Abnormal labor

Supervised By:
Dr. Laila Al-Zaghal
 Objectives :
1) to understand the normal labor
2) to understand the concept of abnormal
labor
3) to know the different types of abnormal
labor
4) how to deal with those abnormality
 LABOUR

Definition :
Labor is the process that permits a series of extensive
physiologic changes in the mother, to allow the
delivery of her fetus through the birth canal.

This process is defined as a progressive cervical

effacement and dilatation resulting from regular
uterine contractions that occur at least every 5
minutes and last 30 to 60 seconds.
• Cervical dilatation: The cervix begins
dilating and stretching beyond the normal
dimensions and is measured in centimeters.
(0-10cm).
• Cervical effacement: softening, thinning
and shortening of the cervix.
 Stages of normal labor
First stage:
• Starts with the onset of true labor pain and ending
with a full cervical dilatation (10cm).
• Its further divided to

1st
stage

Latent Active
phase phase
 1. Latent phase

• The latent phase of labor is the time between the

onset of labor and 3-4cm dilatation.
• By the end of this phase the Cevix will be fully
effaced
• Purpose: prepare Cervix for rapid dilatation through
effacement.

• Essentially no descent of the fetus occurs

• Usually extend up to 20h in primi (ave 6h), 14 in

multi (ave 4h)
 2. Active phase

 This begins Cervical dilatation acceleration, from

the end of latent phase (3-4 cm of dilatation), and
ending with complete Cervical dilatation (10cm).

 Rate of Cevical dilatation:

 1.2 cm/hr in primi
 1.5 cm/hr in multi

 Duration : 2-6 h
• Figure 12-1 Graphic plot of cervical dilatation (in green) and descent of the
fetal presenting part (in red) during labor
• Second stage:
– Starts with the full dilatation of the cervix until
the complete delivery of the fetus.
– Lasts between (1- 2) hours also depending on the
parity.

• Third stage:
– It is the stage of placental expulsion.
– Lasts up to 30 minutes.
• Fourth stage:
The fourth stage is from delivery of the placenta to
stabilization of the patient's condition, usually at
about 6 hours postpartum.
Stage of Definition Duration
labour
Stage I latent •Begins from the onset of regular contractions. <20 hours in PG
phase •Ends with acceleration of dilatation (3-4 cm) <14 hours MG
(affacment)
Stage 1 active •Begins with acceleration of cervical dilatation. <2/hours in PG
phase •Ends at 10 cm dilatation <1.5/ hrs in MG
(dilatation) •Rapid cervical dilatation
Stage 2 •Begins from 10cm dilatation <2 hours in PG
(descent) •Ends with delivery of the baby <1 hours in MG
•Descent of the fetus Add 1 hour in epi
Stage 3 •Begins with delivery of the baby. <30 min.
(expulsion) •Ends with delivery of the placenta
•Delivery of the placenta
Diagnosis
A. symptoms: 1.True labor pains – colicky pain in the abdomen and back

True Labor False Labor

- regular intervals - Irregular How often do the
- last about 30-70 secs - DO NOT get closer together. contractions
?happen
- Get stronger and closer
together with time.

- continue despite movement - stop during walking or rest or Do they change

or changing positions changing the positions. ?with movement

- steadily increase in strength. - usually weak and do not get How strong are
much stronger. Or they may be ?they
strong at first and then get weaker.

- more intense - only felt in the front of the Where do you feel
- start in the lower back and abdomen or pelvis. ?the pain
move to the front of the
abdomen.
2. +/- Show – blood stained mucous.
3. +/- ROM

Signs:
o palpable or recorded uterine contraction
o effacement and dilation of the cervix
o formation of forewater
 Criteria OF normal labor:
• Spontaneous expulsion, through the
natural passages (birth canal) of a single,
mature (37-42 completed weeks of
pregnancy) Alive fetus, presenting by
vertex, within a reasonable time, without
fetal or maternal complications and
without intervention from the doctor.
ABNORMAL
LABOR
 Abnormal labor

Labor becomes abnormal when there is poor progress (by

delay of cervical changes or descent of presenting part), and/
or if the fetus shows sign of compromise .

• Also Induced labor, Multiple gestation, Malpresentation,

Pre/Post term, Assisted delivery, precipitous labor, Uterine
scar is considered abnormal labor
 Poor progress in labour
• Progress in labor depends on three variables :

1- Power (efficiency of uterine contractions )

2- Passenger (fetus size, presentation ,
position)
3- Passage (uterus, cervix and bony pelvis).
 The power
 Effective uterine contractions should be :

Duration 45-60 sec.

