ABNORMAL LABOUR

INTRODUCTION:-

NORMAL LABOUR
Normal labor is defined as regular uterine contractions that cause cervical change.

The onset of painful, regular uterine contractions that lead to effacement and dilatation of the
cervix with descent of the fetus in a vertex presentation High risk pregnancy

ABNORMAL LABOUR
Abnormal labor may be referred to as dysfunctional labor, which simply means difficult labor or
childbirth. When labor slows down, it’s called protraction of labor. When labor stops altogether,
it’s called arrest of labor.

A few examples of abnormal labor patterns may help you understand how the condition is
diagnosed:

An example of an “arrest of dilation” is when the cervix is 6 centimetres dilated during the first
and second examinations, which your doctor performs one to two hours apart. This means that
the cervix hasn’t dilated at all over the course of two hours, indicating labor has stopped.

In an “arrest of descent”, the head of the fetus is in the same place in the birth canal during the
first and second examinations, which your doctor performs one hour apart. This signifies that the
baby hasn’t moved farther down the birth canal within the last hour. Arrest of descent is a
diagnosis made in the second stage, after the cervix is completely dilated.

 Failure to meet defined milestones & time limits for normal labour
 Another name is dystocia.
 Assessment of progress in labour
a) Progressive dilatation of cervix
1 cm / hr in primigravida
1.5 – 2 cm / hr in multigravida
b) Progressive descent of head

DEFINITION:-

NORMAL LABOR-
Normal labor is defined as regular uterine contractions that cause cervical change. Abnormal
labor patterns are characterized as abnormalities of the first, second, or third stage of labor.

1|Page
ABNORMAL LABOR-
Abnormal labor is defined as the abnormal onset of labor - either too early or too late in the
pregnancy - or abnormal duration of the stages of labor.

“No change or minimal change in cervical dilatation in a 2-hour period during the latent or the
active phase of labour, or no change or minimal change in descent of the presenting part during
one hour during the second stage of labour” high risk pregnancy

DISORDERS OF LABOR:-
 Prolonged latent phase
 Primary dysfunctional labour
 Secondary arrest

TYPES OF LABOUR ABNORMALITIES ;-

 Slow Progress “Protraction disorders”: refer to slower-than-normal labour 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 labour
 Precipitate Labour: Complete Delivery within ≤3 hour

DETERMINANTS OF LABOR:-
Power

P Passages

Passenger

Plotting the findings of serial vaginal examinations on partogram

2|Page
ABNORMALITY OF POWER (uterine contractions)

 Inefficient uterine action is characterized by weak, infrequent and irregular contractions

and is the most common cause of poor progress in labour
 3-4 contractions every 10 minutes, each one lasting for minimum of 40 seconds
 In 2nd stage uterine work is complemented by maternal expulsive efforts

ASSESSMENT OF UTERINE CONTRACTIONS

 Clinical examination
 External uterine tocography
 Intrauterine pressure catheter:
 expressed in Montevideo units
 3 contractions in 10 minutes will produce approx. 100-200MVU

Common causes are:

o Primigravida

o Advanced maternal age

o Diabetic mother

o Multiple pregnancy etc.

3|Page
CLASSIFICATIONS:-

 Hypertonic uterine dysfunction:

 frequent, intense and painful contractions having no effect on cervical dilatation and
effacement

 Subtypes are:

a) Uterine tachysystole: increase in frequency of uterine contractions more than 5 every 10

minutes with little or no relaxation

b) Hyper stimulation: tachysystole associated with FHR abnormalities

 Hypotonic uterine dysfunction: another name Uterine inertia

 Decrease in frequency and intensity of uterine contractions

a) primary due to intrinsic failure of uterine muscle

b) secondary to pharmacological interventions

ABNORMALITY OF PASSAGE:-

The passage relates to the uterus, cervix and the bony components of the pelvis

CAUSES:

 Malnourishment
 previous fracture or metabolic bone diseases
 Woman with paraplegia or spina bifida
 Space occupying viscera in the pelvis
 Impacted rectum
 Full bladder
 Cervical fibroid
 Ovarian cysts
 Cervical dystocia: noncompliant cervix which effaces but fails to dilate because of
severe scarring which may be as a result of previous cone biopsy and also because of
malpresentation and malposition
 CPD cephalopelvic disproportion

4|Page
CEPHALOPELVIC DISPROPORTION
 Contracted pelvis

 Contracted inlet plane

 Contracted midpelvis
 Contracted outlet plane

 Pelvic malformation

MECHANISM

 For Contracted pelvis, the fetus has difficulty in passing through birth canal.

