PDF Diagnosis and Management of Abnormal Labour "Dystocia"

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Diagnosis and Management of Abnormal Labour

“Dystocia”

Professor Hassan Nasrat

Department of Obstetrics and Gynecology

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Normal and Abnormal Labor (Dystocia)

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Pattern of Normal Labor

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Consequence of Abnormal Labor (Dystocia)

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Types of Abnormal Labour

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Causes of Abnormal Labour

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Risk Factors for Abnormal labour

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Diagnosis Abnormal Labour

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Management of Abnormal Labor

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Normal Labour

• Normal Labour: Regular Uterine Contractions That Cause Progressive Cervical Changes (Dilation And Effacement) and Descent of the Fetal Head.

The Process of Normal Labour is expected to a take a

“Normal” Period Hours

Prolonged labour may be due to problems in contractions, the cervical dilatation, or the descent of the head

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¾Duration:

¾ Pattern of Progress of Normal

Labour:

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• Second stage:

Time from complete cervical dilatation to expulsion of the fetus Head Descent

• Third stage:

Time from expulsion of the fetus to expulsion of the placenta

latent Active

Acceleration Phase

Maximum slope Deceleration phase

• First stage:

Time from the onset of labor until complete cervical dilatation Cervical Changes

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First Stage Latent phase

- Contractions short, mild, irregular

- cervical effacement, and dilatation

Active phase Accelerate cx dilation at least

1 to 2 cm/ h

Head Descent

2^nd Stage

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Obstetrics Vaginal examination

to check cervical dilatation and relation to cervical spines

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The partogram

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Partogram – Progress Section

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Duration of “Normal” Labour

First Stage

Duration 6-8 2-10 h

Rate of cervical Dilatation 1 cm/h >1.2 cm/ h During Active Phase

Duration >3o/m-3h 5-30/m

Second Stage

Primigravida Multigravida

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Definition: Normal Labor

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Consequence of Abnormal Labor

Short Term On the Mother:

• Postpartum hemorrhage.

• Increased rate of traumatic complications: Lacerations, injuries to adjacent organs.

• Increased risk of infection (prolonged labor)

• Increased rate of difficult operative delivery.

Long Term Consequences:

• Psychological effects of a Traumatic Experience

On the Fetus: {increased rate of perinatal morbidity and mortality }

• Potential Complications of traumatic delivery

• Low Apgar score

• Neonatal complications (Birth Asphyxia, trauma ..etc.)

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• Slow Progress ^“Protraction disorders”: refer to slower-than-normal labor progress.

• Arrest of Progress “arrest disorders”: refer to complete cessation of progress.

Protraction and arrest disorders may occur in both the first and second stage of labor

Types – Of Labor Abnormalities

• Precipitate Labour: Complete Deliver within

≤1 hour

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First Stage Abnormalities

Prolonged First Stage

Abnormalities in the Latent Phase:

Abnormalities in the Active Phase

9 Prolonged (prolonged) Latent Phase

(20 Hours For The Nullipara And 14 Hours For The Multiparous Woman .Occur In 4-6%)

9 Protracted Active Phase

9 Secondary Arrest of Cervical Dilation

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Second Stage Abnormalities

Prolonged Second Stage

• Failure of Descent of The Head

• Arrest of Head Descent

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Second Stage

Latent phase

- Prolonged Latent Phase

Active phase -Protraction

-Secondary Arrest of Cervical Dilation

Head Descent - Failure - Arrest

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Latent Phase

¾ An Abnormally Long Latent Phase (4-6%)

-20 Hours For The Nullipara

-14 Hours For The Multiparous Woman .

Prolonged Latent Phase Is Responsible For 30 % Abnormalities In Nulliparas And Over 50 % Of Abnormalities In Multiparous Women

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Normal Progress

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Protracted (Slow) Progress in the Active Phase of Cervical Dilatation

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Secondary Arrest of Progress in the Active Phase of Cervical

Dilatation

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ETIOLOGY OF PROTRACTION AND ARREST DISORDERS ^:

Abnormal labor can be due to abnormalities in one or more of (i.e. The Passage, The passenger and the Force):

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The cervix.

o

The maternal pelvis

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The Fetus.

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The uterus.

The Passage

The Passenger The Force

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Role of Epidural analgesia:

¾ Dystocia due to cephalopelvic disproportion:

(Absolute) :

¾ Absolute CPD: True disparity between fetal and maternal pelvic dimensions e.g. Macrosomia, Hydroceph, Contracted pelvis.

Protraction or Arrest Of Active Phase:

¾ Relative CPD: Dystocia due to malposition:

E.G. Occiput posterior (OP), Mentum posterior, Brow

Active Phase

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Occipitofrontal Diameter

Diameter of the OP Position

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Diagnosis of Abnormal Labor

¾ Risk Factors

¾ Accurate Diagnosis of onset of Labour

¾ Monitoring of The Progress of Labour (Regular Assessment of Cervical

Dilatation and head descent)

¾ Use of the Partogram

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Diagnostic Criteria For Abnormal Pattern in Active Labour

Active Phase

Protracted (slow) Dilation <1.2 /h <1.5 /h Arrested Dilation >2/ h >2 / h

Arrest of Descent ^(epidural) >3/ h >2/ h Arrest of descent (no epidural) >2/ h >1/ h

Second Stage

Nulligravida Multigravida

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Curves of Normal and Abnormal Labor

Prolonged Latent

Phase Protracted

Active Phase

2ry Arrest of Dilation

Prolonged Latent

Phase Protracted

Active Phase

2ry Arrest of Dilation

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Management of Prolonged Labor

Latent Phase Active Phase

¾No Absolute CPD {if present for CS}

¾Evaluate Maternal and Fetal condition

¾ ?Stimulation of Uterine Contractions

(Amniotomy, Oxytocin)

¾Review Progress hourly for 2 hs

¾ If No Progress CS

Second Stage

• Therapeutic rest

• ? Oxytocin

• ? Amniotomy

• Cervical ripening

¾ Continued observation.

¾ Attempt operative vaginal delivery (forceps, Vento use).

¾ Cesarean delivery.

Important Actions:

•Good Analgesia (Epidural)

•Fluid Balance (in put and output)

•Fetal Monitoring

• Emotional support of the parturient

First Stage

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