1. Diagnosis and Management of Abnormal
Professor Hassan Nasrat
Chairman Department of Obstetrics and Gynecology

2. 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)

3. 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

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

6. 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

7. Pattern of Progress of Normal Labour:
Duration:

8. 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

9. First Stage
Characteristics of the average cervical dilatation curve for nulliparous labor. Friedman EA: 1978.)

10. 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

11. 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

12. Cx changes

13. The partogram

14. Duration of “Normal” Labour
Primigravida
Multigravida
First Stage
Duration h
Rate of cervical Dilatation 1 cm/h >1.2 cm/ h
During Active Phase
Second Stage
Duration >3o/m-3h /m

15. 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

16. 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.)

17. 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

18. 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

19. 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

20. Latent phase Prolonged Latent Phase Head Descent Active phase
Second Stage
Head Descent
- Failure
- Arrest
Active phase
Protraction
Secondary Arrest of Cervical Dilation

21. 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

22. 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:

23. Occipitofrontal Diameter Diameter of the OP Position

25. 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.

26. 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

27. 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

28. 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

29. 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

30. 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

31. Diagnosis of Abnormal Labor
Risk Factors
The Partogram

32. Management of Abnormal Labor

33. 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

34. Therapeutic rest Oxytocin Amniotomy Cervical ripening
MANAGEMENT OPTIONS OF A PROLONGED LATENT PHASE:
Therapeutic rest
Oxytocin
Amniotomy
Cervical ripening

36. 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

37. 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

38. (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.

39. 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.

40. 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.

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