Abnormal Labour

Abnormal labour
Abnormal labour
Labour becomes abnormal when:
1.there is poor progress (as evidenced by a delay in cervical dilatation or
descent of the presenting part)
2. the fetus shows signs of compromise.
3. if there is a fetal malpresentation,
4.a multiple pregnancy.
5.uterine scar.
6.if labour has been induced.
Dystocia means difficult labor and is characterized by
abnormally slow labor progress.
Precipitous labor and delivery is extremely rapid labor

and delivery. Which is expulsion of the fetus within less
than 3 hours.
Progress in labour is dependent on the ‘3 Ps’ as described
previously (powers, passages, passenger).
Abnormalities in one or more of these factors can slow the normal progress of
labour.
Plotting the findings of serial vaginal examinations on the partogram will help to
highlight poor progress during the first and second stages of labour.
Poor progress in labour
Definition:
Poor progress in labour in first stage of labour has been defined already as
cervical dilatation of less than 2 cm in 4 hours, usually associated with
failure of descent and rotation of the fetal head.
Pattern of abnormal progress:
1-Prolong latent phase:
more in primiparous,
MX:
simple analgesia,mobilization and reassurance.
-Oxytocin infusion and ARM increase c/s.
Partogram should not commenced until the latent phase of labour is

complete.
2-primary dysfunctional labour:
more in primiparous,poor progress in active phase of labour ,mostly due to
inefficient uterine contraction but also from CPD and malposition.
3-secondary arrest:active phase of 1st stageinitially good then slow or stops
typically after 7 cm,malposition,malpresentation andCPD are commonly the
cause.
Progress in labour is dependent on three variables:
1. the powers, i.e. the efficiency of uterine

contractions,
2. the passenger, i.e. the fetus (with particular
respect to its size, presentation and position),
3. the passages, i.e. the uterus, cervix and bony
pelvis.
Dysfunctional uterine activity:
Most common cause.
More common in primigravida.
MX:
hydration,pain relief,emotional support,ARM,oxytocin infusion.
If progress fail after 4-6 hours of oxytocin augmentation C/S is
recommended.
Cephalopelvic disproportion (CPD) implies anatomical disproportion
between the fetal head and maternal pelvis.
It can be due to a large head, small pelvis or a combination of the two.

Absolute CPD
fetal matrnal DX
kyphosis Bony abnormalities
Scoliosis
Poliomylitis
Skeletal dysplasia
Rickets
Pelvic fracture
Hydrocephalus cx.dystocia Soft tissue abnormalities
Anencephally cx. Fibroid
Conjoined twins Ovarian tumor
Pelvic kidney
cx.Cancer
Excessive fat
Vaginal,septum ,atrsia
Mento-posterior malpresentation
Brow
Shoulder
compound
.
Women of short stature (<1.60 m) with a large baby in their
first pregnancy are potential candidates to develop this problem.
The pelvis may be unusually small because of previous fracture or metabolic
bone disease.
Rarely, a fetal anomaly will contribute to CPD. Obstructive hydrocephalus

may
cause macrocephaly (abnormally large fetal head), and fetal thyroid and neck
tumours may cause extension at the fetal neck.
Relative CPD is more common and occurs with malposition of the fetal
head.
The OP position is associated with deflexion of the fetal head and presents a
What are the findings that suggest CPD?
Fetal head is not engaged.
Progress is slow or arrests despite efficient uterine contractions.
Vaginal examination shows severe moulding and caput formation.
Head is poorly applied to the cervix.
Haematuria.
Poor progress in the second stage of labour
Delay is diagnosed if delivery is not imminent after2 hours of pushing in a
nulliparous labour (1 hour for a parous woman). The causes of second-stage
delay can again be classified as abnormalities of the powers,the passenger
and the passages.
Secondary uterine inertia is a common cause of second stage delay.

If no mechanical problem is anticipated and the woman is primiparous, the
treatment is with rehydration and intravenous oxytocin. If the woman is
multiparous, a full clinical assessment should be performed by a skilled
obstetrician prior to considering oxytocin due to the risks described above.
Delay in the second stage can occur because of a narrow midpelvis (android
pelvis), which prevents internal rotation of the fetal head (‘passages’). This
may result in arrest of descent of the fetal head at the level of the ischial
spines in the transverse position, a condition called deep transverse arrest.
Deep transverse arrest may also occur due to a resistant perineum, particularly in a
nulliparous woman.
It may also occur due to a resistant perineum, particularly in a nulliparous woman.
Delay can also occur because of a persistent OP position of the fetal head
(‘passenger’). In this situation, the head will either have to undergo a long rotation to OA or
be delivered in the OP position (i.e. face to pubes).
By the time delay in the second stage of labour has been diagnosed, the NICE guidelines
recommend that oxytocin should not be started. Inefficient uterine activity therefore needs
to be corrected proactively at the beginning of the second stage.
Causes:
Secondary uterine inertia(epidural analgesia).
Persistent OPP.
Narrow mid-pelvis(android pelvis).
MX:
Instrumental birth
C/S.
Excessive uterine contractions in a truly obstructed labour may result in
uterine rupture in a multiparous woman, a complication that is extremely
rare in primiparous women.
Augmentation with oxytocin is contraindicated if there are concerns

regarding the condition of the fetus.
If progress fails to occur despite 4–6 hours of augmentation with oxytocin, a