Frequency 4-5 per 10 min.

Intensity >= 50mm hg (IUPC).

 Evaluate the
uterine contractions:

 Palpation
 External
tocodynamometry
 Internal
uterine
pressure
catheters (IUPC)
 Uterine contraction measured by intrauterine pressure
transducer

 Montevideo units : Montevideo unit is the sum of all amplitudes

of all contractions for 10 minutes window.

 The uterine contractile force produced must exceed 200

MVUs/10 min for 2 hours for active labor to be considered
adequate
 Thus a woman with having 4 contractions in 10 min , each with an
amplitude of 50 mmHg , has adequate labor

 Inefficient uterine contractions is the most common

cause of poor progress in labor and more common in
primigravida and older women.
Hyperto Hypoto
nic nic
Uterine Uterine
contract Contrac
ion tion
 Hypertonic uterine contraction
– Present clinically with painful contractions, irregular and more
frequent with slow cervical dilatation.
More in primigravida

• incoordination of the
Colicky uterus different parts of the
uterus in contractions

Hyperactive • so the dominance of

lower uterine the upper segment is
segment lost
• Hypotonic uterine contraction
– Contractions are weak, infrequent and short with slow cervical
dilatation
– Hypotonic contractions occur more frequently during the active phase
of labor
– Might increase risk of PPH and retained placenta
• Causes of hypotonic:

Overstretching of uterus

Bowel/bladder distension that prevent descent

Excessive use of analgesia

CLASSIFICATION AND
DIAGNOSIS OF LABOR
ABNORMALITIES
 Abnormalities according to phases:

• In Latent phase of first stage.

• In Active phase of first stage.

• In Second stage.

• In Third stage.
 Abnormalities in labor stages:

1. Prolonged labor:
prolongation of the first stage of labor only

2. Failure to progress:
prolongation of other stages (not 1st stage )

3- arrest disorder:
Refers to complete cessation of progress in any stage
4- protraction disorder :
Refers to slower than normal progress in any stage
 In Latent phase of first stage
o Prolonged latent phase:
 > 20 hr Nulliparus
 > 14 hr Multiparus

Causes:

1- Power (Inefficient uterine contraction)

2- false labor
3-cervical factors
• Management
Admission policy !!
Depend on the cause :
1- If hypotonic contraction
Wait IV
AROM
1-2 h oxytocin

2- Hypertonic activity respond to rest And reduce dose of

oxytocin
 Admission policy !!

• Policy of delayed admission: policy of delayed admission

may help to avoid premature and unnecessary intervention
in women with prolonged latent phase.

• A number of investigators have found that when women in

early labor (before 3 cm dilatation) are admitted to the
hospital, they tend to experience longer average labors,
increased number of interventions, epidural anesthesia ,
more oxytocin use, and more complications of labor

• Some studies recommend delaying max 36 hours

Reassurance
 In Active phase of first stage
 Prolonged active phase : (primary dysfunctional Labor)

 Protracted dilatation : slower than normal rate of cervical dilatation

 Protracted descend : delyed descend of the fetal head in active

phase

 Combined Protracted :
(both dilation & descend)

 secondary Arrest:
 Dilatation not changed for ≥ 2 hr
 No change in station for ( descend ) >1h
 Active
phase

Protracted Protracted
dilatation descend

cm/hr 1.2< cm/hr 1.5< 1cm/hr in< 2cm/hr in<

in primi in multi primi multi
 Table. Abnormal Labor Indicators

Indication Nullipara Multipara

Prolonged latent phase >20 h >14 h
Average second stage 50 min 20 min
Prolonged second stage >2 h (>3 h) >1 h (>2 h)
without (with) epidural
Protracted dilation < 1.2 cm/h < 1.5 cm/h
Protracted descent < 1 cm/h < 2 cm/h
Arrest of dilation* >2 h >2 h
Arrest of descent* >2 h >1 h
Prolonged third stage >30 min >30 min
*Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours. (Please
refer to the Pathophysiology for information regarding adequate contractions.)
 In Active phase of first stage
• Causes:
1. Power: hypotonic uterine contractions, conduction anesthesia )
2. Passenger: fetal size or orientation
3. Pelvis: small bony pelvis size

Note:The most common cause of a protracted

active phase in nulliparas is inadequate uterine
activity, whereas in multiparas it is cephalopelvic
disproportion caused by malposition
 MANEGMENT
ASSESS THE UTIRINE CONTARCTION :
If inadequate
uterine AROM IV oxytocin
contraction

Efficient mvu 200> Emergency

contraction for 4 hrs C/S
 Second stage of labor
• Prolonged:

• is defined as a second stage longer than 2h in

nulliparas, & 1h in multiparas.

