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: • Second stage: • Third stage: latent Active 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

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: Active phase : Characterized by: short, mild, irregular uterine contractions and cervical changes (i.e. softening, effacement, and dilatation) (< 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

Cx changes

The partogram

Duration of “Normal” Labour Primigravida Multigravida First Stage Duration 6-8 2-10 h Rate of cervical Dilatation 1 cm/h >1.2 cm/ h During Active Phase 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-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

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

Latent phase Prolonged Latent Phase Head Descent Active phase Second Stage 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 Nulligravida Multigravida Active Phase Protracted (slow) Dilation <1.2 /h <1.5 /h Arrested Dilation >2/ h >2 / h Second Stage Arrest of Descent (epidural) >3/ h >2/ h Arrest of descent (no epidural) >2/ h >1/ h

Curves of Normal and Abnormal Labor 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

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

The maternal pelvis The Fetus. The uterus. 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

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

Prevention: by proper management of labor: The diagnosis of 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

Therapeutic rest Oxytocin Amniotomy Cervical ripening 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

(Hypo contractile uterine activity) 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.

Operative vaginal 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 Promontory Vaginal examination to determine the diagonal conjugate