caesarean section will usually be recommended.
Abnormalities of the birth canal (‘passages’)
The bony pelvis may cause delay in the progress of labour as discussed above
(CPD). Abnormalities of the uterus and cervix can also delay labour. Unsuspected
fibroids in the lower uterine segment can prevent descent of the fetal head. Delay
can also be caused by ‘cervical dystocia’, a term used to describe a noncompliant
cervix that effaces but fails to dilate because of severe scarring or rigidity, usually as
a result of previous cervical surgery such as a cone biopsy Caesarean section may be
necessary.
Complications associated with difficult labour ( dystocia)):
Dystocia, especially if labor is prolonged, is associated with a higher incidence

of several common obstetrical and neonatal complications:
1) Infection, either intrapartum chorioamnionitis or postpartum pelvic
infection
2) Postpartum hemorrhage rates from atony are increased with prolonged

and augmented labors.
3) Uterine tears with hysterotomy also occur at greater incidence if the fetal
head is impacted in the pelvis.
4) Uterine rupture:
Abnormal thinning of the lower uterine segment creates a serious danger

during prolonged labor, particularly in women of high parity and in those with
a prior cesarean delivery. When disproportion is so pronounced that there is
no engagement or descent, the lower uterine segment becomes increasingly
stretched, and rupture may follow. In such cases, the normal contraction
ring is usually exaggerated,
Such pathological retraction rings are localized constrictions of the uterus
that develop in association with prolonged obstructed labours.
Seldom encountered today, the pathological retraction ring of Bandl is
associated with marked stretching and thinning of the lower uterine segment.
In contemporary practice, after birth of a first twin, a pathological ring may
still develop occasionally as an hourglass constriction of the uterus.
5) Fistula formation may result from dystocia, as the presenting part is
firmly wedged into the pelvic inlet. Tissues of the birth canal lying between
the leading part and the pelvic wall may be subjected to excessive pressure.
Because of impaired circulation, necrosis can result and become evident
several days after delivery as vesicovaginal, vesicocervical, or rectovaginal
fistulas. Most often, pressure necrosis follows a very prolonged second stage.
Such fistulas are rarely seen today except in undeveloped countries
6) Pelvic floor injury:
The pelvic floor is exposed to direct compression from the fetal head and to
downward pressure from maternal expulsive efforts. These forces stretch and
distend the pelvic floor, resulting in functional and anatomical alterations in
the muscles, nerves, and connective tissues. Such effects on the pelvic floor
during childbirth can affect urinary or anal continence and pelvic support.
7) Lower extremity nerve injury in the mother :

can follow prolonged second-stage labour. the most common mechanism is
external compression of the common fibular (formerly common peroneal)
nerve.
This is usually caused by inappropriate leg positioning in stirrups, especially
during prolonged second-stage labor. Fortunately, symptoms resolve within 6
months of delivery in most women.
Perinatal Complications:
Similar to the mother, the incidence of peripartum fetal sepsis rises with
longer
labors.
Caput succedaneum and molding develop commonly and may be
impressive .
Mechanical trauma such as nerve injury, fractures, and cephalohematoma are
also more frequent.
PRECIPITATE LABOUR
A labor is called precipitate when the combined duration of the first and
second stage is less than 3 hours.
Labor is short as the rate of cervical dilatation is 5 cm/hr or more for the
nulliparous women.
It is common in multiparae and may be repetitive. Rapid expulsion is due to

the combined effect of hyperactive uterine contractions associated with
diminished soft tissue resistance.
Maternal risks include:
(1) Extensive laceration of the cervix, vagina and perineum (to the extent of
complete perineal tear).
(2) PPH due to uterine hypotonia that develops subsequent to unusual
vigorous
contractions.
(3) uterine Inversion.
(4) Uterine rupture.
(5) Infection.
(6) Amniotic fluid embolism.
The fetal risks include:
1) intracranial stress and hemorrhage because of rapid expulsion without time

for molding of the head.
2)The baby may sustain serious injuries if delivery occurs in standing
position;
3) bleeding from the torn cord and direct hit on the skull
4) brachial plexus injury are real hazards.
Treatment:
The patient having previous history of precipitate labor should be
hospitalized prior to labor.
During labor, the uterine contraction may be suppressed by administering
tocolytic ( uterine relaxing agent)during contractions.
Delivery of the head should be controlled. Episiotomy should be done
liberally.
Elective induction of labor by low rupture of membranes and conduction of
controlled delivery is helpful.
Oxytocin augmentation should be avoided.

Abnormal Labour

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Abnormal labour

Precipitous labor and delivery is extremely rapid labor

Partogram should not commenced until the latent phase of labour is

1. the powers, i.e. the efficiency of uterine

It can be due to a large head, small pelvis or a combination of the two.

Rarely, a fetal anomaly will contribute to CPD. Obstructive hydrocephalus

Secondary uterine inertia is a common cause of second stage delay.

Augmentation with oxytocin is contraindicated if there are concerns

If progress fails to occur despite 4–6 hours of augmentation with oxytocin, a

Dystocia, especially if labor is prolonged, is associated with a higher incidence

2) Postpartum hemorrhage rates from atony are increased with prolonged

Abnormal thinning of the lower uterine segment creates a serious danger

7) Lower extremity nerve injury in the mother :

It is common in multiparae and may be repetitive. Rapid expulsion is due to

1) intracranial stress and hemorrhage because of rapid expulsion without time

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