Mudaliar

and
Menon’s
Clinical
Obstetric
s
13TH EDITION
 Chapter 44
ABNORMAL
LABOUR
AND
DYSTOCIA
DUE TO
ANOMALIES
OF THE
EXPULSIVE
FORCE

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NORMAL LABOUR
First stage of labour
It begins with regular uterine contractions and ends with complete cervical dilatation at 10
cm.
It is divided into a latent phase and an active phase.
Latent phase: begins with the onset of true labour pains and ends when the cervix is 4 cm
dilated.
The active phase of labour extends from 4 cm dilatation until full cervical dilatation and the
contractions become progressively more rhythmic and stronger.
Second stage of labour
It begins with full cervical dilatation and ends with the delivery of the baby.

Third stage of labour

This stage extends from the delivery of the baby to the delivery of the placenta.

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 In the first stage of labour:
1. Uterine contractions
2. Resistance offered by the cervix
FACTORS
3. Forward pressure exerted by the fetal head
INFLUENCING
In the second stage of labour:
NORMAL
LABOUR 1. Mechanical relationship between the fetal
head (size and position)
2. Pelvic capacity (fetopelvic relationship)

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Normal uterine activity
From early pregnancy, contractions known as Braxton Hicks contractions occur, which are
painless, irregular and intermittent contractions, not associated with the dilatation of the cervix
or descent of the presenting part.
True labour pains are painful, more frequent and last longer, associated with the dilatation of
the cervix and the descent of the fetus.
Cervical dilatation is the result of a balanced action between the upper and the lower segments
known as polarity.
Pain is felt by the woman when the intrauterine pressure exceeds 15 mmHg.
Baseline pressure 5-10 mmHg
Early labour 3-5 min interval for 30-60 20-30 mmHg
sec
Active labour 2-4 min duration for 60-90 30-50 mm Hg
sec
Pushing 100-150 mmHg

In normal progressive labour, the contractions of the fundus rise quickly to a maximum and are
strong and sustained. The middle zone of the uterus contracts simultaneously, but less intensely
and for a shorter time, while the lower segment remains inactive, and its tone is low.

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Recording uterine activity
The frequency and duration of contractions - cardiotocography (CTG)
machine.
Intrauterine pressure - internal tocography.
The uterine contractions are expressed in Montevideo (MVU) units. A uterine
contraction is considered adequate when it exceeds 200 MVU for a 10-minute
contraction.

Partograph
A partograph is a graphical representation of the progress of labour based on
the rate of cervical dilatation and descent of the presenting part.
Simple and inexpensive tool.
Any deviation from the normal progress is considered abnormal labour.
The original partograph was designed by Friedman.

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 The time at which a woman is seen
with 4 cm dilatation is recorded as 0
hour; the actual time at 0 hour is
noted in the time column
Cervical dilatation is marked with
an X
Vaginal examination is performed
every 2–4 hours, and the cervical
dilatation is noted
The progress of labour is
considered normal when the labour
curve of the woman falls to the left
of the alert line

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ABNORMAL LABOUR
Also known as dysfunctional labour or labour dystocia.
It refers to the abnormally slow progress of labour.

Etiology
1. Abnormality of the uterine contractions and maternal expulsive efforts
2. Abnormalities of the presentation and position or weight of the fetus
3. Abnormalities of the maternal pelvis (contracted pelvis)
4. Abnormalities of the soft tissue of the reproductive tract

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Power  Hypotonic uterine action
 Hypertonic uterine action
 Incoordinate uterine action
 Precipitate labour
 Inadequate maternal powers
Passenger  Large size of the fetus, which leads to CPD
 Occipitoposterior position
 Malpresentations with face, brow and shoulder
 Fetal anomalies such as hydrocephalus, fetal ascites, etc.
Passage  Contracted pelvis
 CPD
 Abnormalities of the soft parts interfering with the labour progress

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 Advanced maternal age
Nulliparity
Short maternal stature
Obesity
Contracted pelvis/CPD/obstructed labour
Malposition and malpresentations

RISK FACTORS Macrosomia

ASSOCIATED WITH Post-term pregnancy (>41 weeks)
LABOUR DYSTOCIA
Uterine overdistension
Injudicious use of oxytocic agents, induction of labour
Medications
Chorioamnionitis
Prelabour rupture of membranes
Psychological factors
Maternal exhaustion or motor blockage from epidural
analgesia
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COMPLICATIONS OF LABOUR
DYSTOCIA
Maternal complications: Neonatal complications:
Obstructed labour Risk of meconium-stained fluid
Maternal exhaustion and dehydration Increased risk of neonatal infection
Genital tract injuries/rupture Increased risk for birth asphyxia
Increased risk of both instrumental and Low APGAR scores
operative deliveries
Admission to NICU
Atonic postpartum hemorrhage
Increased risk of chorioamnionitis and
postpartum endometritis Delayed complications:

