Mgt of abnormal labor & partograph

abnormal labor

1. By
Gelaye Mandefro
Ambo University
Department of Medicine
September 2016
seminar on
Management of abnormal
labor and partograph
09/04/16 1

2. Outline of presentation
Introduction
Section I: Etiologies & management of abnormal labor
Abnormal patterns of labor
 Abnormalities of the passage
 Abnormalities of the passenger
 Abnormalities of the power
Section II: Partograph
09/04/16 2

3. Introduction
Normal Labor is a sequence of uterine contractions that results in
effacement and dilatation of the cervix and voluntary bearing-down
efforts leading to the expulsion per vagina of the products of conception
Abnormal labor is labor that deviates from the course of normal labor
several labor abnormalities that may interfere with the orderly
progression to spontaneous delivery=>dystocia
Without timely intervention, abnormal labor usually leads to prolonged
labor
 Maternal and neonatal complications are increased with increasing
duration of labor
One of the main objectives of monitoring labor is to detect abnormal
progress of labor before it is prolonged
09/04/16 3

4. Incidence of labor abnormalities
 Difficult to determine the exact incidence.
 In nulliparous patients, 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.
409/04/16

5. Etiologies
The causes of abnormal labor are generally fall in to the
following:
A.Abnormal patterns of labor
B. Abnormalities of the passage
C. Abnormalities of the passenger
D. Abnormalities of the power
09/04/16 5

6. Abnormal Patterns of Labor
Friedman described four abnormal patterns of labor
1.prolonged latent phase
2.protraction disorders (protracted active-phase dilatation and protracted descent)
3.arrest disorders (arrest of dilatation, arrest of descent, and failure of descent), and
4.precipitate labor disorders.
09/04/16 6

7. Disorders of latent phase
1. Prolonged latent phase
From the onset of regular uterine contractions to the beginning of the
active phase of cervical dilatation
The latent phase is abnormally prolonged if it lasts:
 more than 20 hours in nulliparas or
more than 14 hours in multiparas
Causes of prolonged latent phase include:
use of general anesthesia before labor enters the active phase,
labor beginning with an unfavorable cervix,
irregular, uncoordinated, and ineffective uterine contractions, and
fetopelvic disproportion
09/04/16 7

8. Prolonged latent phase…
Treatment options
primarily consist of therapeutic rest regimens or active management of
labor
Adequate rest
Rehydration
Oxytocin stimulation OR cesarean delivery for urgent problems.
If immediate delivery is required for clinical reasons (eg, severe
preeclampsia or amnionitis), oxytocin infusion is the treatment of
choice.
09/04/16 8

9. Diagnosis and management of prolonged latent phase of labor
9
Augmentation +
ARM
Note: If there is rupture of fetal
membranes and contractions
cease, manage her as PROM
09/04/16

10. Disorders of the Active Phase…
2. Protraction Disorders
May be divided into:
protracted active-phase dilatation and
 protracted descent
Protracted active-phase dilatation:
characterized by an abnormally slow rate of dilatation in the active
phase,
 less than 1.2 cm/h in nulliparas or less than 1.5 cm/h in multiparas.
 Protracted descent of the fetus:
Characterized by a rate of descent;
less than 1 cm/h in nulliparas or
less than 2 cm/h in multiparas.
The second stage of labor is protracted when the stage exceeds:
 2 hours in nulliparas or 1 hour in multiparas, or
3 and 2 hours, respectively, in the presence of conduction anesthesia.09/04/16 10

11. Protraction Disorders…
 Cause of a protraction disorder:
Is probably multifactorial
Inadequate uterine activity(the most common)
Fetopelvic disproportion
Abnormal positioning of the fetal presenting part
improperly administered conduction anesthesia
excessive sedation and,
pelvic tumors obstructing the birth canal
09/04/16 11

12. Protraction Disorders…
Treatment of protraction disorders:
 Depends on the presence or absence of fetopelvic disproportion, and
The adequacy of uterine contractions,
Cesarean section is indicated in the presence of confirmed fetopelvic
disproportion
In the absence of fetopelvic disproportion,
conservative management:
consisting of support and close observation, and
 therapy with oxytocin augmentation
both carry a good prognosis for vaginal delivery (approximately
two-thirds of patients)
09/04/16 12

