ABNORMAL LABOUR.pptxnnnnnnnnnnnnnnnnnnnnn

abnormal labor

1. Modulator : Dr . Dagmawi ( Oby / gyn Resident, R2) YIRGALEM HOSPITAL MEDICAL COLLEGE SEMINAR PRESENTATION ON ABNORMAL LABOR DEPARTMENT OF OBY/GYN Presenters: Beza T. (C-1) Dinkayehu G. (C-1)

2. Presentation Outline Definition of abnormal labor Etiologies of abnormal labor Classifications of abnormal labor patterns Diagnosis of abnormal labor Evaluation for causes of abnormal labor patterns Management options of abnormal labor patterns 2 1/9/2025 ABNORMAL LABOR

3. NORMAL LABOR Labor is a sequence of uterine contractions that results in effacement & dilatation of the cervix and voluntary bearing-down efforts leading to the expulsion per vagina of the products of conception. 1/9/2025 ABNORMAL LABOR 3

4. NORMAL LABOR ( EUTOCIA) Labor is called normal if it fulfills the following criteria;- Spontaneous in onset . Parturient without any risk (e.g., Pre- eclampsia , Previous scar, etc.), At term. With vertex presentation. Without undue prolongation. Natural termination with minimal aids. Without any complications affecting the health of the mother and/or the baby . 1/9/2025 ABNORMAL LABOR 4

5. False labor pains are: Dull in nature Confined to lower abdomen & groin Not associated with hardening of the uterus They have no other features of true labor pains as discussed above Usually relieved by enema or sedative . Not associated with show 1/9/2025 ABNORMAL LABOR 5

6. CLASSIFICATION OF LABOR Normal labor is classified as: First stage of labor: The period between onset of regular uterine contractions to full cervical dilatation. It is subdivided into two phases: Latent phase: The phase of labor between the onset of regular uterine contraction to 5 cm of cervical dilatation. Active phase: The phase of labor after 5 cm of cervical dilatation. 1/9/2025 ABNORMAL LABOR 6

7. CLASSIFICATION OF LABOR Second stage of labor: The stage of labor between full cervical dilatation and delivery of the last fetus. Third stage of labor: The stage of labor between delivery of the last fetus and delivery of the placenta & membranes . Fourth stage of labor : begins after delivery of placenta & fetal membranes, stage of immediate purepurium & ends after 2 hours. 1/9/2025 ABNORMAL LABOR 7

8. T he minimum rate of acceptable cervical dilation during the active phase of labor was 1.2 cm/hour for nulliparous patients and 1.5 cm/hour for multiparous patients,   1/9/2025 ABNORMAL LABOR 8

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10. DIAGNOSTIC CRITERIA OF TRUE LABOR Regular, rhythmic uterine contractions (≥ 2 contractions in 10 minutes) with one or more of the following: Rupture of the membranes. Cervical dilatation of 4 centimeters. Cervical effacement of ≥ 80 %. Bloody show (If fetal membranes are ruptured or if digital vaginal examination was done within the past 48 hours, show shouldn‘t be used as diagnostic criteria.) 10 1/9/2025 ABNORMAL LABOR

11. 1) Power Powers refer to the forces generated by the uterine musculature. Characteristics of normal uterine activity during labor are The relative intensity of contractions is greater in the fundus than in the mid portion or lower uterine segment (fundal dominance); T he average value of the intensity of contractions is more than 24 mm Hg (in the active phase of labor, pressures often increase to 40–60 mm Hg); 11 1/9/2025 ABNORMAL LABOR

12. 1/9/2025 12 contractions are well synchronized in different parts of the uterus; the basal resting pressure of the uterus is between 12 and 15 mm Hg; the frequency of contractions progresses from 1 every 3–5 minutes to 1 every 2–3 minutes during the active phase; ABNORMAL LABOR

13. T he duration of effective contraction in active labor approaches 60 seconds; and T he rhythm and force of contractions are regular. 1/9/2025 ABNORMAL LABOR 13

14. In the example shown, there were five contractions producing pressure changes of 52, 50, 47, 44, and 49 mm Hg, respectively. The sum of these five contractions is 242 Montevideo units. 1/9/2025 ABNORMAL LABOR 14

