Abnormal Labor.pptx

Abnormal labor constitutes any findings that fall outside the accepted normal labor curve.

1. Post Graduate Interns CS JJA OCF PBEK Department of Obstetrics and Gynecology Abnormal Labor

2. Discussion Outline: ☆ Review of Normal Labor ☆Dystocia: Mechanisms & Complications ☆Labor disorders (Patterns, criteria, treatment)

3. REVIEW ON NORMAL LABOR

4. WHAT IS DYSTOCIA? “difficult labor” abnormally slow labor progress CATEGORIES: Power - poor uterine contractility and maternal expulsive effort Passenger - the fetus Passage - pelvis and lower reproductive tract

5. MECHANISMS OF DYSTOCIA UTERINE DYSFUNCTION power & passenger uterine contractions insufficient or uncoordinated overdistention, obstructed labor, or both CEPHALOPELVIC DISPROPORTION passenger & passage obstructed labor from disparity between the fetal head size and maternal pelvis

6. DIAGNOSTIC CRITERIA & MANAGEMENT LABOR PHASE: Labor Disorder Traditional Criteria and Treatment Obstetrical Care Consensus Criteria Nullipara Multipara Management LATENT PHASE : Prolongation Disorder Prolonged latent phase > 20 hrs > 14 hrs Supportive care Oxytocin/ amniotomy CD not indicated Supportive care Oxytocin/ amniotomy CD not indicated ACTIVE PHASE Protraction Disorders Protracted active-phase dilation < 1.2 cm/ hr 1.5 cm/ hr Expectant care CD for CPD CD not indicated Protracted descent < 1 cm/ hr < 2 cm/ hr Arrest Disorders Prolonged deceleration phase > 3 hrs > 1 hr CD for CPD No CPD: Oxytocin CD indications Ruptured membranes and no progress after 4 hrs of adequate contractions OR No progress after 6 hrs of inadequate contractions despite oxytocin stimulation Secondary arrest of dilation > 2 hrs > 2 hrs Arrest of descent > 1 hr > 1 hr Failure of descent No descent in deceleration phase/ second stage

7. COMPLICATIONS OF DYSTOCIA MATERNAL Postpartum hemorrhage Uterine rupture Pathologic ring of Bandl Pelvic floor injury PERINATAL Caput succedaneum and molding

8. Complications with Dystocia Infection Intrapartum chorioamnionitis or postpartum pelvic infection More common with desultory and prolonged labors Postpartum hemorrhage Due to uterine atony with prolonged and augmental labors Uterine tears with hysterotomy May occur if the fetal head is impacted in the pelvis Uterine rupture In women with high parity and in those with prior CS delivery Pathological Bandl retraction ring Associated with marked stretching & thinning of the uterine segment Maternal Complications

9. Complications with Dystocia Fistula formation Pressure necrosis (due to impaired circulation from prolonged 2nd stage) Can become evident after several days as a vesicovaginal, vesicocervical, or rectovaginal fistula Pelvic floor injury Due to direct compression from the fetal head and to downward pressure from maternal expulsive efforts May affect urinary or anal continence and pelvic support Lower extremity nerve injury Due to prolonged 2nd stage labor Most common mechanism: external compression of the common fibular nerve due to inappropriate leg positioning in stirrups especially during prolonged 2nd stage Maternal Complications

10. Labor disorders

11. LABOR DISORDERS

12. LABOR DISORDERS Remains in the latent phase (Friedman: <4 cm, or Zhang: <6cm)

13. LABOR DISORDERS Must be in the active phase of labor

14. LABOR DISORDERS Prolonged deceleration phase - cervical dilation arrested at 8-9 cm Secondary arrest of cervical dilation - no change in cervical dilation Failure of descent - fetal head remains at station “0” Arrest of descent - progressive descent stops during pelvic division of labor, station +1

15. LABOR DISORDERS Prolonged Second stage Nulliparas: Multiparas: >3 hrs (+) RA > 2 hrs (+) RA >2 hrs (-) RA > 1 hr (-) RA TREATMENT: Forceps/vacuum; CS

16. Power

17. ABNORMALITIES OF THE EXPULSIVE FORCES Uterine contractility Expulsive powers William’s Obstetrics 26th edition

18. ABNORMALITIES OF THE EXPULSIVE FORCES Uterine contraction Good power - should have fundal dominance lower limit of contraction pressure required to dilate the cervix is 15 mm Hg William’s Obstetrics 26th edition

19. ABNORMALITIES OF THE EXPULSIVE FORCES Uterine dysfunction HYPOTONIC UTERINE DYSFUNCTION (low uterine activity) HYPERTONIC UTERINE DYSFUNCTION aka Incoordinate Uterine Dysfunction (high uterine activity) Basal tone normal Normal gradient pattern with fundal dominance Pressure during contraction insufficient to dilate the cervix More common Basal tone elevated Complete asynchronism of the impulses originating from each cornu Gradient pattern is distorted Less common William’s Obstetrics 26th edition

20. ABNORMALITIES OF THE EXPULSIVE FORCES Maternal Pushing Efforts Combined force created by contractions of the uterus and abdominal musculature propels the fetus downward Factors that affect maternal pushing: Heavy sedation or regional reduce the reflex urge to push Intense pain created by bearing down overrides urge to push William’s Obstetrics 26th edition