13. 3. Arrest Disorders
The two patterns of arrest in labor can be characterized as follows:
secondary arrest of dilatation
 with no progressive cervical dilatation in the active phase of labor for 2
hours or more and
Arrest of descent
with descent failing to progress for 1 hour or more.
Causative factors:
fetopelvic disproportion(in approximately 50%)
fetal malpositions,
inappropriately administered anesthesia, and
excessive sedation.
Arrest disorders in the presence of adequate uterine contractions carry a poor
prognosis for vaginal delivery.
 If allowed to continue, arrest disorders are associated with increased perinatal
morbidity.
09/04/16 13

14. Management of abnormal active phase 1st stage of labor
1409/04/16

15. The diagnostic criteria of abnormal labor
1509/04/16

16. 4. Precipitate labor and delivery
Expulsion of the fetus in less than 3 hours
cervical dilation ≥ 5cm /hr in a primigravida
 ≥ 10cm /hr in a multipara.
Causes
abnormally low birth canal resistance
extremely strong uterine contractions
The absence of painful sensations
1609/04/16

17. Complications
 Maternal
uterine rupture
 extensive lacerations of the cervix, vagina, vulva, or perineum
PPH from uterine atony
Fetal
Perinatal mortality and morbidity
 intracranial hemorrhage
 risks associated with unattended delivery
 Management
 stop any oxytocin if being administered
 no significant use of analgesia
terbutaline or ritodrine intravenously
Physical attempts to retard delivery are absolutely contraindicated
1709/04/16

18. Abnormalities of birth canal (passage)
involve aberrations of pelvic structure and its relationship to the
presenting part
 The abnormalities may be related to:
 size or configurational alterations
soft-tissue abnormalities
 reproductive tract masses
 aberrant placental location.
Mechanism
For Contracted pelvis , the fetus has difficulty in passing through birth
canal.
The labor is protracted or arrested.
Secondary uterine inertia occurs.
1809/04/16

19. Assessment of the passages
Bony pelvis – clinical pelvimetry
Soft tissue dystocia – vaginal exam
Contracted pelvis:
Contracted Pelvic inlet
obstetric conjugate <10cm
diagonal conjugate<11.5cm
 greatest transverse diameter
is < 12 cm
1909/04/16

20. Assessment of the passages….
Contracted midpelvis:
convergence of side walls
prominence of ischial spines
Narrow interspinous
diameter.(normally 10cm)
Normally AP diameter =11.5
2009/04/16

21. Assessment of the passages…
Contacted Pelvic out let:
Intertuberous diameter < 8 cm
 narrow subpubic arch
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22. Diagnostic approach and risk assessment
Suspect CPD
Previous prolonged labor with bad
obstetric history or operative delivery
Primigravida especially if age < 16yrs
True conjugate of 8 – 10 cm (borderline
CPD)
Prominent ischial spines, flat sacrum etc

Gross CPD
 Estimated fetal wt ≥ 4kg
 Hydrocephalus
 Gross traumatic or congenital
pelvic abnormality
True conjugate and/or
bituberous diameter <8cm
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23. Abnormalities of birth canal…
Treatment plan
CS for gross CPD with normal fetus
 Hydrocephalus is managed by craniocentesis
 If gross CPD with normal fetus is dxed, elective CS –apro.
Suspected CPD:
 Plan place of delivery at a hospital
Conduct trial of labor using partograph
Emergency CS is done when CPD is diagnosed after trial of labor
N.B. Absolute CI of vaginal delivery after clinical or x-ray estimation
contracted pelvis is out dated, so trial of labor is necessary
2309/04/16

24. Abnormalities of fetus (passenger)
Abnormalities of fetal:
position,
presentation,
lie,
attitude
Macrosomia
Fetal malformation(hydrocephaly)
2409/04/16

