NORMAL AND ABNORMAL

LABOR

• BY: HAFIZAH, MUJAHIDAH

• SV: DR LIZSHA
 CONTENT

NORMALLABOUR ABNORMAL LABOUR

-DEFINITION
-STAGES OF LABOUR
-MATERNAL PELVIC ANATOMY
-CARDINAL MOVEMENT OF LABOUR
-ONSET OF LABOUR
-LABOUR MANAGEMENT
-MONITORING OF LABOUR
-DEFINITION
-ABNORMAL PATTERN OF LABOUR
-ABNORMALITIES OF THE PASSAGE
-ABNORMALITIES OF PASSENGER
-ABNORMALITIES OF POWER
Labor is defined as regular and painful uterine contractions
that cause progressive dilation and effacement of the
cervix. Normal labor results in descent and eventual
expulsion of the fetus.
Parity affects this process: Parous patients who have had a
previous vaginal birth have faster labors than nulliparous
patients.

Latent phase (<4cm) and active phase (≥4cm)

 F I RS T STAG E
This describe the time from the diagnosis of labour to full dilatation
of the cervix (10cm)
Consist of 2 phases:-

Latent phase Active phase

o The latent phase of effacement of the o Active cervical dilatation to full

cervix to 3cm dilatation dilatation

o The duration is between 3 to 8 hours, o Usually last between 2 to 6 hours

shorter in multiparous women
 S EC O ND S TAG E
The time from full dilatation of the cervix to delivery of the foetus or
foetuses.

Passive phase Active phase

o Time between full • Visible fetal head

dilatation and the onset • expulsive contractions
of involuntary expulsive starts
contraction • active maternal effort
o 1 to 2 hours is usually • ends with delivery of the
recommended to allow baby
the head to rotateand • Should not last longer
descend prior active than 2 hours in nulliparous
phase and 1 hour in women who
had vaginaldelivery
previously
 T HI R D S TAG E
Time from delivery of foetus until complete delivery of placenta
Usually placenta would be delivered within few minutes after the birth
of baby.
A third stage lasting more than 30 mins is considered as abnormal
Bony Pelvis made up of 4 bones : Sacrum, Ilium, Pubis & Ischium, joined together by
sacroiliac joint and symphysis pubis

Birth canal can be divided into 3 parts : pelvic inlet, midpelvis, pelvic outlet
• PELVICINLET bounded
- Anteriorly : upper border of symphysis pubis
- Posteriorly : Promontory of sacrum
- Laterally : upper margin of pubic bone, ala of sacrum
Transverse diameter : 13.5cm
Ant-post (AP) diameter : 11.0cm
Having the widest transverse diameter in the birth canal

• PELVIC OUTLET bounded

-Anteriorly: lower border of symphysis pubis
-Posteriorly: last piece of sacrum
-Laterally: descending ramus of pubic bone,
ischial tuberosity
Transverse diameter : 11.0cm
Ant-post (AP) diameter : 13.5cm
Having the widest AP diameter in the birth canal
 Midpelvis bounded
- Anteriorly : Middle of symphysis pubis
- Posteriorly : junction of 2nd and 3rd segment of sacrum
- Laterally : inner aspect of ischial bone and ischial spine
• It's transverse diameter is similar to AP diameter : 12cm

Conclusion,
- The transverse diameter largest at the inlet and AP diameter widest at the outlet, the
midpelvis to be almost rounded.
This is important as fetal head must rotate from transverse to AP position
- the rotation is facilitate by the pelvic floor
It helps fetal head to flex and rotate as it descends through midpelvis towards pelvic
outlet
FBC and GSH
Bladder cares

A full bladder may initially prevent the fetal head from entering the pelvic brim and later impede descent of the fetal
head. It will also inhibit effective uterine action.