Pelvic injuries Pelvic floor dysfunction

Vesiscovaginal fistula (VVF)

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DISORDERS OF THE FIRST STAGE OF
LABOUR
Prolonged latent phase
Prolonged latent phase was defined by Friedman and Sachtleben (1963) as one exceeding 20
hours in the nullipara and 14 hours in the multipara.
Risk factors
An unripe cervix at the onset of labour
Occipitotransverse or posterior positions
Cephalopelvic disproportion
Weak uterine contractions
Induction of labour
Prelabour rupture of amniotic membranes
Early administration of regional anesthetic with heavy motor block
Heavy sedation

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MANAGEMENT
After excluding CPD, malposition and malpresentation, expectant
management is recommended
The maternal and fetal parameters should be checked
The presence of a supportive partner, regular attention to the bladder,
maintaining the fluid balance and relieving the woman’s fear and anxiety
Supine position should be avoided - supine hypotension and compromise the
blood flow to the fetus.
Pain relief
Ambulation should be encouraged.
Labour can be augmented with oxytocin infusion.
Amniotomy should be avoided in the latent phase of labour

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 ACTIVE-
PHASE
DISORDERS
Protraction disorders and
Arrest disorders
1. Protracted active phase:
According to the WHO
partograph, cervical
dilatation of <1 cm/hour
for a minimum of 4 hours
is considered protracted
labour.

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MANAGEMENT
If there is cephalopelvic disproportion, cesarean
section is indicated
Fluid balance and pain relief
Amniotomy—in prolonged labour, in the active phase.
Increases local prostaglandin levels, which, in turn,
increase the strength and frequency of uterine
contractions
Oxytocin—for hypotonic uterine contractions, to
achieve 3–4 strong contractions every 10 minutes
If there is a failure to progress despite oxytocin
augmentation, a cesarean section should be performed

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2. Arrest of dilatation:
According to the WHO
partograph, arrest of
dilatation is defined as
complete cessation of
cervical dilatation for >2
hours with good uterine
contraction in the active
phase of labour.

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Rule out mechanical factors such as CPD,
malposition and malpresentations.
Caution should be taken before augmenting
labour with oxytocin infusion. Most such cases MANAGEMENT
require a cesarean section.

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DISORDERS OF THE SECOND
STAGE OF LABOUR
In protracted descent, the descent of the presenting part is <1 cm/hour in
a nullipara and <2 cm/hour in a multipara.
In the arrest of descent, there is no progress in descent for >2 hours in a
nullipara and for >1 hour in a multipara.
Causes:
Cephalopelvic disproportion
Malpresentation and malposition
Primary inefficient uterine contractions, myometrial fatigue
Maternal exhaustion and poor expulsive efforts
Regional anesthesia
Soft tissue dystocia due to rigid perineum

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Labour can be augmented with oxytocin once
CPD is ruled out.
If the presenting part is below +2 station and
there is no disproportion, the baby can be
delivered by forceps or vacuum. MANAGEMENT

If the woman is in the active phase of

pushing, maternal expulsive efforts should be
encouraged.

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 Labour patterns Diagnostic criteria Treatment Exceptional
treatment

PROLON Nullipara Multipara

GED Prolongation disorder

Bed rest Oxytocin

SECOND Prolonged latent >20 hr

phase
>14 hr

STAGE Protraction disorders

A prolonged second Protracted active <1.2 <1.5 Expectant Caesarean delivery

stage is associated with phase dilatation cm/hr cm/hr management —CPD
increased maternal
Protracted <1 cm/hr <2 cm/hr
risks including descent
chorioamnionitis, Arrest disorders
postpartum
hemorrhage, operative Secondary arrest >2 hr >2hr Rule out CPD, Cesarean section
vaginal delivery and of dilatation malposition
Oxytocin
third- and fourth- augmentationif CPD
degree perineal ruled out
lacerations and fetal Head below +2
asphyxia. Arrest of descent >2 hr >1 hr station—
instrumental
delivery

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Recommendations of Obstetric Care Consensus
Committee (2016)
A prolonged latent phase is not an indication for
cesarean delivery.
Protraction disorder - managed with
observation, assessment of uterine activity and
stimulation of contractions as required.
A cervical dilation of 6 cm and not 4 cm is now
the recommended threshold for active labour.
Cesarean delivery for active-phase arrest ‘should
be reserved for women at or beyond 6 cm of
dilation with ruptured membranes who fail to
progress despite 4 hours of adequate uterine
activity or at least 6 hours of oxytocin
administration with inadequate contractions and
no cervical change’.

