abnormal labor for midwifery students pptx

Obstetrics

1. Abnormal labor

2. Session outline Prolonged latent phase Protraction and arrest disorders Precipitate labor

3. Session objectives By the end of this session you are expected to: Differentiate between normal and abnormal Able to diagnose prolonged, protracted, arrested and precipitated labor Able to manage t h us labour abnormalities

4. Conti… What is normal labour ????????? Abnormal labor (DYSTOCIA ): Any deviation from the definition of normal labor is called an Abnormal labor . Many factors influence whether labor will progress normally and terminate in a safe vaginal delivery

5. Conti… The progression of labour is judged by two criteria: ( 1) The cervical dilatation. ( 2) Descent of the presenting part . Abnormal labour results in high: Fetal and maternal morbidity & mortality Due to obstructed labour , sepsis, ruptured uterus & postpartum hemorrhage …etc.

6. 1. PROLONGED LABOUR labor is said to be prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hours . considered prolonged when The cervical dilatation rate is less than 1 cm/ hr and Descent of the presenting part is < 1 cm/ hr for a period of minimum 4 hours observation (WHO-1994).

7. Conti… Labor is considered abnormal when Cervicograph crosses the alert line and falls on zone 2 and Intervention is required when it crosses the action line and falls on zone 3 Most of the errors occur when the condition is diagnosed As there is no progress while the patient is still in the latent phase or Even did not go into labour from the start.

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10. Conti… Labour Time Frames The mean and least normal rates of progress were historically established by Friedman in the early 1950s based on a mixed population of women . Nulliparous Parous Latent Phase Mean 6.4h 4.8h Longest normal* 20.1h 13.6h Active Phase Mean 3.0cm/h 5.7cm/h Slowest normal 1.2cm/h 1.5cm/h Second Stage Mean 1.1h 0.4h Longest normal* 2.9h 1.1h

11. Conti .. From MoH 2020 guideline

12. Causes of abnormal labour Prolonged labor is not a diagnosis but it is the manifestation of an abnormality, The cause of which should be detected by a thorough abdominal and vaginal examination.

13. Conti.. Causes of abnormal labour Powers Passenger Passage The Powers Dysfunctional uterine activity Inefficient uterine activity In-coordinate uterine activity Hypertonic but asynchronous uterine activity

14. Conti.. The passage Contracted pelvis Abnormal pelvis Bony tumours Fractures Soft tissue tumours of muscles / pelvic organs Cervical dystocia Developmental abnormality of genital tract

15. Conti… T he passenger: Malposition ( occipito -posterior) Malpresentation Big baby Congenital malformation Conjoined twins.

16. Conti… Second stage: Sluggish or non-descent of the presenting part in the second stage is due to: Fault in the power : ( 1) Uterine inertia ( 2) Inability to bear down ( 3) Epidural analgesia ( 4) Constriction ring.

17. Conti… Prolonged labor can be: FIRST STAGE PROLONGATION DISORDER Prolonged latent phase Active phase disorders SECOND STAGE DISORDERS

18. Conti… Classification of dysfunctional labor patterns Disorders of dilatation Prolonged latent phase Protracted active phase Arrest of dilatation Disorders of descent Protracted descent Arrest of descent

19. Prolonged latent phase Latent phase lasts more than 20 hours in nulliparas or 14 hours in multiparas, it is considered prolonged. You will encounter a long latent phase most commonly when labor began with an unprepared cervix ( i.e., one that was thick, uneffaced , and undilated ). Prolonged latent phase is not an indication for cesarean delivery.

20. Conti… Determining the length of the latent phase can be imprecise, because you cannot always ascertain the exact time of labor onset . The simple recognition of the fact that the latent phase may normally be quite long is very important; knowing its precise length is less critical . About 10% of patients with what seemed to be an abnormally long latent phase are later found to have been in false labor.

21. Conti… If there is a compelling reason not to lengthen the labor of your patient with a prolonged latent phase, such as the presence of preeclampsia, prolonged rupture of membranes or chorioamnionitis , oxytocin stimulation is appropriate. In fact, in such situations it is reasonable to begin oxytocin in the latent phase even before the limit of normal has been reached, in the hope of shortening the overall length of labor.