25. Predisposing factors
Maternal:
Contracted pelvis
Pendulous abdomen
Pelvic tumors: fibromyomas,
Uterine anomalies: bicornuate
uterus, uterine septum etc.
Fetal:
Prematurity
Fetal attitude
Fetal anomaly
Poly/oligohydramnious
Multiple pregnancy
Placental & membranes:
Placenta previa
PROM
2509/04/16

26. Abnormalities of fetus (passenger)…
Diagnostic approach
Clinical assessment is usually diagnostic especially in labor with dilated
cervix through which Vaginal Exam. provides adequate information.
Ultrasound is mainly used to:
 investigate predisposing factors (e.g., placenta previa, fetal goiter)
 assess fetal condition
assess attitude of the fetus especially in breech
confirm clinical diagnosis etc
2609/04/16

27. Malposition and Malpresentation
Occiput posterior
The occiput is posterior in relation to the maternal pelvis
(contracted anthropoid or android)
Diagnosis:
Abdominal findings
Anteriorly palpable fetal limbs
Fetal heart heard in the flank
Vaginal findings
Posterior fontanelle towards the sacrum
Anterior fontanelle felt anteriorly if neck is flexed
2709/04/16

28. Occiput posterior…
Management plan
Gross CPD or any other indication for CS CS
⇒
No gross CPD, follow labor closely:
Anterior rotation to OA expect vaginal delivery as OA
⇒
Posterior rotation and if:
 borderline CPD suspected, perform CS
 Grossly adequate pelvic, expect vaginal delivery and manage labor
as OA including augmentation of labor if there are inadequate
uterine contractions.
The use of instrumental vaginal deliveries is also as in vertex
Anterior Position.
2809/04/16

29. Malposition and Malpresentation…
Persistent occiput transverse
No rotation of the OT position for 2 or more hours.
platypelloid or android pelvis
pelvic dystocia, uterine dystocia
Management: C/S
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30. Brow presentation
Partial extension of the fetal neck making the sinciput lower than the
occiput
rarest , o.o6% of all deliveries
Engagement can’t take place _ unless head is small or pelvis is very large
Diagnosis
Abdominal findings
 Occiput felt above sinciput
Vaginal findings
 Anterior fontanelle and orbit are felt
Mgt:-Cesarean delivery if:
 Suspected CPD or any other indication for CS
 Flexion to OP or extension to MP
Persistent brow
 Grossly adequate pelvis with:
Flexion/ extension to occiput posterior/MA expect vaginal delivery
⇒
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31. Face presentation (0.2% of all deliveries)
Hyperextension of the neck with the face being the
leading part
The widest diameter of the fetal head negotiating
the pelvis in face presentation is the
tracheobregmatic or submentobregmatic diameter
Associated risk factors: grand multiparity, advanced
maternal age, pelvic masses, multiple gestation,
polyhydramnios, macrosomia, congenital anomalies
Diagnosis
Abdominal findings
Groove may be felt between the occiput and
the back
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32. Face presentation…
Vaginal findings
Face palpated and the finger may get
into the mouth
The mouth with the two malar bone
prominences make a triangle (unlike in
breech where the anal orifice with two
trochanteric eminences are in a line)
MA: Chin anterior position
MP: Chin posterior
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33. Landmarks of fetal skull for determination of fetal position
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34. Management of Face presentation
Suspected CPD or any other indication for CS CS
⇒
MA:− Grossly adequate pelvis, manage labor as vertex anterior.
Augmentation and
forceps delivery can also be used when the indications arise.
Vacuum delivery is CI.
MP :− Cesarean delivery if:
Suspected CPD or any other indication for CS
Persistent brow (no rotation or late admission)
− Early admission with rotation to MA expect vaginal delivery
⇒
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35. Abnormal fetal lies (0.33% of all deliveries )
 Transverse or oblique
Causative factors: grand multiparity, prematurity(6 times more
frequently ), pelvic contraction, and abnormal placental implantation
Management option:
ECV to undergo vaginal delivery(3
rd
Tx ,)
Cesarean section(mandatory with onset of labor or membrane
rupture)
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36. Breech presentation (3–4% of all deliveries)
 a longitudinal lie with the fetal head occupying the
fundus
Occurs more frequently in second and early third
trimesters
Subtypes:
frank breech:a breech presentation with flexed
hips and extended knees
complete breech :flexion at both hips and knees
incomplete (footling) breech :extension of one or
both hips
Conditions that are associated with breech
presentation:
Multiple gestation
Polyhydramnios
Anencephaly
Uterine anomalies
previous breech presentation
09/04/16 36