• With epidural analgesia add 1h.

 Second stage of labor

• Arrest disorder
• An arrest of descent can be diagnosed after
one hour if there is no descent, despite good
maternal pushing efforts
 Protraction and arrest disorder
Causes :
1- Passenger ( Fetal malposition or malpresentation).
2- Passage (pelvic inadequacy i.e. CPD).
3- Power (Inefficient uterine contractions: hypotonic,
secondary uterine inertia)
4- Excessive sedation.
 Management
• Assessment of uterine contractions & maternal pushing effort >> IV
oxytocin OR enhaced coaching as needed.
• Assess fetal head if engaged (do C/S if not)

• Assess maternal pelvis, macrosomia, malposition, Operative

intervention is also indicated when cephalopelvic disproportion is
suspected
• However, manual rotation of occiput posterior or transverse positions is
reasonable before moving to operation

• Instrumental delivery
 Third stage of labor
• Failure to deliver the placenta in 30 minutes

• Causes: inadequate uterine contractions

 If the placenta does not separate, in spite of IV oxytocin
stimulation or myometrium contractions, think of
abnormal placental implantation (e.g., placenta accreta,
increta or percreta)

• Management : you can wait for 90 minutes before manual

placental removal under GA or rarely even hysterectomy
(PPH)
 Precipitate labor
• Precipitate delivery refers to a delivery which
results after an unusually rapid labor and culminates
in the rapid, spontaneous expulsion of the infant.
Delivery often occurs without the benefit of asepsis.

• Strong and frequent contractions causing

abnormally rapid progress of delivery within 1 hr in
multipara and 3 hrs in primipara.

• Over-efficient contractions in the absence of

obstruction.
 Precipitate labor
• Risk factors:
– Strong uterine contractions.
– Small sized fetus.
– Minimal soft tissue resistance.
– Previous history of precipitate labor.
 Complications

 Maternal:
• Laceration: Cervix, vagina, and perineum.
• Uterine inversion – PPH
• Uterine atony – PPH
• Amniotic fluid embolism
• Infection : as a result of unsterile delivery
 Fetal:
• Intracranial hemorrhage
• Fetal distress
• Delivery in inappropriate place
 Management
1. Stop oxytocin infusion (if used).
2. Tocolytics (Mg sulfate, terbutaline).
3. Episiotomy to avoid fetal and birth canal
injuries.
4. Observe for PPH.
5. Observe fetus for injuries
Active Management of labor

Dublin Protocol
 Dublin Protocol

• Introduced in 1969 at the National Maternity

Hospital in Dublin Ireland to shorten the
length of labor in nulliparous women.
• The basic principle of active management is
strict criteria for the diagnosis of labor and
prompt intervention according to established
guidelines if progress is unsatisfactory
• Safely reduces the incidence of Ceserean
deliveries
 Organizational compenents
• Components & Criteria of protocol:
 Medical components

Inclusion criteria : pt who are candidate for Active managemnt of labor are :
nullparous , uncomplicated term gestation with singleton cephalic presentation
• If progress fails to occur over the next 4-6
hours Caesarean will be necessary
The Passenger
 The Passenger

• Any thing that interfere with the :

1. Size of infant
2. Presentation
3. Position
 Size of infant

• Fetal macrosomia:

- > 90th percentile for a particular GA after correcting for neonatal sex and
ethnicity, or greater than 4000-4500 g regardless GA
- macrosomia affects 1-10% of all pregnancies.