22. Conti… Following rest therapy about 10% of women awaken out of labor, and 85% are in the active phase. In the remaining 5%, the original condition recurs; contractions are ineffective in producing dilatation

23. Conti… Do not to perform amniotomy in these cases in an attempt to augment labor progress. Delivery may not occur for many hours, and having ruptured membranes raises the likelihood of infection

24. Active phase disorders Can be divided into: Protraction—slow progress Arrest disorders — no progress

25. Conti… If dilatation advances linearly, but at a rate below the limit of normal (1.2 cm/h in nulliparas ; 1.5 cm/h in multiparas), you should diagnose a protracted active phase dilatation. If, once in the active phase, cervical dilatation ceases for two hours, diagnose an arrest of dilatation .

26. A related abnormality is the prolonged deceleration phase, in which the deceleration phase exceeds 3 h in nulliparas or 1 h in multiparas . For practical purposes, you can use the time from 8 cm to complete dilatation to demarcate the deceleration phase.

27. Conti… If fetal descent is progressive, but slower than the expected minimum (1 cm/h in nulliparas , 2 cm /h in multiparas), protracted descent is present. When descent has become linear, and then ceases for one hour, an arrest of descent has occurred.

28. Another descent abnormality, failure of descent , is much less common, but very important because of its exceptionally strong association with disproportion. Diagnose failure of descent when you have observed no descent of the fetus from the latent phase through the deceleration phase or the beginning of the second stage

29. Conti… The most common cause of protraction and arrest abnormalities is CPD It is present in at least 25–30% of protraction and 40–50% of arrest disorders When your clinical pelvimetry identifies features consistent with a high probability of disproportion in the presence of any active phase or second stage abnormality, c/s is the safest approach.

30. ( A) Protracted active phase : Protracted active phase may be due to — ( i) Inadequate uterine contractions ( ii) Cephalopelvic disproportion ( iii) Malposition (OP) or malpresentation (brow) or (iv) Epidual anesthesia .

31. RISK FACTORS(CAUSES) Are generally denoted by the “three Ps” Power: Dysfunctional Uterine Contraction Passage: Contracted Pelvis Passenger: Macrosomia , Malpresentation , malposition Labor abnormality can be as a consequence of combination of the three Ps

32. SIGN AND SYMPTOM Failure of or poor progress of labor is a sign of abnormal labor (see the classification) NB : Clinical Pelvimetry is used Intrapartum to check for adequacy of the pelvis in case of prolonged second stage in primigravid .

33. INVESTIGATIONS Diagnosis of labor abnormality is mainly clinical by close observation of progress of labor and Appropriate use of Partograph .

34. COMPLICATIONS If not managed timely, abnormal labor will contribute to bad maternal, fetal and neonatal outcome. Complications include: Obstructed labor, obstetric fistula, etc Uterine rupture, hemorrhage, sepsis and maternal death Fetal distress, asphyxia, and death

35. Management of labour abnormalities You should not institute any therapy for arrest or protraction disorders before you adequately investigate the fetopelvic relationships. Is directed towards the stage and cause of abnormal labor RULING OUT FALSE LABOR False labor is characterized by change in cervical effacement and dilatation after 4 to 8hours of revaluation. Once false labor is ascertained explain to the woman (relatives ) about false labor, true labor and danger symptoms of pregnancy and labor . Discharge the woman if she has no other problem requiring inpatient management. Give psychological support for the mother

36. Managing latent phase abnormalities Dysfunctional uterine contraction is treated by augmentation of labor if there is no contraindication. Scarred cervix due to operations such as conization or cautery may lead to prolonged first stage of labor. In such scenario C/S delivery should be considered Management of latent phase abnormality in the presence of malpresentations and malposition depends on the specific abnormality.