37. Diagnosed: with Leopold maneuvers, pelvic
examination, U/S
Management of Breech Presentation
External cephalic version – applying pressure to
abdomen to turn fetus in a forward or backward
•Successful 50% of the time
Selection Criteria
•Preferred candidates have completed 37
weeks gestation
Risks
•Rupture of membranes
•Placental abruption
•Uterine rupture
Procedure
•Tocolysis with terbutaline
Cesarean delivery
Vaginal delivery
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38. Fetal Malformation
 hydrocephalus, with an incidence of 0.05%
distended bladder, ascites, or abdominal neoplasms; or other fetal masses
Shoulder dystocia
difficult delivery of the shoulders after delivery of the fetal head
0.6–1.4% of all vaginal deliveries
R/F:
estimated fetal weights >4500 g in nondiabetic patients and >4250 g in diabetic
patients
Other fetal causes of dystocia: Hydrocephalus, distended bladder, ascites,
enlarged kidneys or liver
3809/04/16

39. Shoulder dystocia…
Diagnosis
Shoulder dystocia is a subjective clinical diagnosis.
 It should be suspected when the fetal head retracts into the
perineum (ie, turtle sign) after expulsion due to reverse
traction from the shoulders being impacted in the pelvic inlet.
The diagnosis can be made when the routine practice of gentle,
downward traction of the fetal head fails to accomplish
delivery of the anterior shoulder.
09/04/16 39

40. Shoulder dystocia…
Maternal consequences
PPH- atony, laceration
Fetal consequences
 fetal morbidity and mortality
Brachial plexus injury due to down ward traction on the
brachial plexus during delivery of the ant shoulder
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41. Shoulder dystocia…
MX of shoulder dystocia
Techniques used to free the ant shoulder
from its impacted position
Moderate suprapubic pressure with
down ward traction to the fetal head
The MC Roberts maneuver
hyperflexion of maternal legs upon
to the abdomen
•Cause straightening of the sacrum
relative to the lumbar vertebrae
09/04/16 41

42. Shoulder dystocia…
Rubin
The fetal shoulders are rocked from
side to side by applying force to the
maternal abdomen
The pelvic hand pushes accessible
fetal shoulder toward the ant. surface
of the chest
results in abduction of both
shoulders
produce smaller shoulder to
shoulder diameter
Fracture of the clavicle
 by pressing the ant clavicle against
the ramus of the pubis
to free the shoulder impaction
Zavanelli maneuver
cephalic replacement into the pelvis
and then c/ delivery
09/04/16 42

43. Compound presentation(complicates 0.1% of deliveries)
A prolapsed extremity alongside the
presenting part
Hand with head.
 Hand with breach
 Leg with head
Mgt:-If suspected CPD or any other indication
for CS

⇒
CS
Closely monitor labor or put the woman in
the knee-chest position; push the arm above
the pelvic brim; and hold it there till a
contraction pushes the head into the pelvis:
If procedure succeeds, expect
vaginal delivery
If procedure fails or complication
arise (cord prolapse), deliver by CS
09/04/16 43

44. Abnormalities of the powers
it is the most important expulsive force.
Bring about dilation of cervix and expulsion of fetus and
placenta.
Common causes:
1° uterine inertia – abnormal uterine contraction frequency,
duration and intensity that is due to inherent myometrial
dysfunction
Mainly affects primigravid labors without other additional
factors
4409/04/16

45. Etiologies….
2° uterine inertia – causes
Prolonged labor
Malpresentations/ malpositions
Epidural analgesia
 Uterine myomata
Fetopelvic disproportion
Abruptio placentae
4509/04/16

