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

2. 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

3. 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

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

5. 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.

6. 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

7. 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

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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