 The labour is protracted or arrested.

 Secondary uterine inertia occurs.

CONTRACTED INLET PLANE

 Criteria: sacral-pubic diameter<18cm

 Clinical findings: fetal head palpable above the inlet plane. prolonged latent phase

CONTRACTED MIDPELVIS AND OUTLET PLANE

 Bi-ischial spine diameter<10cm

 Bi-ischial tubercle diameter<8cm

 Clinical findings: disorders of active phase and the second stage.

ABNORMALITIES OF THE PASSENGER:-

 Refers to the fetus
 Fetal macrosomia
 Fetal abnormalities such as hydrocephaly, fetal ascites, and fetal tumors
 Abnormal fetal presentation (brow, shoulder, face) more common in high parity
 Malposition (occiput posterior, occiput transverse)
 Attitude (extension, asynclitism)

Fetal head diameter

 Bi-parietal dimension: 9.5cm

 Suboccipitobregmatic dimension: 9.5cm
 Occipitofrontal dimension:11.5cm

5|Page
  Occipitomental dimension: 13cm

6|Page
INTERACTION
a) Abnormalities of fetus
 Abnormalities of fetal development
 Abnormalities of fetal size
 Abnormalities of fetal position
b) Abnormalities of birth canal
 Contracted pelvis
 Pelvic malformation
 Abnormalities of soft tissue
c) Abnormalities of labor force
 Primary inertia
 Secondary inertia

PROLONGED LATENT PHASE :-

 Lack of change or minimal change in cervical effacement and dilatation before the beginning
of active phase of labour i-e cervical dilatation of 4cm and effacement -80%

 The mean duration of latent phase:

 8.6 hours in nullipara

 5.3 hours in multipara

 Prolonged when duration exceeds

 more than 20 hours in nullipara

 more than 14 hours in multipara

ETIOLOGY-
  Primipara
  Unripe cervix
  False labour
  Ineffective, inadequate uterine contractions
  Unrecognized pelvic disproportion

OUTCOME:

7|Page
   Increased incidence of cesarean section
  Chorio-amnionitis
  Postpartum bleeding
  Thick meconium
  Low 5-minute Apgar score
  Admission to NICU

PRIMARY DYSFUNCTIONAL LABOUR

 Poor progress during the active phase of labour

  26% in nullipara
  8% in multipara

 Protracted dilation

 Primipara < 1.2 cm/h

 Multipara < 1.5 cm/h

 Arrest of dilation

 Primipara >2 h

 Multipara >2 h

ETIOLOGY:

 Cephalopelvic disproportion…early

 Abnormal uterine contraction…any time

 Fetal malpositions …late

SECONDARY ARREST:

 6% nullipara

 2% multipara

 Cessation of cervical dilatation following a normal period of active phase dilatation

8|Page
 More likely cause is CPD

SECONDARY ARREST IN DECELERATIVE PHASE:

 Between cervical dilatation of 7 and 10 cm

 ASSESSMENT:

  An estimate of fetal size

  The degree of engagement
  Position of the presenting part
  Signs of obstruction (moulding)
  Presence of pelvic masses
  Descent of presenting part with contractions
  Contraction frequency
  Fetal wellbeing

 Variable decelerations and a rising baseline are common in obstructed labour

 If fetal scalp sampling shows normal PH then CTG changes represent obstruction rather than
fetal intolerance to labour

SECONDARY ARREST IN SECOND STAGE OF LABOUR

 Protracted or no descent of the presenting part into the birth canal during 2nd stage of labour
 Normal rate:

 nullipara: 6.6cm/hour
 multipara: 3.3cm/hour

 In nullipara: Protracted descent < 1cm/hour

 In multipara: protracted descent < 2.0cm/hour

 Arrest or failure of descent .. no progress in the movement of fetus through the birth canal in
the second stage of labour for one hour as documented by appropriately spaced vaginal
examinations

 Prolonged second stage

 without epidural:

