ABNORMAL LABOUR Dr Riffat Jaleel Assistant Professor OBGYN Unit II

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1 ABNORMAL LABOUR Dr Riffat Jaleel Assistant Professor OBGYN Unit II Abnormal Labour Failure to meet defined milestones & time limits for normal labour Phases of labour Assessment of progress in labour Progressive dilatation of cervix 1 cm / hr in primigravida cm / hr in multigravida Progressive descent of head PARTOGRAPH Cervicogram

2 Poor progress in labour Precipitate labour Malpresentations Fetal compromise Trial of uterine scar Multiple gestation Induced labour Types of abnormal labour Terminologies for poor progress of labour Poor progress of labour Non-progress of labour Dysfunctional labour Labour dystocia Cephalo-pelvic disproportion Obstructed labour Significance Prolonged/Abnormal labour results in high fetal & maternal morbidity & mortality due to obstructed labour, sepsis, ruptured uterus & postpartum hemorrhage Powers Passenger Passage Determinants Of Labour The Powers Dysfunctional uterine activity Inefficient uterine activity In-coordinate uterine activity Hypertonic but asynchronus uterine activity

3 Macrosomia Malpresentation Malposition Abnormal fetus The passenger Fetal tumours The passage Cephalopelvic disproportion Contracted pelvis Abnormal pelvis Bony tumours Fractures Soft tissue tumours of muscles / pelvic organs Cervical dystocia Developmental abn of genital tract Patterns of dysfunctional labour Prolonged latent phase Primary dysfunctional labour Secondary arrest

4 Indication Nullipara Multipara Prolonged latent phase >20 h >14 h Prolonged second stage without (with) epidural >2 h (>3 h) >1 h (>2 h) Protracted dilatation < 1.2 cm/h < 1.5 cm/h Protracted descent < 1 cm/h < 2 cm/h Arrest of dilatation* >2 h >2 h Arrest of descent* >2 h >1 h Prolonged third stage >30 min >30 min *Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours. (Please refer to the Pathophy information regarding adequate contractions.) Prolonged latent phase During latent phase changes occur in ground substance glycoprotien, collagen content & hydration state of cervix. These changes result in remodelling & effacement(shortening) of cervix. Median duration 8.6 hr, may last upto 20 hr in nullipara & 14 hr in multipara. Painful contractions Prolonged latent phase

5 CAUSES Unripe cervix Ineffective, inadequate uterine contractions Abnormal fetal position Unrecognized pelvic disproportion Dysfunctional labour Primary dysfunctional labour It is the prolonged active phase of first stage. Slow dilatation of active phase occurs in 25% primiparae & 10% multipara It is defined as rate of cervical dialtation <1.2cm/hr in primipara & <1.5cm/hr in multipara. CAUSE: Poor & incoordinate uterine contractions Cephalopelvic disproportion & Malposition such as ocipitoposterior position Primary dysfunctional labour Active phase disorders can be divided into two distinct groups. PROTRACTION DISORDER: When there is progressive but slow dilatation of cervix.(<1.2cm/hr in primigravida & <1.5cm/hr in multipara) ARREST DISORDER: When there is arrest of dilatation of cervix or descent of presenting part.(no dilatation in 2 hours or no descent for 2 hours in primigravida & for 1 hour in multipara) Secondary arrest Cessation of cervical dilatation following a normal period of active phase dilatation. It may occur in any stage of active phase. After a period of normal rate of cervical dilatation in active phase, no further dilatation occurs for a minimum time period of 2 hours. It results in flattening of curve in partogram over 2-4 hours.

6 It affects 6% of nullipare & 2% multiparae. Secondary arrest CAUSES: Cephalopelvic disproportion Contracted pelvis Malposition Complications of abnormal labour MATERNAL COMPLICATIONS Obstructed labour Sepsis. Ruptured uterus. Increased risk of operative delivery Increased risk of anaesthesia Increased risk of PPH Vesicovaginal fistula(following Obstructed labour) Complications of abnormal labour FETAL COMPLICATIONS Birth asphyxia Still birth Neonatal sepsis Cephalhaematoma Skull fractures Diagnosis of prolonged labour History Examination: depends on type & cause of prolonged labour & actual duration for which a woman is in labour Diagnostic aids PARTOGRAM: Graphic illustartion of patient s progress in labour as well as record of maternal & fetal observations. It is a valuable tool for managing intrapartum women. Helps in identifying slow progress in labour. Cervicogram is the portion of Partogram in which cervical dilatation in hours is plotted against time in hours & it also shows descent of presenting part with time.

7 prolonged latent phase Reassurance Adequate analgesia. Careful consideration before embarking on active management interventions e.g use of prostaglandins for cervical ripening. primary dysfunctional labour Optimization of maternal condition by adequate hydration, & pain relief. In 40% of women progress in labour improves by improving hydration. Provision of one to one care.(not necessarily a midwife; but any caregiver) A longer time period to allow labour to progress. Mobilization. Oxytocin augmentation.;70% of nullipare & 80% of multiparae respond. Caesarean section. secondary arrest Careful clinical assessment is required for the following before any intervention is undertaken. Estimate of fetal size Degree of engagement(5ths) Position of presenting part Signs of obstruction(moulding) Fetal well being(fhs, liquor) Descent of presenting part with contractions. Frequency of contractions Presence of pelvic masses Abnormalities of bony pelvis secondary arrest

8 After careful assessment, when oxytocin augmentation is done 60% of nullipara & 70% of multipara improve their progress but CS rate is 10 times increased. secondary arrest For secondary arrest of labour in second stage ( full cervical dilatation) after careful assessment of prerequisites & instrumental delivery my be considered. Caesarean section. Cephalo-pelvic disproportion Anatomical disproportion between fetal head and maternal pelvis Should be a retrospective diagnosis after a well conducted trial of labour Absolute & Relative Cephalo-pelvic disproportion Causes in mother: Contracted pelvis Abnormal pelvis; cong abn, acquired abn, metabolic bone disease, fracture, polio, tumour Causes in fetus: Macrosomia Malpresentation, malposition, asynclitism Abnormal fetus; hydroceph, hydrops, thyroid and neck tumours Cephalo-pelvic disproportion Diagnosis Poor progress or arrest of labour inspite of efficient uterine cont Fetal head not engaged Severe moulding, caput Cervix poorly applied to head Find cause Cephalo-pelvic disproportion Augmentation with oxytocin in a carefully selected patient Operative delivery Precipitate labour Labour lasting <3 hours.

9 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. THANKYOU

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