PPT Slide 1

(1)

Diagnosis and Management of Abnormal

Professor Hassan Nasrat

Chairman Department of Obstetrics and Gynecology

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Pattern of Normal Labour

• Normal Labour: Regular Uterine Contractions (force) That Cause Progressive Dilation And Effacement Of The Cervix (Passage) Descent of

the Fetal Head (Passenger)

•

(3)

 Definition: Normal Labor

 Pattern of Normal Labor (Stages and Phases)

 Consequence of Abnormal Labor (Dystocia)

 Types of Abnormal Labour

 Diagnosis Abnormal Labour

 Causes of Abnormal Labour

 Management of Abnormal Labor

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• Regular Uterine Contractions (force)

• That Cause Progressive Dilation And Effacement Of The Cervix (Passage)

• Descent of the Fetal Head (Passenger)

Normal Labor

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 Definitions (Normal and Abnormal Labor)

 Consequence of Abnormal Labor ((Dystocia)

 Diagnosis Abnormal Labour

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 Duration:

 Pattern of Progress of Normal

Labour:

(8)

• 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

(9)

Characteristics of the average cervical dilatation curve for nulliparous

First Stage

(10)

Second Stage

Latent phase

- Contractions short, mild, irregular

- cervical changes

softening, effacement, and dilatation

Active phase Accelerate cx dilation at least 1 to 2 cm/ h

Head Descent

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Characterized by:

short, mild, irregular uterine contractions and cervical changes (i.e. softening, effacement, and dilatation) (< 1 cm/h).

latent phase

:

• Starts at 3 to 5 cm dilation cervical dilation.

• Accelerate to at least 1 to 2 cm/ h (depending on parity) per hour and the fetus descends into the birth canal

Active phase

:

(12)

Cx changes

(13)

The partogram

(14)

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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 Consequence of Abnormal Labor

 Diagnosis Abnormal Labour

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Consequence of Abnormal Labor

Short Term On the Mother:

• Postpartum hemorrhage.

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

• Increased risk of infection (prolonged labor)

• Increased rate of difficult operative delivery.

Long Term Consequences:

• Psychological trauma of 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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 Definitions (Normal and Abnormal Labor)



(18)

•

Protraction disorders: refer to slower-than-

normal labor 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: (for each Stage)

• Precipitate Labour: Complete Deliver within

1 hour

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Classification Of Labor Abnormalities By Stages :

Abnormalities in the Latent Phase:

Abnormalities in the Active Phase

Second Stage Abnormalities:

 Prolonged (prolonged) Latent Phase

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

 Protracted Active Phase

 Secondary Arrest of Cervical Dilation

 Failure of Head Descent

 Arrest of Head Descent

(20)

Second Stage

Latent phase

- Prolonged Latent Phase

Active phase

-Protraction

-Secondary Arrest of Cervical Dilation

Head Descent

- Failure

- Arrest

(21)

Latent Phase

 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

(22)

Role of Epidural analgesia:

 Dystocia due to cephalopelvic disproportion:

(Absolute) :

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

Causes of Abnormality (Dystocia) Protraction or Arrest) Of Active Phase:

 Relative CPD: Dystocia due to malposition:

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

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Occipitofrontal Diameter

Diameter of the OP Position

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Risks:

- Longer second stage.

- higher incidence of operative delivery.

- larger episiotomies.

- more severe perineal lacerations.

Occiput posterior position

A small increase in second stage length in the presence of a reassuring fetal heart rate, favorable clinical assessment of fetal relative to maternal size, and progress in the second stage does not mandate rotation or operative delivery.

Management of OP:

 Operative Delivery From OP Position.

 Manual Or Instrumental Rotation To Occiput Anterior.

 Cesarean Delivery.

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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 Second Stage

Nulligravida Multigravida

(27)

Prolonged Latent Phase Protracted

Active Phase

2ry Arrest of Dilation

Prolonged Latent Phase Protracted

Active Phase

2ry Arrest of Dilation

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 Pattern of Normal Labor (Stages and Phases)

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ETIOLOGY OF PROTRACTION AND ARREST DISORDERS

^:

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

o The cervix.

o The maternal pelvis

o The Fetus.

o The uterus.

The Passage

The Passenger The Force

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Diagnosis of Abnormal Labor

 Risk Factors

 The Partogram

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Management of Abnormal Labor

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Prevention: by proper management of labor:

 The diagnosis of labor.

 Monitoring of labor progress.

 assessment of maternal and fetal well-being.

(

Women should undergo cervical examination every one to two hours once active labor is diagnosed to determine whether progression is adequate)

 The use of partogram

APPROACH TO THE PATIENT WITH ABNORMAL LABOR

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MANAGEMENT OPTIONS OF A PROLONGED LATENT PHASE:

• Therapeutic rest

• Oxytocin

• Amniotomy

• Cervical ripening

(35)

(36)

Diagnosis:

When There Is No Progress (Protraction Disorder Persists) Despite Oxytocin Therapy For Greater Than Two Hours.

MANAGEMENT OPTIONS OF Active Phase Arrest

Treatment:

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•

Amniotomy

• Oxytocin for treatment of Hypo contractile uterine activity

Low dose regimens: (to avoid uterine hyperstimulation) High dose regimens: (shorten labor )

Management of Dystocia in the first stage^:

Oxytocin is typically infused to titrate dose to effect, as prediction of a women's response to a particular dose is not possible

Options f management include

(38)



It refers to uterine activity that is either not sufficiently strong or not appropriately coordinated to dilate the cervix and expel the fetus.



Is the most common cause of protraction or arrest disorders in the first stage of labor.



It occurs in 3 to 8 percent of parturients and can be quantified as uterine contraction pressures less than 200 Montevideo units.

Defect in The Force:

(Hypo contractile uterine activity)

(39)



Continued observation.



Attempt at operative vaginal delivery.



Cesarean delivery.

Prolonged (Dystocia) in the second stage

Risk factors include:

nulliparity, diabetes, macrosomia, epidural anesthesia, oxytocin usage, and chorioamnionitis

(40)

Observation:

Most women with a prolonged 2nd stage ultimately deliver vaginally.

Suggested noninvasive interventions:

- changes in maternal position.

- continuous emotional support of the parturient

- delaying pushing if the fetal head is high in the pelvis at full dilatation and the woman has no urge to do so

- active management using high dose oxytocin.

Operative vaginal delivery :

The choice of instrument require careful assessment of the mother and fetus.

success is dependent upon the training and skill of the

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Sacral Promon

tory

Symphysis Pubis