46. Abnormalities of the powers…
2 categories
 Hypotonic
insufficient force, irregular or infrequent rhythm
Cause: Sedation, over distension of the uterus, early
administration of anesthesia
Rx: -augmentation(ARM or oxytocin)
-general labor support mgt

4609/04/16

47. Abnormalities of the powers …
Hypertonic
Uncoordinated and frequent intense uterine contractions
Midsegment of uterus has more pressure power than the
fundus
Cause: over use of oxytocin,
Rx:tocolysis, decrease in oxytocin infusion, or C/S
4709/04/16

48. Abnormalities of the powers …
Assessment of powers of labor
3 ways:
Palpation of uterine contractions
External tocodynamometer
Intrauterine pressure catheter monitoring
Clinical presentation
Abdominal palpation: uterine contraction is weak, and intervals is
prolonged.
Abnormal labor course: the most important clinical presentation.
4809/04/16

49. Abnormalities of the powers …
Management
The Vaginal examination: r/o CPD
To determine fetal presentation, position and station.
To assess the cephalopelvic relation.
To consider the route of delivery.
The supportive management
Sufficient rest
To relieve anxiety and fear.
Fluid and food intake.
4909/04/16

50. Abnormalities of the powers …
Augmentation
Increase the frequency and force of the existing uterine contractions.
Methods:
Amniotomy
oxytocin administration
Amniotomy :
If the fetal head is engaged, amniotomy is a choice to facilitate the uterine
activity.
After amniotomy the fetal head descends , pressing directly on cervix to
enforce uterine contractionÞ accelerating labor.
5009/04/16

51. Abnormalities of the powers …
Oxytocin
uterine contraction
CI:
CPD,
severe fetal malposition.
 placenta previa, brow presentation, face with MP, twin pregnancy,
extensive genital wart, cervical cancer, uterine scar, NRFHR
Secondary powers failure – Instrumental assistance
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52. Partogram
and detection of fetal condition in labor
09/04/16 52

53. Outline
Introduction
Partograph &its use
Observations charted on the Partograph
Abnormal Progress of Labor
Management of Labor
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54. Partograph
Graphic recording of the progress of labor
Recording of salient conditions of the mother and fetus
Early warning system
Uses
To detect abnormal labor
To indicate when augmentation of labor is appropriate
To recognize CPD
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55. WHO Partograph: Results of Study
All WomenAll Women Before Before
ImplementationImplementation
After After
ImplementationImplementation
pp
Total deliveriesTotal deliveries 1825418254 1723017230
Labor > 18 hoursLabor > 18 hours 6.4%6.4% 3.4%3.4% 0.0020.002
Labor augmentedLabor augmented 20.7%20.7% 9.1%9.1% 0.0230.023
Postpartum sepsisPostpartum sepsis 0.70%0.70% 0.21%0.21% 0.0280.028
Normal WomenNormal Women
Mode of deliveryMode of delivery
Spontaneous Spontaneous
cephaliccephalic
ForcepsForceps
8428 (83.9%)8428 (83.9%)
341 (3.4%)341 (3.4%)
7869 (86.3%)7869 (86.3%)
227 (2.5%)227 (2.5%)
<0.001<0.001
0.0050.005
WHO 1994.
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56. WHO’s partogram
Identification
Fetal condition
Progress of labor
Maternal condition
09/04/16 56

57. Observations charted on the Partograph
Progress of labor
Cervical dilatation
Descent of fetal head
Uterine contractions –duration, frequency
Fetal condition
Fetal heart rate
Membranes and liquor
Moulding of the fetal skull
Maternal condition
Pulse/ BP / Temp
Urine –volume, acetone, protein
Drugs & IV Fluids
Oxytocin regime
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58. Conditions that does not need the use of partograph
Antepartum hemorrhage
Severe pre-eclampsia and eclampsia
Fetal distress
Previous cesarean section
Malpresentation
09/04/16 58

59. Starting a Partograph
A partograph should be started only when a woman is in active
phase of labour
Contractions must be 1 or more in 10mins, each lasting for
20secs or more
Cervical dilatation ≥ 4cms
5909/04/16