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Recent revisions made to the criteria for the diagnosis of
abnormal labour by partograph (WHO, 2018)
The latent phase of labour lasts upto 5 cm dilatation.
Active phase of labour is said to start at 6 cm dilatation
and hence, the partograph should be plotted from 6 cm
dilatation.
Arrest of labour in the first stage should be defined as
more ≥6cm dilatation with ruptured membranes and one
of the following - 4 hours or more of adequate
contractions or 6 hours or more of inadequate
contractions and no cervical change.

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Hypotonic uterine dysfunction Hypertonic uterine dysfunction
• Low or no basal tone, the interval • Elevated resting pressure, frequent
between the contractions is long and the contractions that last for a longer time and
contractions are weak, lasting for <40 a delay in return to baseline uterine tone.
seconds each insufficient to dilate the • Causes: Oxytocic drugs such asoxytocin
cervix or prostaglandins- misoprostol and in
• Leads to prolonged labour which can be obstructed labour, especially in a
easily identified on a partograph multigravida

•Rule out CPD, malposition and •Oxytocin infusion - stopped

malpresentations •Left lateral position oxygen through a face
•Labour can be augmented with ARM and mask
oxytocin infusion •0.25 mg terbutaline injection s/c
•Careful monitoring should be continued •Fetal hypoxia - cesarean section

DYSTOCIA DUE TO ABNORMALITIES OF THE

EXPULSIVE FORCE

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INCOORDINATE UTERINE ACTION
Type of hypertonic dysfunction, wherein the frequency, duration and intensity
of contractions are irregular.
Despite strong contractions, cervical dilatation proceeds slowly.
The woman is usually anxious and distressed, which makes the incoordination
worse.
Labour is prolonged.
Management: Adequate analgesia and fluid balance. Stimulation of the uterus
by oxytocin is best avoided.
Conditions such as elderly primiparity and disproportion or malpresentation,
when found in association with incoordinate uterine action - immediate
cesarean section.

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 Pathological ring Constriction ring
Occurs in prolonged second Occurs in prolonged first,
Tonic uterine contraction stage second or third stage
Occasionally, the uterus goes
into tetanic contractions, Always between upper and Could develop at any level of
wherein there is no relaxation, lower uterine segments the uterus
and the contractions last for 2–
3 minutes. Uterus rises The position of the uterus does
not change
Tetanic contractions are
highly dangerous and lead to
fetal death, abruption and Felt and seen abdominally Diagnosis is usually made at
rupture. the time of cesarean section

The uterus should be relaxed Uterus is tonically retracted and The uterus is not tonically
using uterine relaxants, and an tender; fetal parts cannot be retracted; fetal parts can be
immediate cesarean section felt felt
carried out.
Maternal and fetal distress , Maternal and fetal distress
fetal death may occur may not be present

Relieved only by delivery of the May be relieved by aesthetics

fetus and antispasmodics

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OTHER ABNORMAL LABOURS
Precipitate labour
Precipitate labour, otherwise called rapid labour, is defined as the
expulsion of the fetus in less than three hours of the onset of labour
Etiology
A multipara with abnormally low resistance and
relaxed pelvic or perineal floor muscles
Multipara with spontaneous, unusually strong and forceful
contractions
Hypertonic uterine contractions following induction or
augmentation with oxytocic agents
A previous history of precipitate labour

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COMPLICATIONS
Maternal complications Fetal complications
Lacerations of the cervix, Fetal asphyxia
vaginal walls and perineum
Intracranial hemorrhage
Uterine rupture
The cord may snap, leading to
Uterine atony - PPH severe hemorrhage before
assistance is available
Infection
Inversion of the uterus

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 As precipitate labour is very rapid, it is most
often recognised only after it has occurred.
The use of tocolytics or general anesthesia to
impair uterine contractility has been attempted.

MANAGEME Oxytocic agents – discontinued immediately.

NT After delivery – examine for any tears – suture

with antiseptic precautions.
The third stage of labour must be carefully
conducted.

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CERVICAL DYSTOCIA
When the cervix fails to dilate even in the presence of good, regular uterine
contractions, it is called cervical dystocia. There are two types of cervical
dystocia.
Primary cervical dystocia Secondary cervical dystocia
• Seen in primigravidae • Excess scarring or rigidity of the
• The external os of the cervix fails to cervix
dilate and remains rigid
• Overactive sympathetic tone or
excessive fibrous tissue.

Management
The general condition of the woman is monitored based on maternal pulse
and blood pressure; hydration and ketoacidosisare monitored and corrected as
required.
Careful monitoring of the fetal heart is important. Malposition and
malpresentations should be ruled out. The labour should be monitored using a
partograph. Cervical dystocia usually manifests as protraction or arrest disorder
in the first stage of labour.
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