The woman should be encouraged to empty her bladder every 1½ -2 hours during labour. If the woman is ambulant
is ambulant she may visit the toilet. If she is unable to visit the toilet it will become necessary to pass a catheter.
Systemic analgesia
●Inhalational analgesia
➢ Entonox (50% Nitrous oxide and 50% oxygen)
➢ Flurane derivatives (Isoflurane, Sevoflurane,
Methoxyflurane, Enflurane or Desflurane)

●Parenteralanalgesia
➢ Opioids (Pethidine, Pentazocine)
➢ Non-opioids (Paracetamol, NSAIDs)

Types of analgesia in labour Regional analgesia

●Epidural analgesia
●Spinal analgesia
●Combined spinal-epidural analgesia
 PARTOGRAPH
Patient Information

Fetal condition
Progress of Labour

Medications

Maternal condition
13
 PROGRESS OF LABOUR
6 hrs (12 squares)

6 cm

4 hours

½ hr 1 hr

ALERT LINE – starts at 4 cm of cervical dilatation to the point of

expected full dilatation (10 cm) at the rate of 1 cm per hour

ACTION LINE – parallel and four hours to the right of alert line

24
 PROGRESS OF LABOUR
DESCENT OF HEAD

Y axis – 0 to 5

Recorded as a circle at every

abdominal examination

INITIAL PLOTTING – on the VERTICAL LINE at which cervicaldilatation

is recorded (according to the no of fifths palpated)

28
 Part 2: Uterine contraction
Duration Symbols
<20 sec

Uterine contractions 20-40 sec

>40 sec

3 in 10 minutes – 35 seconds 4 in 10 minutes – 50 seconds

RECORD number of contractions in 10 min and their duration in seconds.

30
 Part 3: maternal condition
Name / DOB /Gestation Medical /
Obstetrical issues Assess
maternal condition
regularly by monitoring :
• Drugs , IV fluids , and oxytocin,
if labour is augmented
• Pulse , blood pressure
• Temperature
• Urine volume , analysis for
protein and acetone
Fetal heart tracing
DR C BRVADO

Define Risk
Contraction
Baseline Rate
Variability
Acceleration
Uterine activity Deceleration
Overall comment

CTG consist of 2 “lined” traces

One big box represents 1 minute
• Important features need to be described in CTG
• Uterine contraction - Number of contraction in 10 minutes
- Duration of contraction

• Fetal heart tracing -Baseline heart rate

-Baseline variability
-Acceleration
-Deceleration
BHR :135 bpm
 180
. · •. .

Early onset Early onset E a r l y ,onset

so
UC
0
t t
Head compression Ea r ly D e c e le r a ti o n ·(HC)
A

160 !!!!!! - illll!!l-1!!!1111•• !Ill ---- - - -- • - ll l l! ! !! l ll l ll l !i -

F HR
1·00
t
Late-o n s e t :

mpres
o f v es s el 50 ·1 m i n .

UC
t t
·
Uteroplacental insufficiency 0
Late Deceleration
B

Variable onset V a r i a b l e onsei!I:

!SO

UC f
U m b ilic a l c o r d c o mp ression 0
C
 Concerningcharacteristics for decelerations
• lastingmore than 60 seconds
• reduced baseline variability within the deceleration
• failure to return to baseline
• biphasic (W) shape no
• shouldering
 Shouldering
= acceleration befo
or after deceleratio
 ABNORMAL LABOUR
DEFINITION

• Difficult labor or childbirth

• It may be associated with the abnormalities involving:

• Abnormalities of the Passage
• Abnormalities of the Passenger
• Abnormalities of the Powers
or a combination of these factors
ABNORMAL PATTERN OF
LABOUR

• The progress of labor is evaluated primarily

through estimates of cervical dilatation and
descent of the fetal presenting part.