- risk factors: poorly controlled diabetes , maternal obesity , excessive wt gain

durin prgnancy , post-term, multiparity, genetic determinants , polyhydraminos
, Hx of macrosomic baby

• Others: anomalies and other developmental abnormalities

( including hydrocephalus, encephalocele, fetal goiter, cystic hygroma,
hydrops, ascitis, organomegaly, meningocele, meningomyelocele )
• Maternal risks:
●Protracted or arrested labor
●Operative vaginal delivery
●Cesarean delivery
●Genital tract lacerations
●Postpartum hemorrhage
●Uterine rupture

• Fetal and neonatal risks:

●Shoulder dystocia leading to birth trauma (brachial plexus injury, fracture)
or asphyxia
●Neonatal hypoglycemia

Long-term risks in offspring:

●Development of impaired glucose tolerance and obesity
●Development of metabolic syndrome
●Increase in aorta intima-media thickness, left ventricular mass, and
abnormal lipid profile
-Investigation :- serial SFH (*) , US-predictors (AC ,
polyhydramnious , HC/AC ratio , FL / AC ratio )

We suggest prophylactic cesarean delivery rather than

expectant management in the following clinical settings:
●Estimated fetal weight >5000 g in women without diabetes or >4500 g in
women with diabetes
●Prior shoulder dystocia, especially with a severe neonatal injury
Definitions
• Presentation: the part of the fetus that occupies the lower part
of the uterus
• Lie: the relation of the fetus longitudinal axis to the mother
longitudinal axis
• Position: the relation between the dominator bony part of the
fetus to the pelvic wall.
• Station: the relation between the lowest bony part of the
presenting part to an imaginary line between the two ischeal
spines.
• Attitude: the relation of the fetal parts to each other
• Engagement: when the widest diameter of the presenting part
pass through the pelvic inlet.
 Presentation
• Part of the fetus that occupies the lower part of the uterus ,
normal presentation is cephalic.
• Cephalic  where the fetus is in a longitudinal lie and
the head enters the pelvis first;

• the most common form of cephalic presentation is the vertex

presentation where the occiput is the leading part (the part that
first enters the birth canal).

• All other presentations are abnormal (malpresentations)

• which are either more difficult to deliver or not deliverable by
natural means.
The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the
coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally
by 2 lines passing through the parietal eminences.

vertex presentation the occiput typically is anterior and thus in an optimal position
to pass the pelvic curve by extending the head.

The presenting diameter is the suboccipito-bregmatic = 9.5 cm

vertex presentations are further classified according the position of the occiput, it being
right, left, or transverse, and anterior or posterior:

The Occipito-Anterior position is ideal for birth

In an Occiput-posterior position, labor becomes prolonged and more operative

interventions are deemed necessary.
 Malpresentation:
• Any fetal presentation other than cephalic
vertex.

• Types:
– face
– brow
– breech
– Shoulder
– compound
.
'
"
'

I
!
1
\

1
1

A
B
i
i

c
D (A) vertex (B) brow (C) brow (D) face
head is extended
vertex presentation the head is slightly extended, but less
head is flexed and than in the face presentation.
the occiput leads the
way.
 Face Presentation

• Fetal head is hyper-extended such that the fetal face, between the chin and
orbits is the presenting part

• Incidence 1:500-600 deliveries

• Factors that predispose to face presentation are:- grand multiparus , Neck
swelling (C.hygroma , goiter) , anencephaly , CPD

• Diagnosis is made by VE during labor, when soft tissues of fetal mouth and
nose are felt. Confirmed with U/S.

• Face presentations are classified according to the position of the chin

(mentum)
 Presenting diameter is the = 13cm = very
Presenting diameter is the large = won’t deliver vaginally .
submento-pregmatic = 9.5 =
can deliver vaginally
 Brow Presentation

• The head occupies a position midway between full flexion

(vertex) and full extension (face).

• 1 in 1400
• 50-75% of brow presentations will convert to either face or
vertex presentations.
• Persistent brow presentation will make vaginal delivery
impossible due to the presenting diameter which is the
mentovertical diameter (13.5cm)  Cesarean section
Non-cephalic presentations are the breech presentation (3.5%) and the shoulder
presentation (0.5%).
 Breech presentation
• Occurs when fetal buttocks or lower extremities present into the maternal
pelvis
• Incidence is 3-4%
• Prior to 28 weeks, approximately 25% of fetuses are in breech presentation . ….
By 34 weeks gestation, most fetuses have assumed the vertex presentation

• The major factor predisposing to breech presentation is prematurity :-

• Maternal causes :- multiparity , fibroid or cervical or pelvic tumor occupying

the lower part of the uterus , polyhy or oligohydramnius , congenital uterine
anomalies

• Fetal factors :- multiple gestation , prematurity , fetal anomalies (anenceph ,

hydroceph …)

• Management :- CS , External Cephalic Version (ECV) , vaginal breach delivery .