15. Dystocia Dystocia literally means difficult labor and is characterized by abnormally slow labor progress. Powers — poor uterine contractility and maternal expulsive effort. Passenger — the fetus. Passage — the pelvis and lower reproductive tract 1/9/2025 ABNORMAL LABOR 15

16. Incidence of Dystocia Difficult to determine the exact incidence. Dx is usually retrospective. In nulliparous pts , the incidence of labor disorders is ≈ 25%. Dystocia is currently the most common (50 - 60%) indication for 1˚ C/S, 3X more common than either NRFHRP or Malpresentation . 16 1/9/2025 ABNORMAL LABOR

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18. Dystocia To describe ineffective labors, two commonly used terms are cephalopelvic disproportion (CPD) and failure to progress. CPD describes disparity between the fetal head size and maternal pelvis. F ailure to progress in either spontaneous or stimulated labor, has become an increasingly popular description of ineffectual labor. 1/9/2025 ABNORMAL LABOR 18

19. ABNORMALITIES OF THE EXPULSIVE FORCES 1) Hypotonic uterine dysfunction, basal tone is normal and uterine contractions have a normal gradient pattern(synchronous). However, pressure during a contraction is insufficient to dilate the cervix. 2) Hypertonic uterine dysfunction or incoordinate uterine dysfunction , either basal tone is elevated appreciably or the pressure gradient is distorted. 1/9/2025 ABNORMAL LABOR 19

20. Risk Factors for Uterine Dysfunction Neuraxial analgesia Chorioamnionitis A higher station at the onset of labor maternal age Maternal obesity F etal weight and parity 1/9/2025 ABNORMAL LABOR 20

21. Labor Disorders L atent phase may be prolonged: w hich is defined as >20 hours in the nullipara and >14 hours in the multipara. 1/9/2025 ABNORMAL LABOR 21

22. Labor Disorders Active-phase Disorders: P rotraction disorder - slow progress. An arrest disorder - halted progress. To be diagnosed with either of these, a woman must be in the active phase of labor. 1/9/2025 ABNORMAL LABOR 22

23. Labor Disorders Active-phase Protraction P rotraction has been defined as <1 cm/ hr cervical dilation for a minimum of 4 hours If hypotonic contractions are strongly suspected ,internal monitors may be placed with amniotomy and again cervical change and contraction pattern are reassessed. Deficient Montevideo units and poor active labor progress typically prompts oxytocin augmentation. 1/9/2025 ABNORMAL LABOR 23

24. Labor Disorders Active-phase Arrest: D efined as no dilation for ≥2 hours, in 5 percent of term nulliparas . Inadequate uterine contractions, defined as <180 Montevideo units. 1/9/2025 ABNORMAL LABOR 24

25. Labor Disorders First, the latent phase should be completed, and the cervix is dilated ≥4 cm. Uterine contraction pattern of ≥200 Montevideo units in a 10-minute period has been present for ≥4 hours without cervical change. 90 percent of women achieve 200 to 225 Montevideo units, and 40 percent achieve at least 300 Montevideo units after oxytocin augmentation. 1/9/2025 ABNORMAL LABOR 25

26. Labor Disorders Obstetric Care Consensus Committee: 1) A prolonged latent phase should not be the sole indication for cesarean delivery. 2) A protraction disorder. This instance is typically managed with observation, assessment of uterine activity. 3 ) The active phase beginning at 6 cm . 5 cm as the active-labor threshold ( WHO, 2018) 1/9/2025 ABNORMAL LABOR 26

27. Labor Disorders 4 ) Active-phase arrest is best reserved for women with cervical dilation ≥6 cm and ruptured membranes who fail to progress despite 4 hours of adequate uterine activity or despite at least 6 hours of oxytocin administration but inadequate contractions. 5) These recommend that a nullipara push for at least 3 hours and a multipara push for at least 2 hours before second-stage labor arrest is diagnosed. 1/9/2025 ABNORMAL LABOR 27