21. Passenger

22. Fetopelvic Disproportion

23. FACE PRESENTATION

24. ETIOLOGY

25. Because face presentations among term-size fetuses - more common with some degree of pelvic inlet contraction, thus, cesarean delivery frequently is indicated. AVOID TO ATTEMPT: converting face presentation manually into a vertex presentation manual or forceps rotation of a persistently posterior chin to a mentum anterior position internal podalic version and extraction Management

26. Brow Presentation

27. Breech Presentation Occurs when the breech (fetal buttocks) or lower extremities present into the maternal pelvis Ethiopathogenesis Risk factors for Breech Presentation Complications of Breech Presentation Prematurity Uterine relaxation (multiparity) Multiple pregnancy Hydramnios, oligohydramnios Hydrocephalus Anencephaly Uterine anomalies/tumor Placenta previa Perinatal morbidity/mortality Low birth weight Prolapsed cord Placenta previa Uterine anomalies/tumors

28. Breech Presentation Diagnosis Vaginal Examination Frank Breech Presentation Lower extremities are flexed at the hips and extended at the knees The feet lie in close proximity to the head Findings: palpable fetal buttocks, anus, sacrum, ischial tuberosities Feet cannot be palpated

29. Breech Presentation Diagnosis Vaginal Examination Complete Breech Presentation One or both knees are flexed Both legs are at the hips Findings: Ischial tuberosities Sacrum Anus External genitalia

30. Breech Presentation Diagnosis Vaginal Examination Incomplete/Footling Breech Presentation One or both hips are not flexed One or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal Findings: One or both feet Sacrum cannot be palpated

31. Breech Presentation Management Vaginal Delivery may be attempted for the following: Frank or complete breech presentation Partial breech extraction (PBE) Complete or (total) breech extraction

32. Breech Presentation Management Cesarean Section is indicated for the following Maternal Factors Fetal Factors Pelvis is contracted or has an unfavorable shape Delivery is indicated Uterine dysfunction Lack of experienced operator for vaginal breech delivery Large fetus Hyperextended head (“stargazing breech”) Incomplete/Footling breech Healthy preterm fetus where delivery is indicated Severe IUGR Previous perinatal death/birth trauma

33. Transverse Lie The fetus’ long axis lies approximately perpendicular to that of the mother Shlulder is usually positioned over the pelvic inlet “Shoulder presentation” Always delivered by cesarean section

34. Transverse Lie Etiology Abdominal wall relaxation Preterm fetus Placenta previa Abnormal uterine anatomy Polyhydramnios Contracted pelvis

35. Transverse Lie Diagnosis No fetal pole is detected at the fundus The ballotable head is found in one iliac fossa and the breech in the other Position of back is readily identifiable When back is anterior, a hard resistance plane extends across front of abdomen

36. Transverse Lie Management Transverse Lie is usually an indication for Cesarean delivery

37. Compound Presentation an extremity prolapses alongside the presenting part, and both present simultaneously in the pelvis Causes of compound presentations are conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm labor

38. Compound Presentation Management

39. Passage

40. William’s Obstetrics 26th edition

41. William’s Obstetrics 26th edition

42. https://akusher-one.pdmu.edu.ua/ Fetopelvic disproportion -Arises from diminished pelvic capacity or from abnormal fetal size, structure, presentation or position -Any contraction of the pelvic diameter that diminished the pelvic capacity can create dystocia William’s Obstetrics 26th edition

43. Contracted Inlet Fetal biparietal diameter: 9.5-9. 8 cm Shortest AP diameter: <10 cm Greatest transverse diameter : <12cm Diagonal conjugate: <11.5 cm William’s Obstetrics 26th edition

44. Contracted Midpelvis More common finding Causes transverse arrest of fetal head difficult midforceps operation or CS Suspected interspinous diameter:<10 cm <8 cm midpelvis is contracted No precise method permits measuring spines are prominent, pelvic sidewalls converge or the sacrosciatic notch is narrow William’s Obstetrics 26th edition

45. Contracted Outlet Interischial tuberous diameter: <8cm or less Outlet contraction without concomitant midplane contraction is rare Increased narrowing of the pubic arch, occiput cannot emerge directly but is forced farther down the ischiopubic rami perineum becomes increasingly distended exposed to risk of laceration William’s Obstetrics 26th edition

46. Pelvic Fractures Trauma from automobile collisions was the most common cause. Fracture pattern, minor malaligment, and retained hardware not absolute indications for CS Fracture healing requires 8 to 12 weeks William’s Obstetrics 26th edition

47. Prematurely Ruptured Membranes at TERM Labor stimulation was initiated if contractipms did not begin after 6 to 12 hours Labor with intravenous oxytocin was preferred management Fewet intrapartum and postpartum infections Lower rates of chorioamnionitis, metritis, and NICU admissions for induced than expectant management Membrane ruptured longer than 18 hours, antibiotics are given as GBS infection prohylaxis

48. Precipitous Labor and Delivery Expulsion of the fetus in <3 hours Results from low resistance of the soft parts of the birth canal strong uterine and abdominal contractions lack of pain with contractions Maternal complications uterine rupture or extensive lacerations of the cervix, v

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50. Complications with Dystocia Perinatal Complications Fetal sepsis rises with longer labors Caput succedaneum and molding develop Mechanical trauma: Nerve injury Fractures Cephalhematoma

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