 Classification

Frank breech Complete breech Footling breech

commonest (2*flexed) (2*extened)
(Flexed*extened)
 Shoulder presentation

• Occurs in 1:250-300 deliveries

• More common in multiparous rather than primiparous women

• Causes:
– abdominal/uterine wall laxity
– Polyhydramnios
– Multiple gestations
– Placenta previa
– Fibroid , Cervical cancer

• Complication :- cord prolapse , obtructed labour…

• Management :- CS .
 Compound Presentation

• Fetal extremity (hand) prolapses alongside the

presenting part (the head) and both parts
enter the maternal pelvis at the same time.
– may be observed more commonly after premature rupture of membranes,
with preterm labor, with pelvic masses displacing the main fetal pole, or
after inductions of labor involving floating presenting parts  are more
likely with obstetric interventions than with spontaneous events
– 1 in 700
• Usually the prolapsed part does not interfere with labor… As
suggested, in most cases, these events need not greatly influence the plans already made for the
route of management of the birth process. Simple stimuli designed to get the child to withdraw
the abnormal part may succeed. Management of labor and delivery after discovery of the intrusive
part should be conservative and compatible with otherwise traditional obstetric principles.
 Position

• The relation between the Dominator bony part of the fetus to

the pelvis wall
• LOA : is the most common position
• Malposition = any position rather than occipito anterior

• Affected by the passage (pelvis)

 Occipito posterior
• It’s a vertex presentation in which the fetal back is directed post
• This is the most common malposition where the head initially engages
normally but then the occiput rotates posteriorly rather than anteriorly.
• Causes :- * pelvic factor (50 % associated with anthropoid or android pelvis )
* fetal factor (poorly flexed head)
* uterine factor (weak uterine contraction )
• Effect on labour :- Prolongation of 1st and 2nd stage of labour , early
membrane ruptured , delayed engagement
• If the head comes into a face to pubis position then vaginal delivery is
possible as long as there is a reasonable pelvic size. Otherwise, forceps or
Caesarean section may be required.
Normally :- OT  posteriorly towards the sacrum
Turning of the head from the OT 135º
position  anteriorly towards the
symphysis pubis ie. Occiput moves
from transverse to ant 45º
The Passage
 Passage : pelvis

 Its classify according to its shape by Caldwell-

moloy class. To :
1. gynecoid,
2. android,
3. anthropoid,
4. and patypelloid.
 Pelvic Shapes

1. Gynecoid :

• classical female pelvis (50%)

• Inlet is round oval with largest transverse diameter, straight
side walls, well-curved sacrum .
2) Android Pelvis:

- 30% of women

- typical male pelvis

- Inlet is triangular

- This pelvis is restricted at all levels , arrest of descent in

labor is common .
3) Anthropoid Pelvis:

- 20% of women
- Inlet is larger AP
- Fetal head engages AP-ly , often in OP position ,
making delivery difficult .
4) Platypelloid Pelvis:

- 3% of women
- Oval shaped inlet with wide transverse diameter
- Fetal head has to engage in the transverse diameter and
delivers occiput transverse position .
- Increased risk of obstructed labor.
 Gynecoid Android Anthropoid Ptypelloid

% of females 50% 30% 20% ~ 3%

Typical female Typical male
Pelvis Pelvis

Inlet Mainly rounded , Triangular Larger in AP Flattened

slightly oval , gynecoid
Widest
transverse
diameter

Problem ? _________ Arrest of The head will Risk of

descent in engage in obstructed
labor occipitoposterior labor
Position , so
difficult delivery
Cephalo-pelvic disproportion
 The passage : cephalo-pelvic disproportion:

• Absolute CPD: when one or more of metrnal pelvis diameter

shortens by 2cm of the standered
• A disproportion between the size of the fetus relative to the
maternal pelvis, due to large baby or small pelvis or both of
them.
• It is usually due to fetal malposition or malpresentation, rather
than a true disparity between fetal and maternal pelvic
dimensions.

• The most common form of CPD results from an Occipito-

Posterior malposition
 Epidemiology
• Rare
• According to ACNM ( American college of nurse
midwives ) , CPD occurs in 1 out of 250
pregnancies .
• More than 65% of women who had previous
CPD were able to deliver vaginally in
subsequent pregnancies ( according to a study
published by the American Journal of Public Health )
 CPD

Absolute Relative

Fetal Maternal Malposition Malpresentation

Macrosomia Bony pelvis

Congenital
Uterus (fibroids)
anomalies

Organomegaly Cervix
 MATERNAL CAUSES OF CPD

1. Suspected fibroids of lower uterine segment.

2. Cervical dystocia.
3. Abnormal shapes of the pelvis.
4. Pelvic tumors
5. Previous pelvic trauma and previous surgeries.