28. Labor Disorders Second-stage Descent Disorders The second stage in nulliparas has been limited to 2 hours and extended to 3 hours when regional analgesia is used. For multiparas, 1 hour has been the limit, extended to 2 hours with regional analgesia. 1/9/2025 ABNORMAL LABOR 28

29. Labor Disorders However, of maternal outcomes of prolonged second stage are : higher rates of chorioamnionitis , Anal sphincter injury, operative vaginal birth, and postpartum hemorrhage 1/9/2025 ABNORMAL LABOR 29

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31. Maternal Pushing Efforts The combined force created by contractions of the uterus and abdominal musculature propels the fetus downward. Compromised by Options Heavy sedation or regional analgesia intense pain emotional support encouragement, parenteral analgesia, pudendal blockade, Neuraxial analgesia 1/9/2025 ABNORMAL LABOR 31

32. PREMATURELY RUPTURED MEMBRANES AT TERM A pproximately 8 percent of pregnancies. In the past, labor stimulation was initiated if contractions did not begin after 6 to 12 hours. L ower rates of chorioamnionitis , metritis , and neonatal intensive care unit admissions for women with term ruptured membranes whose labors were induced compared with those managed expectantly. 1/9/2025 ABNORMAL LABOR 32

33. PREMATURELY RUPTURED MEMBRANES AT TERM H ypotonic contractions or with advanced cervical dilation, oxytocin is selected. U nfavorable cervix, no or few contraction, and no significant fetal heart rate decelerations, prostaglandin E1 (misoprostol) is chosen to promote cervical ripening and contractions. 1/9/2025 ABNORMAL LABOR 33

34. PRECIPITOUS LABOR AND DELIVERY Precipitous labor and delivery is extremely rapid labor and delivery. Precipitous labor terminates in expulsion of the fetus in <3 hours. V igorous uterine contractions combined with a long, firm cervix and a noncompliant birth canal may lead to uterine rupture or extensive lacerations of the cervix, vagina, vulva, or perineum. 1/9/2025 ABNORMAL LABOR 34

35. PRECIPITOUS LABOR AND DELIVERY Precipitous labors have been linked to cocaine abuse and associated with: Placental abruption Meconium Postpartum hemorrhage, and Low Apgar scores 1/9/2025 ABNORMAL LABOR 35

36. PRECIPITOUS LABOR AND DELIVERY Analgesia is unlikely to modify these forceful contractions significantly. The use of tocolytic agents such as magnesium sulfate or terbutaline is unproven in these circumstances. T he risk of associated uterine atony if delivery is imminent. Certainly, oxytocin administration should be stopped. 1/9/2025 ABNORMAL LABOR 36

37. 1/9/2025 ABNORMAL LABOR 37 Case scenario This is G3(both alive, SVD) and her previous deliveries were uneventful, admitted to YGH at 3: 00 DLT, up on evaluation her vital signs were stable, FHB= 140, cervix was 6cm dilated and membrane was ruptured. After following with partograph for 4hrs, she had 4 strong contaction per 10 minute and her cervix remain 6cm dilated. How do you proceed to manage? To augment with oxytocin To do emergency c/s for cervical dilatation arrest.

38. 2) Maternal Pelvis (Passage) The passage consists of the: bony pelvis (composed of the sacrum, ilium, ischium, and pubis) and the resistance provided by the soft tissues. 38 1/9/2025 ABNORMAL LABOR

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43. Gynecoid pelvis F emale type Most favorable for uncomplicated vaginal delivery. Pelvic inlet has an oval configuration TD slightly greater than the APD Pelvic side walls are straight, ischial spines are not prominent, subpubic arch is wide, and the sacrum is concave. 43 1/9/2025 ABNORMAL LABOR

44. Android pelvis Male type Inlet is wedge-shaped with convergent side walls, Ischial spines are prominent, Subpubic arch is narrowed, and The sacrum is inclined anteriorly in its lower third. Associated with persistent occiput posterior position and deep transverse arrest. 44 1/9/2025 ABNORMAL LABOR

45. Anthropoid pelvis Inlet is oval, APD>TD Pelvic side walls are divergent, and S acrum is inclined posteriorly. O ften associated with persistent occiput posterior position 45 1/9/2025 ABNORMAL LABOR

