ABNORMAL LABOUR AND ITS MANAGEMENT DR. AMEL F. AL-SAYED

Causes of Abnormal Labor Abnormalities of the explusive forces - Weak uterine contractions - Discordemoted contractions - Inadequate voluntary muscle effect Abnormal presentation, position or development Abnormal maternal bony pelvis Abnormalities of the birth canal

Lack of progress of labour is the most common documented indication for primary C/S. 43% - The next common is fetal distress 14% Diagnosis of Labour The commencement of uterine contractions that results in Cx effacement and dilatation 1st stage: The 1st stage consist of 2 phases Phases of labour 1st stage of labor: I. Latent Phase II. Active Phase - Accel Phase - Phase of maximum slope - Decelaration Phase

Prolonged latent Phase : > 20 hrs in primps > 14 hrs in multips Active Phase Max. 11.7 hrs. - dilatation 1.2 cm /hr in primi 1.5 cm/hr in multi active phase

2nd Stage full dilation  expulsion of the fetus 50 min primps 20 min multips Current recommendations with conduction of analgesia is 2nd stage of 2-3 hrs in primps 1-2 hrs in multips When time breaches in normal labor boundaries are the only pregnancy complications, interventions other than cesarean delivery must be considered thoroughly before resorting to this method of delivery for failure to progress.

Important facts to be remebered Undue prolongation of labor may  prenatal mortality and morbidity.  psychological trauma to the mother. There is a role for the use of dilute I.V. Oxytocin infusion C/S is safer than a diffiucult mid forceps delivery

I. UTERINE DYSFUNCTION Normal uterine contractions normally exert a pressure of about 90 mmHg.<25 of Hg is not effective. a. Hypotonic uterine dysfunction b. Hypertonic uterine dysfunction Both are ineffective Causes of uterine dysfunction: 50% unknown 1. Pelvic contraction 2. Fetal malposition 3. Over distension of the uterus 4. Rarely Cx fibrosis or rigidity

II. CPD Absolute: Discrepancy between the pelvic size and fetal head size Relative: due to malposition or asynclitism Fact: It is over diagnosed because most C/S done for this indication are done in the latent phase.

Treatment of uterine dysfunction: Provided that CPP is excluded: 1. Stripping of membranes 2. Amniotomy 3. Oxytocin augmentation Treatment of hypertonic activity is tocolytics, ventolin Mgso4 etc. C/S if no response. Abruption has to be R/O.

Rx of inadequate expulsive forces: Proper coaching Timing and type of sedation Outlet forceps, vacuum extraction Precipitate labor and delivery May lead to birth canal lacerations Amniotic fluid embolism PPHge Perinatal Hypoxia Intracranial trauma, Hge

Abnormal labor due to abnormal presentations, position. The presence of the fetal head in the normal position helps the proper performance of the uterine muscle. Breech presentation Face presentation - mentum ant. (vaginal) - mentum post (C/S) Brow presentation Transverse lie Deep transverse arrest Occiput posterior

Abnormal labor due to abnormal fetal development Hydrocephalus Enlarged fetal abdomen Conjoint twins Abnormal Labor due to pelvic contraction Inlet contraction Mid pelvis contraction Pelvic outlet contraction Combination of the above

Pelvic contractions lead to abnormal presentation and positions which in turn lead to abnormal activity and abnormal labor. Warning signs: Excessive caput Excessive moulding Contraction ring

Abnormal labour due to soft tissue abnormalities of the genital tract Vulva - Congenital stenosis - lymphogranulosa venereum - Chron’s disease - Condyloma Vagina - Septum - Stricture - Large cysts Cx - Incomplete atresia or stenosis - Cx ca - Cx myomas Uterine: - Uterine displacement - Uterine fibroids - fetal malposition - local obstruction Other intrauterine abdominal masses: - Ovarian - renal - Splenic - GI