uterine activity
Fetal malpositions ..OT &OP
Epidural anaesthesia
Fetal macrosomia .. 9% of protracted labour
DIAGNOSIS:
Vaginal examinations
Caput formation and excessive moulding
Assessment of station on abdominal examination
MANAGEMENT:
Assess fetomaternal wellbeing
Mueller-hillis maneuver
IUPC to evaluate uterine activity
Bedside ultrasound to diagnose malposition
Support
Hydration
Pain relief
Reassurance
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Mobilization
One to one care
A longer period of time to allow labour to
progress
Check for cause
Continued observation
Augmentation of labour
Attempt operative vaginal delivery (forceps, ventous )
Caesarean delivery
AUGMENTATION OF LABOUR :-
Increase the frequency and force of the existing uterine contractions
Methods: amniotomy oxytocin administration
OXYTOCIN
Capable of inducing uterine contraction in the third trimester
Contraindication: cephalopelvic disproportion and severe fetal malposition
Relatively safe in nulliparous women, less safe in multiparous women because of the
risk of hyperstimulation, fetal compromise and uterine rupture in face of obstruction
Oxytocin stimulation is not beneficial in prolonged latent phase as it causes the 10 fold
increase in caesarean section rates and 3 fold increase in low apgar scores in the neonates
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Oxytocin stimulation..response rate 70% nullipara & 80% multiparae in 3 hours
Early augmentation shortens labour and reduces the need of instrumental delivery in
2nd stage but does not affect the cesarean section rates
If no progress and fetal compromise then Cesarean section
Dilute 10 units oxytocin in 500ml normal saline
Initiate infusion at 0.5-2mU/min
Increase the dose by 1-2mU/min, until an adequate pattern of contractions is achieved
AMNIOTOMY
Amniotomy is another method to facilitate the uterine activity
After amniotomy the fetal head descends, pressing directly on cervix to enforce uterine
contraction. Accelerating labour
Prostaglandins are released that increase sensitivity of oxytocin receptors
Assess cephalopelvic relationship by a series of examination
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Mild cephalopelvic disproportion: trial labour
Obvious cephalopelvic disproportion: cesarean section.
PRECIPITATE LABOR:-
Labour lasting <3 hours
ETIOLOGY
More common in multipara; with
Strong uterine contractions,
Small size baby,
Roomy pelvis
Minimal soft tissue resistance
COMPLICATIONS:
• Genital trauma
• Laceration of cervix, vagina
• Uterine inversion
• PPH
• Fetal asphyxia due to increased uterine contractions
• Fetal ICH
• Trauma to baby due to risk of falling down
ABNORMAL LABOUR INDICATORS
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PROGNOSIS:
Good prognosis in multiparous than in nulliparous
Poor prognosis when diagnosis is made early in active phase before 6 cm
Poor prognosis when there is high station
CONSEQUENCES OF ABNORMAL LABOUR
Short Term On the Mother:
Postpartum hemorrhage.
Increased rate of traumatic complications: Lacerations, injuries to adjacent organs
Increased risk of infection (prolonged labour)
Increased rate of difficult operative delivery
Long Term Consequences:
Psychological effects of a Traumatic Experience
On the Fetus:
Increased rate of perinatal morbidity and mortality
Potential Complications of traumatic delivery
Low Apgar score
Neonatal complications (Birth Asphyxia, trauma
CONCLUSIONS
Efforts to identify abnormal labor and correct abnormal contraction patterns, fetal malposition,
and inadequate expulsive efforts may help eliminate many CS without compromising the
outcome for either mother or fetus
A-Active management of labor
B-Instrumental deliveries
C-CS
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BIBLIOGRAPHY
Dutta, DC (2011) Text Book. Of Obstetrics Including Perinatology and Contraception.
(7 ed), New Delhi, New Central Book Agency 357- 364
Bhaskar N. Midwifery & obstetrical nursing (2nd ed.) Bangalore; (2015) page no 464-465
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