Transcript Document 7134722

Diagnosis and Management
of Abnormal
Professor Hassan Nasrat
Chairman Department of Obstetrics and
Gynecology
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)
•
 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
Normal Labor
• Regular Uterine Contractions (force)
• That Cause Progressive Dilation And Effacement
Of The Cervix (Passage)
• Descent of the Fetal Head (Passenger)
 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
 Pattern of Progress of Normal
Labour:
Duration:
• First stage:
latent
Acceleration Phase
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
First Stage
Characteristics of the average cervical dilatation curve for nulliparous
labor. Friedman EA: 1978.)
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
latent phase:
Characterized by: short, mild, irregular uterine
contractions and cervical changes (i.e.
effacement, and dilatation) (< 1 cm/h).
softening,
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
Cx changes
The partogram
Duration of “Normal” Labour
Primigravida Multigravida
First Stage
Duration
Rate of cervical Dilatation
During Active Phase
6-8
1 cm/h
2-10 h
>1.2 cm/ h
Second Stage
Duration
>3o/m-3h
5-30/m
 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
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.)
 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
Types – Of Labor Abnormalities: (for each Stage)
Protraction disorders: refer to slower-thannormal 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
Classification Of Labor Abnormalities By Stages:
Abnormalities in the Latent Phase:
 Prolonged (prolonged) Latent Phase
(20 Hours For The Nullipara And 14 Hours For The Multiparous Woman
.Occur In 4-6%)
Abnormalities in the Active Phase
 Protracted Active
Phase
 Secondary Arrest of Cervical Dilation
Second Stage Abnormalities:
 Failure of Head Descent
 Arrest of Head Descent
Latent phase
Second
Stage
- Prolonged Latent Phase
Head
Descent
- Failure
- Arrest
Active phase
-Protraction
-Secondary Arrest
of Cervical Dilation
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
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:
Occipitofrontal
Diameter
Diameter of the OP
Position
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.
Diagnostic Criteria For Abnormal Pattern
in Active Labour
Active Phase
Protracted (slow) Dilation
Arrested Dilation
Nulligravida Multigravida
<1.2 /h
>2/ h
<1.5 /h
>2 / h
>3/ h
>2/ h
>2/ h
>1/ h
Second Stage
Arrest of Descent (epidural)
Arrest of descent (no epidural)
2ry Arrest
of Dilation
Prolonged
Latent
Phase
Protracted
Active Phase
Protracted
Active Phase
2ry Arrest
of Dilation
Prolonged
Latent
Phase
Curves of Normal and Abnormal Labor
 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
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
 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
Diagnosis of Abnormal Labor
 Risk Factors
 The Partogram
Management of Abnormal Labor
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
MANAGEMENT OPTIONS OF A PROLONGED
LATENT PHASE:
•
•
•
•
Therapeutic rest
Oxytocin
Amniotomy
Cervical ripening
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
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
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.
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.
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.
Symphysis Pubis
Sacral
Promon
tory
Vaginal examination to determine the diagonal conjugate