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:
 latent Acceleration Phase

First stage: Maximum slope

Active

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, Second
mild, irregular Stage
- cervical changes
softening, effacement,
and dilatation
Head
Descent

Active phase
Accelerate cx
dilation at least
1 to 2 cm/ h
latent 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

First Stage Primigravida Multigravida

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:

Prolonged (prolonged) Latent Phase
(20 Hours For The Nullipara And 14 Hours For The Multiparous Woman
.Occur In 4-6%)

Abnormalities in the Active Phase

Protracted Active Phase
Secondary Arrest of Cervical Dilation

Second Stage Abnormalities:

Failure of Head Descent
Arrest of Head Descent
Latent phase Second
- Prolonged Latent Phase 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

Active Phase Nulligravida Multigravida

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
 2ry Arrest
of Dilation
Protracted Prolonged
Active Phase Latent
Phase

2ry Arrest
of Dilation Prolonged
Protracted
Active Phase Latent
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
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):

o The cervix. The Passage

o The maternal pelvis
o The Fetus. The Passenger

o The uterus. 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
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

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
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.
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
Promon
tory

Vaginal examination to determine the diagonal conjugate