9|Page
  Primipara- ----- >2 hr
 Multipara------- >1 hr

 With epidural:

 Primipara------- >3hr
 Multipara------- >2hr

ETIOLOGY:
 CPD:

 50% in nullipara
 30% in multipara

 Inadequate uterine activity

 Fetal malpositions ..OT &OP

 Epidural anaesthesia

 Fetal macrosomia .. 9% of protracted labour

DIAGNOSIS:
 Vaginal examinations

 Caput formation and excessive moulding

 Assessment of station on abdominal examination

MANAGEMENT:
 Assess fetomaternal wellbeing

 Mueller-hillis maneuver

 IUPC to evaluate uterine activity

 Bedside ultrasound to diagnose malposition

 Support

 Hydration

 Pain relief

 Reassurance

10 | P a g e
 Mobilization

 One to one care

 A longer period of time to allow labour to

progress

 Check for cause

 Continued observation

 Augmentation of labour

 Attempt operative vaginal delivery (forceps, ventous )

 Caesarean delivery

AUGMENTATION OF LABOUR :-
 Increase the frequency and force of the existing uterine contractions

 Methods: amniotomy oxytocin administration

OXYTOCIN

  Capable of inducing uterine contraction in the third trimester

  Contraindication: cephalopelvic disproportion and severe fetal malposition
  Relatively safe in nulliparous women, less safe in multiparous women because of the
risk of hyperstimulation, fetal compromise and uterine rupture in face of obstruction
  Oxytocin stimulation is not beneficial in prolonged latent phase as it causes the 10 fold
increase in caesarean section rates and 3 fold increase in low apgar scores in the neonates

11 | P a g e
   Oxytocin stimulation..response rate 70% nullipara & 80% multiparae in 3 hours
  Early augmentation shortens labour and reduces the need of instrumental delivery in
2nd stage but does not affect the cesarean section rates
  If no progress and fetal compromise then Cesarean section
  Dilute 10 units oxytocin in 500ml normal saline
  Initiate infusion at 0.5-2mU/min
  Increase the dose by 1-2mU/min, until an adequate pattern of contractions is achieved

AMNIOTOMY
 Amniotomy is another method to facilitate the uterine activity
 After amniotomy the fetal head descends, pressing directly on cervix to enforce uterine
contraction. Accelerating labour
 Prostaglandins are released that increase sensitivity of oxytocin receptors
 Assess cephalopelvic relationship by a series of examination

12 | P a g e
  Mild cephalopelvic disproportion: trial labour
 Obvious cephalopelvic disproportion: cesarean section.

PRECIPITATE LABOR:-
 Labour lasting <3 hours

ETIOLOGY
More common in multipara; with

 Strong uterine contractions,

 Small size baby,
 Roomy pelvis
 Minimal soft tissue resistance

COMPLICATIONS:

• Genital trauma

• Laceration of cervix, vagina

• Uterine inversion

• PPH

• Fetal asphyxia due to increased uterine contractions

• Fetal ICH

• Trauma to baby due to risk of falling down

ABNORMAL LABOUR INDICATORS

13 | P a g e
PROGNOSIS:

 Good prognosis in multiparous than in nulliparous

 Poor prognosis when diagnosis is made early in active phase before 6 cm

 Poor prognosis when there is high station

CONSEQUENCES OF ABNORMAL LABOUR

 Short Term On the Mother:

 Postpartum hemorrhage.
 Increased rate of traumatic complications: Lacerations, injuries to adjacent organs
 Increased risk of infection (prolonged labour)
 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

CONCLUSIONS
Efforts to identify abnormal labor and correct abnormal contraction patterns, fetal malposition,
and inadequate expulsive efforts may help eliminate many CS without compromising the
outcome for either mother or fetus

A-Active management of labor

B-Instrumental deliveries

C-CS

14 | P a g e
 BIBLIOGRAPHY

 Dutta, DC (2011) Text Book. Of Obstetrics Including Perinatology and Contraception.

(7 ed), New Delhi, New Central Book Agency 357- 364

 Bhaskar N. Midwifery & obstetrical nursing (2nd ed.) Bangalore; (2015) page no 464-465

 WWW.google.com

 https:// www SlideShare abnormal labor

……………..

15 | P a g e