• Described four abnormal patterns of labor:

1. Prolonged latent phase
2. Cervical dystocia
3. Protraction disorder (protracted active
phase dilatation and protracted descent)
4. Arrest disorder (including 2nd arrest)
5. Precipitate of labour
6. Prolonged 2nd stage of labor
 1. PROLONGED LATENT PHASE OF LABOR
Begins with the onset of regular uterine contraction and extends to
the beginning of the active phase of cervical dilatation

The duration averages 6 hours in nulliparas and 4 hours in multiparas

The causes include:

• Excessive sedation or sedation given before the end of the latent phase
of labor beginning with an unfavorable cervix.
Uterine dysfunction characterized by weak, irregular, uncoordinated,
and ineffective uterine contractions
Fetopelvic disproportion.
TREATMENT LPOL

• Therapeutic rest with sedation and hydration.

• Active management of labor

❖ 85% of patients spontaneously enter the active phase of labor.

❖ 10% of patients will have been in false labor and may be allowed to return home to await the onset
of true labor if fetal status is reassuring.

❖ In the remaining 5% of patients, uterine contractions remain ineffective in producing dilatation, in

the absence of any contraindication, active stimulation of labor with oxytocin infusion may be
effective in terminating the latent phase of labor.
 Progressive cervical dilatation needs effective stretching force by
presenting part

May be due to (a) Inefficient uterine contractions (b) Malpresentation,

malposition (c) Spasm of the cervix.

Cervical dystocia may be primary or secondary.

2. CERVICAL Primary: Commonly during the (i) First birth where the external os fails
DYSTOCIA to dilate, (ii) Rigid cervix, (iii) Inefficient uterine contractions
Treatment: In presence of associated complications (malpresentation,
malposition), cesarean section is preferred.
If the head is sufficiently low down with only thin rim of cervix left
behind, the rim may be pushed up manually during contraction or
traction is given by ventouse
Secondary: Due to excess scarring or rigidity of the cervix from the
effect of previous operation or disease. Others are: (i) Post-delivery (ii)
Postoperative scarring (iii) Cervical cancer
 3. PROTRACTION DISORDER

1. Protracted active phase dilatation is characterized by an abnormally slow rate of dilatation

in the active phase, less than 1cm/h in nullipara and less than 1.5cm/h in multiparas

2. Protracted descent of the foetus is characterized by a rate of descent under 1cm/h in

nulliparas and under 2cm/h in multiparas
PATHOGENESIS
The underlying pathogenesis of protracted labor is probably multifactorial
➢ Fetopelvic disproportion.
➢ Minor malposition such as occiput posterior
➢ Improperly administered conduction anesthesia
➢ Excessive sedation
➢ Pelvic tumors obstructing the birth canal

• Cesarean section is indicated in the presence of confirmed fetopelvic disproportion.

• In the absence of fetopelvic disproportion, conservative management, consisting of support and close
observation, and therapy with oxytocin augmentation both carry a good prognosis for vaginal delivery.
 4. ARREST DISORDER

Prolonged deceleration, with deceleration phase

lasting more than 3h in nullipara and more than 1h
in multipara
• Secondary arrest: Failure to progress after 7cm
dilatation then stop or slow down

Secondary arrest of dilatation, with no

progressive cervical dilatation in the active
phase of labour for 2h or more

Arrest of descent, with descent failing

to progress for 1h or more
 • About 50% of patients with arrest disorders demonstrate fetopelvic
CAUSES disproportion.

• Various fetal malposition (eg. occiput posterior, occiput transverse,

face, or brow)

• Inappropriately administered anesthesia, or excessive sedation.

• If fetopelvic disproportion is established, cesarean section is to be

done.

