Abnormal Labour of people in Scotland who .pptx

Abnormal labour

1. ABNORMAL LABOR Ahmmed Vidad , Aleena Eliza, Aleena Emil

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

3. CAUSES OF ABNORMAL LABOUR OR DYSTOCIA (ACOG) 1. Abnormalities of power Abnormal uterine action (most common causes) Inadequate maternal expulsive effort 2.Abnormalities of the Passenger Malposition(occipitoposterior) Malpresentation (face, brow, shoulder, breech and compound) Macrosomia Fetal malformations(hydrocephalus, fetal tumours, fetal ascites )

4. 3.Abnormalities of the Passage Contracted pelvis and cephalopelvic disproportion Soft tissue abnormalities (congenital anomalies of uterus and vagina, myomas and ovarian tumours)

5. Complications

6. DISORDERS OF FIRST STAGE Prolongation disorders Prolonged latent phase Protraction disorders Protracted active phase dilatation Arrest disorders Arrest of dilatation

7. Prolonged latent phase Painful uterine contractions are present for an extended period of time, without entering the active phase of labour. A standard duration of the latent phase has not been established and can vary widely from one woman to another. Labour may not naturally accelerate until 5 cm cervical dilatation is reached. Hence the use of interventions to accelerate labour and birth before 5 cm is not recommended, provided fetal and maternal conditions are reassuring. A prolonged latent phase does not cause danger to the mother or baby and so the management is usually conservative.This involves reassurance, bed rest, proper hydration, analgesia and ambulation.

8. Protraction disorders The active phase is from 5 cm cervical dilatation until full dilatation . Active phase usually does not extend beyond 12 hrs in a nullipara,beyond 10 hrs in multipara. Neither protraction disorders nor arrest disorders should be diagnosed before 6 cm.

9. Protracted active phase dilatation When cervical changes continue in the active phase of labour, but over a longer time period than anticipated, protracted active phase dilatation is diagnosed. Causes :inadequate uterine activity (most common) Malposition like occipitoposterior position. Cephalopelvic disproportion and macrosomia

10. Arrest disorders Arrest of dilatation Active phase commences normally, but then there is arrest in cervical dilatation. ACOG defines arrest of dilatation as no cervical dilatation after 6cm with 4 hrs of adequate contractions or 6 hrs of inadequate contractions. Causes :inadequate uterine activity (most common) Malposition like occipitoposterior position. Cephalopelvic disproportion and macrosomia

11. DISORDERS OF SECOND STAGE The second stage of labour is defined as the period from complete cervical dilatation to delivery of the fetus The second stage is identified to have two phases; a pelvic and a perineal phase In the pelvic phase, the cervix is fully dilated, but the presenting part is higher up In the perineal phase the presenting part is deep down in the pelvis and exerts pressure on the rectum.

12. M edian duration of the second stage is about one hour in a nullipara and 30 min in a multipara, but the range is highly variable T he second stage has been considered prolonged if it lasts for more than 2 hrs in a nullipara or 1 hr in a multipara A prolonged second stage is associated with increased maternal (chorioamnionitis, instrumental delivery and PPH) and fetal risks (low Apgar scores, birth depression and ICU admission).

13. 1. Protracted descent This is defined as descent of the presenting part in the second stage of labour at less than 1 cm/hr in nullipara and less than 2 cm/hr in multipara. 2. Arrest of descent Arrest of descent in the second stage refers to no progress in decent

14. Causes • Inadequate uterine activity • Poor maternal expulsive efforts • Malposition • Macrosomia • CPD

15. Management Management of the second stage of labour can be difficult and decisions should be individualised. General measures like correction of dehydration and acidosis are carried out as described above. 1. If the head is below the ischial spines and low down in the pelvis, instrumental vaginal delivery with low forceps or vacuum can be carried out, provided all the conditions are Satisfied. Currently the RCOG recommends the vacuum extractor as the first choice although both are comparable in experienced hands. 2. If the head is not low cephalopelvic disproportion is a possibility especially in the presence of excessive caput and moulding. In such cases, caesarean section is better.

16. 3. If there is no cephalopelvic disproportion, the cause is likely to be either malposition (deep transverse arrest) or poor uterine action. Provided there is no maternal or fetal distress and the pelvis is normal, oxytocin can be used for augmentation with caution. Cardiotocography monitoring is mandatory in such cases. If the head does not descend, caesarean section is better. In a multipara - oxytocin augmentation might increase the risk of rupture. 4. The use of epidural analgesia is another cause for prolonged second stage. In these cases, stopping the analgesia infusion and allowing more time can reduce the chance of instrumental delivery. Allowing time will usually help the woman regain the sensory urge to push.

17. OTHER ASSOCIATIONS WITH UTERINE DYSFUNCTION Epidural Analgesia The first stage duration is not increased with an appropriately timed epidural. However, if an epidural is given in the latent phase the duration of the first stage may be prolonged. Hence usually an epidural is only instituted when the woman enters the active phase and the cervix is 5 cm dilated. The incidence of caesarean delivery is the same with and without an epidural. However instrumental delivery may be more with an epidural.

18. Chorioamnionitis Infection in labour is a marker of caesarean section and associated with dysfunctional labour. But it may also be that chorioamnionitis is a consequence of prolonged labour, rather than its cause. Maternal Position in Labour Ambulation in labour is shown to be associated with shorter labours, decreased need for analgesia and oxytocin and reduced frequency of instrumental delivery. However, most women prefer the lying down or sitting position once active labour begins. If lying down, a left lateral position may be better. Ambulation is not harmful and the woman can be given the choice.

19. MANAGEMENT 1. Use of the partogram : A key adjunct to management is the use of some form of labour curve. The WHO partogram can be used for this, but should be plotted only after 5 cm cervical dilatation. Partogram is the graphical record of the progress of labour. The alert line and the arbitrary rate of 1 cm/hr cervical dilatation is not recommended today to diagnose prolonged labour or for augmentation of labour. However, in health care facilities where interventions such as augmentation and caesarean section cannot be performed and where referral-level facilities are difficult to reach, the alert line could still be used for triaging women who may require additional care.

20. 2. Assessment of cause Inadequate uterine action • Malposition (occipitoposterior position) • Cephalopelvic disproportion • Macrosomia • Malpresentation like brow or face • Fetal causes (tumours, hydrocephalus, etc) If the cause is CPD, macrosomia or malpresentation, caesarean section is indicated. If these are ruled out and labour is pronged, labour can be augmented with oxytocin. In about 70% of cases, inadequate uterine action or malposition is the cause for prolonged labour in nulliparous women. Oxytocin augmentation if used in multiparous women should be with extreme caution, due to the risk of hyperstimulation and rupture uterus.

21. 3.General measures IV fluids are given to correct dehydration and acidosis. Antibiotics are necessary to combat infection. Adequate analgesia is given. If epidural analgesia is available, it would be preferred. 4.ARM It should be employed only when the patient is in active labour and the cervix is well applied to the head. Amniotomy in the latent phase for augmentation of labour is not advocated. It should not be done in early labour.

22. 5.Oxytocin Augmentation The next step is oxytocin infusion if the contractions are inadequate. Clinical judgement should be used prior to using oxytocin. There should be no evidence of cephalopelvic disproportion or malpresentations. It is effective for correcting inadequate uterine action and in cases of occipitoposterior position. 6.Indication for Caesarean Section -Cephalopelvic disproportion -Malpresentation -No progress with oxytocin

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