Abnormal Labor

Abnormal Labor
Sara A.(M.D)
February 2013
• labor(eutocia)?
• Normal labor?
• True labor vs false labor?
• Stages of labor?
Friedman's curve of progress of labor
Abnormal Labor/Dystocia
 Definition
 a labor that deviates from the course of the
normal labor
 difficult labor or childbirth.
 The clinical diagnosis of dystocia often is
retrospective
Abnormal labor
 Incidence
 Nulíparas, 25% of all labors.
 Multiparas, 10% of all labors
 40% of the indications for C/S.
• 50% of primary C/S.
• 21% of repeat C/S.
Abnormal labor
 causes:
• the maternal pelvis (passage)
• the fetus (passenger)
• the expulsive forces (powers)
• or a combination of these factors
 abnomalities of the passage
• size or configurational alterations of the bony pelvis,
• soft-tissue abnormalities of the birth canal,
• reproductive tract masses or neoplasia,
• or aberrant placental location.
Abnormalities in the passage cont..
Types of bony pelvis
 Gynecoid:
 Classic female shape
 Oval shaped inlet
 Diverging pelvic sidewalls
 Far-spaced spines
 Found in almost 50 percent of women
 Anthropoid:
 exaggerated oval shape at the inlet, antero-posteriorly
• Often associated with delivery in occipto-posterior positions
• Found in about one third of women
 Android:
 male in pattern, heart shaped inlet
• Prominent sacral promontory and ischial spines
• Shallow sacrum
• Converging pelvic sidewalls
 platyploid:
 broad flat pelvis with exaggerated oval shaped inlet
transversely
• Predisposes to deep transverse arrest
• Pure varieties are found in fewer than 3 percent of
women
Bony pelvis
Abnormalities in the passage cont...
 Contracted pelvis
 Contracted inlet:diagonal conjugate<11.5cm
 Contraced mid pelvis: interspinous
diametr<8cm,prominent ischal
spine,converging pelvic sidewalls
 Contraced outlet: intertuberous diameter<8 cm,
narrow (acute angled) sub pubic arch,
 Abnormalitiesof the passenger
 Excessive size: risk factors include
• maternal diabetes,
• maternal obesity (> 70 kg),
• excessive maternal weight gain (> 20 kg),
• postdates pregnancy
• previous delivery of a macrosomic infant
 abnormalities of fetal position, presentation, attitude, or lie
 Congenital anomalies: hydrocephalus,
meningomylocele…
 Multiple gestation
 abnormalities of the power
• Hypotonia : contraction of the uterus with insufficient
force, irregular or infrequent rhythm, or both.
• Hypertonia: characterized by elevated resting tone of
the uterus, dyssynchronous contractions with elevated
tone in the lower uterine segment, and frequent intense
uterine contractions.
• Lack of voluntary expulsive effort in 2nd stage
 abnormal patterns of labor
• prolonged latent phase