46. Platypelloid Pelvis characterized by a transverse diameter that is wide with respect to the anteroposterior diameter. commonly associated with deep transverse arrest 46 1/9/2025 ABNORMAL LABOR

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48. FETOPELVIC DISPROPORTION Fetopelvic disproportion arises from: D iminished pelvic capacity or From abnormal fetal size, structure, presentation, or position. The pelvic inlet, midpelvis , or pelvic outlet may be contracted solely or in combination. Any contraction of the pelvic diameters that diminishes pelvic capacity can create dystocia. 1/9/2025 ABNORMAL LABOR 48

49. Contracted Inlet T he fetal biparietal diameter averages from 9.5 to 9.8 cm. The incidence of difficult deliveries rises when either the anteroposterior diameter of the inlet is <10 cm or the transverse diameter is <12 cm. 1/9/2025 ABNORMAL LABOR 49

50. Contracted Inlet Inlet contraction usually is defined as a diagonal conjugate <11.5cm. The anteroposterior diameter of the inlet is also called the obstetrical conjugate. It is commonly approximated by manually measuring the diagonal conjugate, which is approximately 1.5 cm greater. 1/9/2025 ABNORMAL LABOR 50

51. Contracted Inlet In contracted pelves , however, because the head is arrested in the pelvic inlet, the entire force exerted by contractions acts directly on the portion of membranes. Consequently, early spontaneous rupture of the membranes is more likely. 1/9/2025 ABNORMAL LABOR 51

52. Contracted Inlet A contracted inlet also plays an important part in the production of abnormal presentations. If the inlet is contracted considerably or if asynclitism is marked . 1/9/2025 ABNORMAL LABOR 52

53. Contracted Midpelvis M idpelvis extends from the inferior margin of the symphysis pubis through the ischial spines and touches the sacrum near the junction of the fourth and fifth vertebrae. M ore common than inlet contraction. 1/9/2025 ABNORMAL LABOR 53

54. Contracted Midpelvis Interspinous diameter is 10 cm. Anteroposterior diameter at level of ischial spine is 11.5cm. The midpelvis is likely contracted when the sum of the interspinous and posterior sagittal diameters of the midpelvis . normally, 10.5 plus 5 cm, or 15.5 cm—falls to13.5 cm or less. 1/9/2025 ABNORMAL LABOR 54

55. Contracted Midpelvis Midpelvic contraction is suspected whenever the interspinous diameter is <10 cm. When it measures <8 cm, the midpelvis is contracted. 1/9/2025 ABNORMAL LABOR 55

56. Contracted outlet These pubic rami unite at an angle of 90 to 100 degrees to form a rounded arch under which the fetal head must pass. A rch under which the fetal head must pass Contracted pelvis suspected when the inter ischial tuberous diameter is 8 cm or less. 56 1/9/2025 ABNORMAL LABOR

57. Contracted outlet Palpating the subpubic arch- it should be acute. A contracted outlet is often associated with midpelvic contraction. Disproportion at the outlet may not give rise to severe dystocia, but may cause perineal tears. 1/9/2025 ABNORMAL LABOR 57

58. 3) Fetus (Passenger) 1.Fetal size : Fetal macrosomia (birth weight greater than 4,500 g)= ACOG 2.Lie : other than longitudinal lie is abnormal 1/9/2025 ABNORMAL LABOR

59. Face Presentation The rate is approximately 0.1 percent of births T he neck is hyperextended so that the occiput is in contact with the fetal back, and the chin ( mentum ) is presenting. Preterm fetuses, High parity, anencephaly, congenital goiter are predisposing factors. 1/9/2025 ABNORMAL LABOR 59

60. How can we differentiate face presentation from breech? Breech presentation finger encounters muscular resistance with the anus. Meconium stained fingers The ischial tuberosities and anus lie in a straight line. Face presentation T he bony, less-yielding jaws and palate are felt through the mouth. The mouth and malar eminences form a triangular shape. 1/9/2025 ABNORMAL LABOR 60

61. Mechanism of Labor The fetal face may present with the chin ( mentum ) anteriorly, transversely, or posteriorly. 1/9/2025 ABNORMAL LABOR 61

