Diagnosis and Management of Abnormal

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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)

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• 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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Normal Labor

• Regular Uterine Contractions (force)
• That Cause Progressive Dilation And Effacement
  Of The Cervix (Passage)
• Descent of the Fetal Head (Passenger)

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• Definitions (Normal and Abnormal Labor)
• Consequence of Abnormal Labor ((Dystocia)
• Pattern of Normal Labor (Stages and Phases)
• Types of Abnormal Labour
• Diagnosis Abnormal Labour
• Causes of Abnormal Labour
• Management of Abnormal Labor

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• Pattern of Progress of Normal Labour

• Duration

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latent
Acceleration Phase

• First stage

Active
Maximum slope
Deceleration phase
Time from the onset of labor until complete
cervical dilatation Cervical Changes
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
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First Stage
Characteristics of the average cervical
dilatation curve for nulliparous labor. Friedman
EA 1978.)
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• Latent phase
• Contractions short, mild, irregular
• cervical changes softening, effacement, and
  dilatation

Second Stage
Head Descent
Active phase Accelerate cx dilation at least 1 to
2 cm/ h
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latent phase
Characterized by short, mild, irregular uterine
contractions and cervical changes (i.e.
softening, effacement, and dilatation) (lt 1 cm/h).
Active 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

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Cx changes
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The partogram
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Duration of Normal Labour
Primigravida
Multigravida
First Stage
Duration 6-8 2-10 h Rate of cervical
Dilatation 1 cm/h gt1.2 cm/ h During Active Phase
Second Stage
Duration gt3o/m-3h
5-30/m
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• Definitions (Normal and Abnormal Labor)
• Consequence of Abnormal Labor
• Pattern of Normal Labor (Stages and Phases)
• Types of Abnormal Labour
• Diagnosis Abnormal Labour
• Causes of Abnormal Labour
• Management of Abnormal Labor

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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)
• Consequence of Abnormal Labor
• Pattern of Normal Labor (Stages and Phases)
• Types of Abnormal Labour
• Causes of Abnormal Labour
• Diagnosis Abnormal Labour
• Management of Abnormal Labor

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Types Of Labor Abnormalities (for each Stage)
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

• 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

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• Latent phase
• Prolonged Latent Phase

Second Stage
Head Descent - Failure - Arrest

• Active phase
• Protraction
• Secondary Arrest of Cervical Dilation

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

• Dystocia due to cephalopelvic disproportion
• (Absolute)
• Absolute CPD True disparity between fetal and
  maternal pelvic dimensions e.g. Macrosomia,
  Hydroceph, Contracted pelvis.

• Relative CPD Dystocia due to malposition
• E.G. Occiput posterior (OP), Mentum posterior,
  Brow

Role of Epidural analgesia
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Occipitofrontal Diameter Diameter of the OP
Position
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Occiput posterior position

• Risks
• Longer second stage.
• higher incidence of operative delivery.
• larger episiotomies.
• more severe perineal lacerations.

• Management of OP
• Operative Delivery From OP Position.
• Manual Or Instrumental Rotation To Occiput
  Anterior.
• Cesarean Delivery.

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.
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Diagnostic Criteria For Abnormal Pattern in
Active Labour
Nulligravida
Multigravida
Active Phase
Protracted (slow) Dilation lt1.2 /h lt1.5
/h Arrested Dilation gt2/ h gt2 / h
Second Stage
Arrest of Descent (epidural) gt3/ h gt2/
h Arrest of descent (no epidural) gt2/ h gt1/
h
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2ry Arrest of Dilation
Prolonged Latent Phase
Protracted Active Phase
2ry Arrest of Dilation
Prolonged Latent Phase
Protracted Active Phase
Curves of Normal and Abnormal Labor
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• Definitions (Normal and Abnormal Labor)
• Consequence of Abnormal Labor
• Pattern of Normal Labor (Stages and Phases)
• Types of Abnormal Labour
• Diagnosis Abnormal Labour
• Causes of Abnormal Labour
• Management of Abnormal Labor

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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)
• The cervix.
• The maternal pelvis
• The Fetus.
• The uterus.

The Passage
The Passenger
The Force
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• Definitions (Normal and Abnormal Labor)
• Consequence of Abnormal Labor
• Pattern of Normal Labor (Stages and Phases)
• Types of Abnormal Labour
• Diagnosis Abnormal Labour
• Causes of Abnormal Labour
• Management of Abnormal Labor

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Diagnosis of Abnormal Labor

• Risk Factors
• The Partogram

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Management of Abnormal Labor
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APPROACH TO THE PATIENT WITH ABNORMAL LABOR

• 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

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• MANAGEMENT OPTIONS OF A PROLONGED LATENT PHASE
• Therapeutic rest
• Oxytocin
• Amniotomy
• Cervical ripening

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MANAGEMENT OPTIONS OF Active Phase Arrest
Diagnosis When There Is No Progress
(Protraction Disorder Persists) Despite Oxytocin
Therapy For Greater Than Two Hours.
Treatment Cesarean Delivery Is Typically
Performed At This Point
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Management of Dystocia in the first stage
Options f management include
Amniotomy Oxytocin for treatment of
Hypo contractile uterine activity Low dose
regimens (to avoid uterine hyperstimulation)
High dose regimens (shorten labor )
Oxytocin is typically infused to titrate dose to
effect, as prediction of a women's response to a
particular dose is not possible
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Defect in The Force (Hypo contractile uterine
activity)

• 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.

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Prolonged (Dystocia) in the second stage
Risk factors include nulliparity, diabetes,
macrosomia, epidural anesthesia, oxytocin usage,
and chorioamnionitis

• Continued observation.
• Attempt at operative vaginal delivery.
• Cesarean delivery.

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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 obstetrician.
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Symphysis Pubis
Sacral Promontory
Vaginal examination to determine the diagonal
conjugate