60. 1.Progress of labour
In the centre of Partograph , along the left side are
numbers 0 -10 against squares ; each square represents
1cm dilatation.
The dilatation of Cx is plotted with an “X . Vaginal
‟
examinations are done at admission and once in 4 hours
Along the bottom of the graph are numbers 0-24;each
square represents 1hour
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61. Example
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62. Descent of fetal head
It is measured in terms of fifths above the pelvic brim
The width of the 5 fingers is a guide to the expression in fifths
of the head above the brim
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63. Descent of fetal head
2/5 = engaged 5/5=floating head
09/04/16 63

64. Descent of fetal head….
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65. Plotting the Descent of the Head
On the left hand side of the graph is the word “descent’ with
lines going from 5 –0
Descent is plotted with an “O’ on the Partograph
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66. Example 1
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67. Uterine Contractions
Observations are every half hour in active phase
Frequency -Number of contractions in a 10 minutes period
Duration –Measured in seconds from the time the contraction
sets in to the time the contraction passes off
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68. Recording Uterine Contractions
On the Partograph below the time line,
there are 5 blank squares going across
the length of the graph.
Each square represents 1 contraction
09/04/16 68

69. Example 2
6909/04/16

70. 2.Fetal condition
Fetal Heart Rate
Listen
Patient in left lateral position
Just after the contraction has passed its
strongest phase
For 1 full minute, if abnormal every 15mins
If abnormal over 3 observations, take action
Record Every half hour
09/04/16 70

71. Membranes & Liquor
State of Liquor &Record
Membranes intact I
Clear C
Meconium M
Absent A
Blood Stained B
09/04/16 71

72. Moulding
If bones Separate & sutures felt easily ……………….…………..O
If bones just Touching each other not over lapping ………….+
If bones overlapping &separate(reducible )digitally ………++
If bones severely overlapping ( Non – reducible ) …………...+++
Generally, summarized as “STONE”
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73. Example 3
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74. 3.Maternal Condition
Recorded at the foot of the Partograph
Oxytocin:dosage/unit& drop/min
Drugs:any drug & iv fliud
Pulse: every half hour
BP: every 4 hrs or more frequently(any problem)
Temp: every 4 hrs or more frequently
Urine: Protein ,Acetone ,Volume
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75. Example 4
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76. Abnormal Progress of Labor
Prolonged Active Phase
In the active phase, plotting of cervical dilatation will remain on the left of
or on the alert line
If it moves to the right of the alert line, labour may be prolonged
Transfer if facility for emergencies is not available
Carful reassessment of labour and decision on further management made

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77. Example 5
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78. At the Action Line
It is 4 hours to the right of Alert line
Assess the cause of slow progress and take action
Action may include; termination of preg, augmentation,
observation with supportive therapy
Remember
Reaching the action line means
POSSIBLE DANGER
Think possible cause manage accordingly
7809/04/16

79. Management of Labor
Normal Latent and Active Phases
Not intervene unless complications develop
ARM may be done at any time in the active phase
7909/04/16

80. Between Alert and Action lines
•In a Health Centre:
Transfer to hospital with facilities for Cesarean section, unless
Cervix is almost fully dilated
ARM may be performed if membranes are still intact and observe
labor for a short period before transfer
•In Hospital:
Perform ARM if membranes are intact and continue routine
observations
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81. THIS INTERVAL
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82. At or Beyond Active phase Action Line
Full medical assessment
Consider IV infusion/bladder catheterization
Options: Delivery if fetal distress or obstructed labor
Oxytocin augmentation if no contraindication
Supportive therapy (only if satisfactory progress is now established and
dilatation could be anticipated at 1cm/hr or faster)
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83. Exp.Dilatation that reaches the Action
•Cs done
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84. Example
•Inadequate uterine
contraction
corrected with
oxytocin
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85. References
Williams obstetrics, 24
th
edition
Current Obstetric & Gynecology. 2007
Management protocol on selected obstetric topics EFDRE-MOH, January,
2010
Up to dates 21.
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86. 09/04/16 86