62. Chin anterior, internal rotation of the face brings the chin under the symphysis pubis. Once the chin clears the symphysis , the neck can flex. The nose, eyes, brow, and occiput then appear in succession over the anterior margin of the perineum. birth of the head, the occiput sags backward toward the anus. 1/9/2025 ABNORMAL LABOR 62

63. Mx – fetal heart rate monitoring is best done with external devices low or outlet forceps delivery of a mentum anterior Vacuum application C/I Manual rotation of chin or head 1/9/2025 ABNORMAL LABOR 63

64. Brow Presentation Rates range from 0.1 to 0.2 percent of births the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet . 1/9/2025 ABNORMAL LABOR 64

65. Mechanism of labor Engagement is impossible until marked molding shortens the occipitomental diameter or, more commonly, until the neck either flexes to an occiput presentation or extends to a face presentation. Except when the fetal head is small or the pelvis is unusually large, engagement of the fetal head and subsequent delivery cannot take place Mx – C/S for persistent brow 1/9/2025 ABNORMAL LABOR 65

66. Transverse Lie The fetus’ long axis lies approximately perpendicular to that of the mother. T ransverse lie complicates approximately 0.3 percent of births. Common causes include abdominal wall relaxation from high parity, preterm fetus, placenta previa , abnormal uterine anatomy, hydramnios , and contracted maternal pelvis . 1/9/2025 ABNORMAL LABOR 66

67. shoulder presentation in which the side of the mother on which the acromion rests determines the designation of the position as right or left acromial . In addition, the back may be directed anteriorly or posteriorly and also superiorly or inferiorly. 1/9/2025 ABNORMAL LABOR 67

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69. Transverse Lie Mechanism of Labor Spontaneous delivery of a fully developed newborn is impossible with a persistent transverse lie. With time, a uterine contraction ring rises increasingly higher and becomes more marked. An extreme form is the Bandl ring, described in the complication section. With a neglected transverse lie, the uterus will eventually rupture. 1/9/2025 ABNORMAL LABOR 69

70. Transverse Lie Frequent association with placenta previa , umbilical cord prolapse, and fetal manipulations during cesarean delivery. If the fetus is small—usually <800 g—and the pelvis is large, spontaneous delivery is possible despite persistence of the abnormal lie . 1/9/2025 ABNORMAL LABOR 70

71. Transverse Lie The head and thorax then pass through the pelvic cavity at the same time referred to as conduplicato corpore . Mx – c/s With dorsoanterior or back down position, neither the fetal feet nor head occupies the lower uterine segment, a vertical hysterotomy incision is typically indicated. 1/9/2025 ABNORMAL LABOR 71

72. Umbilical Cord Prolapse Risk factors hydramnios , contracted pelvis breech presentation transverse lie premature or small fetus with weight <2500 g preterm rupture of membranes , and multifetal gestation grand multiparity a distorting leiomyoma müllerian uterine anomal y 1/9/2025 ABNORMAL LABOR 72

73. Umbilical Cord Prolapse Mx – knee chest position - T redlimberg position Finally C/S 1/9/2025 ABNORMAL LABOR 73

74. Compound Presentation An incidence of 1 in 1000. an extremity prolapses alongside the presenting part, and both present simultaneously in the pelvis. 1/9/2025 ABNORMAL LABOR 74

75. Mx - If it fails to retract and if it appears to prevent descent of the head , the prolapsed part can be pushed gently upward and the head simultaneously downward by fundal pressure. 1/9/2025 ABNORMAL LABOR 75

76. COMPLICATIONS WITH DYSTOCIA M aternal infection Postpartum hemorrhage Uterine tears Uterine rupture pathological retraction ring of Bandle Fistula formation Lower-extremity nerve injury Caput succedaneum and molding 1/9/2025 ABNORMAL LABOR 76

77. REFERENCES Williams obstetrics, 26 th edition. Gabbe obstetrics, 8 th edition. Dutta text book of obstetrics, 8 th edition. Up to date 21.6 Management protocol on selected obstetric cases, 2021. 1/9/2025 ABNORMAL LABOR 77

78. THANK YOU !! 1/9/2025 ABNORMAL LABOR 78