• If fetopelvic disproportion is not present and uterine activity

is less than optimal, oxytocin stimulation is generally
effective in producing further progress
 • Precipitate dilatation occurs if cervical dilatation occurs at a
5. PRECIPITATE rate of 5cm or more over 1 hour in primigravida and 10cm
LABOUR or more over 1 hour in multipara

DISORDER • Precipitate descent occurs with descent of the fetal

presenting part of 5cm/1h in primigravida or 10cm/1h in
multipara

• Causes
• Extremely strong uterine contractions
• Low birth canal resistance
6. PROLONGED SECOND STAGE OF LABOR
The second stage of labour, which normally averages 20 minutes for parous
women and 50 minutes in nulliparous women
-> Protracted when it exceeds 2 hours in nulliparas and 1 hour in multiparas,
or 3 and 2 hours respectively in the presence of conduction anaesthesia.

If favorable (station 0/5, no caput, no obstruction) for instrumental delivery. If

not favorable, for Csec.
ABNORMALITIES OF PASSAGE
• Bony abnormalities (pelvic dystocia)

• Soft tissue obstruction of the birth canal

• Abnormal placenta location

 PELVIC INLET CONTRACTION
• Suspected if the AP diameter of the pelvis is less than 10 cm, the
transverse diameter is less than 12 cm, or both.

• Floating vertex presentation with no descent during labor, abnormal

presentation, prolapsed cord or extremity, considerable molding of
the fetal head, caput succedaneum formation, and prolonged rupture
of the membranes.

• If allowed to continue, abnormal thinning of the lower uterine segment

may occur, with development of a Bandl's retraction ring, or even frank
uterine rupture.

• Cesarean section is the treatment of choice in true inlet contraction.

 MIDPELVIS CONTRACTION
• More frequent than inlet dystocia because the
midpelvis is smaller than the inlet and positional
abnormality is more common at this level

• Presentation:
• Arrest of descent
• Poor application of the head to the cervix
• Abnormal rate of cervical dilatation
 MIDPELVIS CONTRACTION
• It may present as a prolonged second stage, persistent occiput posterior
position, deep transverse arrest.

• Molding of the fetal head and caput succedaneum formation are

common.

• Uterine rupture may occur in prolonged labor complicated by midpelvic

outlet obstruction, and vesicovaginal or rectovaginal fistula formation may
result with pressure necrosis of the surrounding tissues of the birth canal
by the fetal head.

• Cesarean section is therefore the delivery method of choice in this

complication.
ABNORMALITIES OF THE PASSENGER
a. Fetal malposition and malpresentation

Fetal malpresentations are abnormalities of fetal position, presentation, attitude or lie

• Vertex malposition
• Occiput posterior
• Occiput transverse
• Brow presentation
• Deflexion of fetal head
• Face presentation
• Fetal head is fully deflexed
• Abnormal fetal lie
• In transverse/ oblique lie
• Breech presentation
ABNORMALITIES OF THE PASSENGER
b. Fetal macrosomia

c. Fetal malformation
➢ Hydrocephalus
➢ Enlargement of the fetal abdomen caused by distended bladder,
ascites or abdominal neoplasms or other fetal masses, including
meningomyelocele
 ABNORMALITIES OF POWER
Uterine
•
dysfunction generally comprises of
these categories
•
❖ Hypotonic
•
dysfunction
❖ Hypertonic
• dysfunction
❖ Uncoordinated dysfunction
HYPOTONIC Uterine activity characterized by contraction of the uterus within
sufficient force (<24 mmHg), irregular or infrequent rhythm, or both
DYSFUNCTION May be caused by
• Excessive sedation
• Early administration of conduction anaesthesia
• Twins
• Polyhydramnios
• Overdistention of uterus

Hypotonic dysfunction responds well to oxytocin

 HYPERTONIC AND UNCOORDINATED
CONTRACTION
• Often occur together and are characterized by elevated resting tone of the uterus with elevated tone in the lower
uterine segment and frequent intense uterine contractions

• It is generally associated with abruptio placenta, overuse of oxytocin, cephalopelvic disproportion, fetal
malpresentation and the latent phase of labor

• Treatment
• Tocolysis, decreasein oxytocin infusion
• Cesarean section is indicated for concomitant malpresentation, cephalopelvic disproportion or fetal distress
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