37. MANAGING ACTIVE PHASE ABNORMALITIES Crossing the alert line, thorough assessment of the mother, fetus and progress of labor should be done to identify the cause. In the absence of adequate uterine contractions: Provide labor support: Sometimes rehydration, emptying the bladder and encouraging the woman to be more active and move around or adopt an upright position. Consider ARM and augmentation if no contraindication Re-evaluation 2-4 hours later

38. Conti… Presence of adequate labor progress with above interventions ( Cervicogram remains or to the left of the action line):Expect vaginal delivery Inadequate labor progress despite intervention ( Cervicogram crosses the action line): Cesarean delivery

39. Conti… Crossing the action line: When cervical dilatation crosses this line, action must be taken immediately depending on identified cause. Management options of dysfunctional uterine contraction include performing ARM, rehydration, augmentation of labor. Presence of contraindication for augmentation, features of CPD or non-reassuring fetal status (thick meconium, NRFHR) are indications for emergency caesarean section delivery.

40. Managing second stage abnormalities Abnormal progress in the second stage is entertained if there is not progressive descent (or head rotation to a favorable position) with uterine contraction. Management depends on identified cause and presence of complications. Management options are: Augmentation of labor (particularly in primigravid ), Caesarean delivery, instrumental vaginal delivery (in the absence of contraindications) or Destructive vaginal delivery (if prerequisites are fulfilled)

41. Summary Management: Reassessment of the condition. 2 . Pain relief : Pethidine or epidural analgesia. 3 . Amniotomy : if membranes still intact. Oxytocin: if amniotomy does not bring good uterine contractions and there is no contraindication for it. 4 . Caesarean section is indicated in : 1-Failure of the above measures. 2- Disproportion. 3- Malpresentations not amenable for vaginal delivery. 4- Contraindications to oxytocin. 5- Foetal distress.

42. Precipitated labor

43. An abnormally fast, tumultuous labor in which Cervical dilatation occurs quickly and Descent of the presenting part is rapid is called precipitate labor. It has been variously defined according to length as a labor of two to four hours when the combined duration of the first and second stage is less than three hours.

44. Conti… Rapid expulsion is due to the combined effect of: hyperactive uterine contractions associated with diminished soft tissue resistance . you can diagnose precipitate dilatation or precipitate descent. This is an objective clinical entity and can be identified graphically

45. Causes and risk factors Conti … Etiologic factors are not clearly defined, but precipitate labor may occur even in the presence of heavy sedation and m ild disproportions

46. Conti… Results: From uterine contractions that occur too frequently and too intensely in conjunction with Excessive oxytocin administration is an iatrogenic cause. Negligible resistance of maternal soft parts. When precipitate labor occurs spontaneously, it is generally unpredictable and unpreventable .

47. Conti… This perspective disregards the latent phase, which may or may not be short, and concentrates on unusually rapid dilatation and descent. Using this approach, when cervical dilatation or fetal descent is greater than 5 cm/h in nulliparas or 10 cm/h in multiparas ,

48. Complications Precipitate labor may be injurious to both mother and baby. Maternal risks include: Extensive laceration of the cervix, vagina and perineum (to the extent of complete perineal tear ) PPH due to uterine hypotonia that develops subsequent to unusual vigorous contractions Inversion Uterine rupture Infection Amniotic fluid embolism.

49. Conti… The fetal risks include Intracranial stress and hemorrhage because of rapid expulsion without time for moulding of the head. The baby may sustain serious injuries If delivery occurs in standing position; bleeding from the torn cord and direct hit on the skull are real hazards.

50. It is often associated with fetal bradycardia , probably from head compression during rapid descent, meconium passage, brachial plexus palsy or, in rare cases, intracranial bleeding, can occur.

51. Managements The most you can do is try to control the expulsion of the fetus, making sure the head extends as it crosses the perineum. Thoroughly examine the birth canal after delivery to detect and then Repair injuries to uterus, cervix, vagina or perineum if happened.

52. Conti… The patient having previous history of precipitate labor should be hospitalized prior to labor. During labor, the uterine contraction may be suppressed by administering ether or magnesium sulfate during contractions . Delivery of the head should be controlled. Episiotomy should be done liberally. Elective induction of labor by low rupture of membranes and conduction of controlled delivery is helpful. Oxytocin augmentation should be avoided