• protraction disorders
• arrest disorders
• precipitate labor disorders
Abnormal patterns of labor cont....
 Prolonged Latent Phase
 if it lasts > 20 hours in nulliparas or 14 hours in
multiparas.
 Causes
• excessive sedation, conduction or general anesthesia
• labor beginning with an unfavorable cervix
• uterine dysfunction
• fetopelvic disproportion.
 Rx
• rest,hydration,send home if in false labor
• Augmentation with oxytocin
 Protraction Disorders
 Protracted cervical dilatation
• < 1.2 cm/h in nulliparas
• < 1.5 cm/h in multiparas.
 Protracted descent
• < 1 cm/h in nulliparas
• < 2 cm/h in multiparas.
 Protracted second stage
• > 2 hrs in nulliparas ,>3 hrs with conduction anesthesia
• > 1 hour in multiparas, > 2 hrs, with conduction anesthesia
 Protraction disordesr cont...
 C auses
• Fetopelvic disproportion
• malpositions such as occiput posterior,
• improperly administered conduction anesthesia excessive
sedation
• pelvic tumors obstructing the birth canal.
 Rx
• C/S if CPD
• Instrumental delivery
• Augmentation with oxytocin if in adequate contraction
Abnormal paterns cont...
 Arrest Disorders
 secondary arrest of dilatation
• no cervical dilatation for 2 hours or more
 arrest of descent
• with descent failing to progress for 1 hour or more.
 Causes
• fetopelvic disproportion
• various fetal malpositions (eg, occiput posterior, occiput transverse, face,
or brow)
• inappropriately administered anesthesia, and excessive sedation
 Rx
• C/S if there is CPD
• Oxytocin if inadequate uterine contraction
 Precipitate Labor
 delivery in <3 hrs from the onset of uterine contraction
 causes
 extremely strong uterine contractions or
 low birth canal resistance.
 Complications
 Maternal complications
• are rare if the cervix and birth canal are relaxed.
• when the birth canal is rigid and extraordinary
contractions occur: uterine rupture, Lacerations of the birth
canal, postpartum hemorrhage.
 Precipitate labor...
 Perinatal mortality is increased
• possible decreased uteroplacental blood flow,
• possible intracranial hemorrhage, and
• risks associated with unattended delivery.
 Rx
• Stop oxytocin if any
• Position in LLP
• sedation
Summary of abnormal patterns of labor
Obstructed labor
 Definition: failure of desent of the fetal
presenting part in maternal birth canal for
mechanical reasons despite the presence of
adequate uterine contraction
 Is an absolute not a relative condition.
 Important cause of maternal mortality and
longstanding morbidity
 Contribute to 7% of maternal death WW and
22% in Ethiopia
Obstruced labor cont...
 causes
 Cephalopelvic disproportion
 Contracted pelvis:neutritional
deficiency,trauma,genetics
 Malpositions: OP,OT,asynclitsm
 Big fetus
 Malpresentations
 Impacted transverse lie
 Breech presentation:big baby, aftercoming head
 Face presentation: persistent mento posterior position
 Causes cont...
• Brow presentation
• Compound presentation
• Shoulder dystocia
 Soft tissue abnormalities
• Cervical stenosis, viginal stenosis
• Myoma impacted in the pelvis
 Fetal abnormalities
• Hydrocephalus
• Hydrops fetalis
• Conjoined twins
• Fetal tumor
 Antecipation During ANC
• Short stature, small shoe no.
• Previous hx of dificul labor
• Contracted pelvis
• Obstetric palpation: malpresentation, twin
 Anticipations in labor
• Abnormal paterns of labor
 Clinical features
• Prolonged labor, prolonged rupture of membrane
• Pain, exhuastion & signs of dehydration
• Birth canal infection
• Blood stained urine
• Theree tumor abdomen: hard and tender upper and lower uterine
segment with distended balder and the pathological retraction/bandals
ring
• Edematous vulva and vigina/Kanula syndrom
• Cervix fully dilated with ruptured mambranes
• Moulding and caput
• Cause of obstructed labor such as malposition
• Fetal death
 Complications
 Maternal
• Dehdration, sepsis, acidosis
• Uterine rupture
• PPH
• Genital fistula
• Foot drop
• Secondary amenorrhea
 Fetal
• Asphyxia
• ICH, birth trauma, infection
 Management
 Obstruced labor must be relieved without delay
 General
• Correct fluid and electrolyte imbalance
• Control sepsis
• Catheterization
• Determine BG ,Rh, Hct, cross match
 Obstetric Mx
• C/S: alive baby, when destructive delivery is C/I
• Destructive
delivery(craniotomy,eviceration,cleidotomy,decaptation)
• symphysiotomy
 Prevention
 Good neutrition
 Avoid early marriage & early pregnancy
 Antenatal detection of possible causes
 Pelvimetry
 Elective C/S when indicated
 Follw labor with partograph,timely
intervention for prolonged labor
THE END

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Abnormal Labor

• prolonged latent phase

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