poor progress of labour

1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1
POOR PROGRESS OF
LABOUR
Dr.M.Thirukumar
Consultant obstetrician and Gynaecologist
Teaching Hospital
Batticaloa

2. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2
What is the importance?
•1/3 of caesarean section, mainly in
nulliparous –due to poor progress of labour.
•Uncommon in multiparous- only in 2%
•The rates of dystocia differs among
practitioners mainly due to difference in
labour management.
•Success in decreasing the incidence of
dystocia among nulliparous will have impact
on overall rate of caesareans birth

3. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3
Labour
•Regular, frequent uterine
contraction which leads to
progressive cervical
effacement and dilatation
to culminate progressive
descend of fetus to have
vaginal delivery.

4. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4
Progress of Labour
•Effacement (thinning)
•Dilatation (opening)
•Descent (progress through the
birth canal)
•Delivery of the baby and
placenta

5. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5
The Labour Curve
•First stage - A: latent phase; B + C + D: active phase; B: acceleration; C:
maximum slope of dilation; D: deceleration; E: second stage.
Adapted from: Friedman. Labor: Clinical evaluation and management,
2nd ed, Appleton, New York 1978.

6. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6
Definition of the first stage
•Latent first stage of labour – when
-there are painful contractions, and
-there is some cervical change, including cervical
effacement and dilatation up to 4 cm.
•Established first stage of labour – when:
regular painful contractions, and
progressive cervical dilatation from 4 cm.

7. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7
Disorders of labour
•3 major disorders
1)prolonged latent phase
2)primary dysfunctional labour
3)secondary arrest

8. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8

9. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9
Latent Phase Labour
•<4 cm dilated
•Contractions may or may
not be painful
•Dilate very slowly
•Can talk or laugh through
contractions
•May last days or longer
•May be treated with
sedation, hydration,
ambulation or rest.

10. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10
•During latent phase changes occurs in
-collagen content of the cervix
-ground substance of the cervix
-hydration state of the cervix
so remodelling effacement of the cervix occur

11. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11
•Duration of latent phase
• Primi -20 hours(average-8.6 hours)
•Multi -14 hours(average 5.3 hours)

12. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12
Management of latent phase
•Reassurance
•Pain relief
•Mobilisation
•Augmentation with oxytocin increases
-caesarean rates by 10 fold
-3 fold increase in law apgar score

13. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13
Active Phase Labour
•At least 4 cm dilated
•Regular, frequent, usually
painful contractions
•Dilate at least 1.2-1.5 cm/hr
•Are not comfortable with
talking or laughing during
their contractions

14. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14
Duration of the first stage
•varies between women,
•first labours last on average 8 hours and
are unlikely to last over 18 hours.
• Second and subsequent labours last on
average 5 hours and are unlikely to last
over 12 hours.

15. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15
Definition of delay in the established
first stage
• needs to take into consideration all aspects
of progress in labour and should include:
•cervical dilatation of less than 2 cm in
4 hours for first labours
•cervical dilatation of less than 2 cm in 4
hours or a slowing in the progress of labour
for second or subsequent labours

16. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16
•descent and rotation of the fetal head
•changes in the strength, duration and
frequency of uterine contractions.

17. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17
Primary dysfunctional labour
•Poor progress in active phase of labour(up to
7 cm dilation of the cervix)
•Affects 26% of nullipara
8% of multipara

18. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18
Causes of dystocia
•1)inefficient uterine activity is a significant
factor. Due to
-induction of labour
-inadequate stimulation of contraction
-failure of uterine response to stimulation
•2) relative disproportion due to deflexion of
the fetal head-OPP,asynclitism,inaduate
cephalic flexion

19. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19
•3) Cephalo pelvic dispropotion

20. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20
Possible outcome of primary
dysfunctional labour
•It leads to-obstructed labour
- infection
- uterine rupture
-PPH
•70% of nullipara and 80% of multipara will
respond to oxytocin

21. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21
Secondary arrest
•Cessation of cervical dilation following a
normal period of active phase dilatation.
i.e after 7 cm of cervical dilation
•Affects 6% of nulliparae and 2 % of
multiparae
•CPD is more likely to be associated with it

22. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22
Assessment in secondary arrest
•1) fetal size-fundal height >40 cm in this
stage is due to large baby
•2)degree of engagement(fifth palpable)
•3)position of the presenting part
•4)signs of obstruction
•5)any pelvic mass

23. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23
•6)descent of presenting part with contraction
•7)contraction frequency
•8)fetal well being

24. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 24
station
•SO assess following before any intervention
1)EFW-fundal height > 40 cm at this stage is
large baby
2)Degree of engagement
3)Position of the presenting part
4)Evidence of obstruction
5)Any pelvic mass

25. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 25
Engagement
• entrance of the largest diameter of the
presenting part into the true pelvis.
•In relation to the head, the fetus is said to
be engaged when it reaches the midpelvis
or at a zero (0) station.
•Once engaged, fetus does not go back up.
Prior to engagement occurring, the fetus
is said to be "floating" or ballottable.

26. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 26
Position of the presenting part
•Determine by
COUNTING SUTURE
TECHNIQE
•Junction of 3 suture
lines is posterior
fontanel
•Junction of 4 suture
lines-anterior
fontanel

27. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 27

28. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 28
Occiput transverse positions 
Occiput anterior positions 
Fetal position

29. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 29
Degree of flexion/Attitude
• If only posterior fontanel is felt-it is well
flexed fetal head. Here the cervix is
regularly dilated
•If only anterior fontanel is felt-It is deflexed
head(face /mento vertex presentation)
•If both fontanels are felt .-it is partially
deflexed head. Here the cervix is also
irregularly dilated

30. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 30
Types of attitude

31. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 31
Complete flexion-
•(a) normal attitude in cephalic presentation.
"chin is on his chest." This allows the
smallest cephalic diameter to enter the
pelvis, which gives the fewest mechanical
problems with descent and delivery.

32. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 32
Moderate flexion
•(b) - head is only partially flexed or not
flexed. It gives the appearance of a military
person at attention. A larger diameter of the
head would be coming through the
passageway.

33. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 33
DEGREE OF FLEXION

34. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 34
Poor flexion or marked extension
•. it is extended or bent backwards. This
would be called a brow presentation. It is
difficult to deliver because the widest
diameter of the head enters the pelvis first.
This type of cephalic presentation may
require a C/Section if the attitude cannot be
changed.

35. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 35
Hyperextended
•. In reference to the cephalic position, the
fetus head is extended all the way back. This
allows a face or chin to present first in the
pelvis. If there is adequate room in the
pelvis, the fetus may be delivered vaginally.

36. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 36
Asynclitism
•One parietal bone presents at a higher plane
than other ,with the head in the transeverse
position as it enters the pelvis.
•Anterior asynclitism –physiological
•Posterior asynclitism is unfavourable and
may indicate dispropotion

37. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 37
ASYNCLITISM

38. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 38

39. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 39
Management of poor progress in
labour
•Decide whether it is safe to continue the
labour
•If obstruction of labour / fetal distress-need
operative delivery
• decide whether expectant policy is
appropriate

40. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 40
Management of poor progress in
labour
(1)One to one care
- it decreases the likelihood of medication
for pain relief, instrumental delivery,C/S,
APGAR <7in 5 minutes
-encourage to adopt whatever the position
comfortable-sitting, reclining,lateral semi
recumbent position

41. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 41
(2) Maternal hydration and pain relief
-40 % of nulliparous will respond to normal
saline infusion
-edidural or narcotics
(3) Mobilization
(4) Amniotomy –if not done earlier

42. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 42
•If delay in the established first stage of
labour is suspected, amniotomy should be
considered for all women with intact
membranes.
•perform a vaginal examination 2 h .and if
progress is less than 1 cm a diagnosis of
delay is made.

43. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 43
•When delay in the established first stage of
labour is confirmed the use of oxytocin
should be considered

44. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 44
5) Oxytocin for augmentation
-evaluate clinical situation i.e exclude
obstructed labour and fetal distress .also
consider maternal wishes in decision
making.
-for poor progress due to inefficient/ in
coordinate uterus contraction.
-60-80% of patients will respond to oxytocin
by improving cervical dilation.

45. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 45
•perform a vaginal examination 4 hours after
commencing oxytocin in established labour.
If there is less than 2 cm progress after
4 hours of oxytocin, further obstetric review
is required to consider caesarean section. If
there is 2 cm or more progress, vaginal
examinations should be advised 4-hourly.

46. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 46
•Titrate every 30 minutes till 4 contraction for
10 min with each last 40 seconds.
•Moniter continuously –CTG
•If augmentation exceeds 8 hours duration it
is unlikely to result in successful vaginal
delivery
•8% of muliparae and 22% of nulliparae -fail
to respond to oxytocin

47. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 47
Ways to reduce the poor progress
of labour
•Correct diagnosis of labour.(Pay attention on
effacement of the cervix)
•Good midwifery care in labour room.
•Sustaining the morale of the woman and her
partner
•Maintain hydration well
•Provide adequate analgesia
•maintain the partogram

48. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 48
THANK YOU