• CPD is one of the most common reasons

for doing a C/S due to failure to progress.
 fetal causes of CPD

• Large fetus :-
* Hereditary * Diabetes
* Post maturity

• Fetus position :-
* OP position

• Malpresentation :-
* Brow * face
 Diagnosis Of CPD
• When to suspect CPD in labor?

1. Progress is slow or arrested despite efficient

uterine contractions.
2. Fetal head is not engaged.
3. Vaginal examination shows severe moulding
and caput formation.
4. The head is poorly applied to the cervix.
 Diagnosis of CPD
• History:
– Rickets , Osteomalacia
– Trauma or diseases : of the pelvis, spines or lower limbs.
– Bad obstetric history , Indicators of a large baby

• Examination:

– General examination:
• Abnormal gait  abnormalities in the pelvis, spines or
lower limbs.
• Stature: <150 cm height  contracted pelvis.
• Manifestations of rickets  rosary beads in the costal
ridges, pigeon chest, Harrison’s sulcus and bow legs.
• Abdominal examination:
• Nonengagement of the head: in the last 3-4 weeks in primigravida.
• Malpresentations

 Pelvimetry
It includes:
* Clinical pelvimetry * Imaging pelvimetry

 Clinical or radiological assessment of the maternal pelvis and

fetal size is an inexact science with poor predictive value. The
best test for an adequate pelvis is a trial of labor.
 Clinical pelvimetry
* It is not possible to assess all pelvic dimensions clinically.
* The clinical evaluation started by assessing the pelvic inlet which can be
evaluated clinically for its ant.post. Diameter.
* The obstetric conjugate can be estimated from diagonal conjugate.
• Diagonal Conjugate :- distance from the lower
border of pubis to the S.P .
• Clinically measured by vaginal examination which
equals to the distance between the tip of the 2nd
finger and the point where the index finger
meets the pubis
• Briefly, the examiner attempts to:
 judge the anteroposterior diameter of the inlet
(the diagonal conjugate: at least 11.5cm )
 the interspinous diameter of the midpelvis (at
least 10 cm),
 and the intertuberous distance of the pelvic
outlet (at least 8 cm).
 Pelvic adequacy assessment
• Pelvic inlet:
Measure diagonal conjugate by your fingers, then calculate the
obstetric conjugate
(obstetric conjugate= diagonal conjugate- 1.5)

If the diagonal conjugate >= 11.5 cm , the AP diameter of the inlet

is considered adequate.
Then the ant. Surface of the sacrum is palpated , usually it is
concave. If it is flat or convex > narrow pelvis (sacral
promontory shouldn’t be felt)
• Midpelvis:
Adequate if:
- sacrospinous ligament accommodates 3 fingers

-Interspinous distance >= 10 cm

• Pelvic outlet:
Adequate if:
* can accommodate a fist between ischial
tuberosities

* Intertuberous distance >= 8 cm

* Suprapubic angle >= 90˚ (measured by 2 thumbs)

• Imaging pelvemitry

1. Transvaginal ultrasound pelvimetry

2. X-ray
3. CT
4. MRI

• These studies are not error free because dystocia

or abnormal labor can arise from soft tissue
obstructions in the pelvic outlet, particularly in
women who are obese.
• Cephalometry: fetal heads were measured within
one week before delivery

– Ultrasonography: is the safe accurate and easy

method and can detect:
• The biparietal diameter (BPD).
• The occipito-frontal diameter.
• The circumference of the head.
 Trial of labor

• A woman with known complications, may be

given a trial of labor to see if she is able to give
birth naturally.
• After a certain time, if labor fails to progress
satisfactorily and it seems unlikely that the
baby can be delivered safely through the
vagina, she will be offered a Caesarean

• If uterine rupture is suspected, deliver

immediately by cesarean section and repair
the uterus or perform hysterectomy
 Obstructed labor
It is arrest of vaginal delivery of the fetus due
to mechanical obstruction.

This occurs when the uterus is contracting

strongly, but there’s arrest of cervical dilation
and descent of the fetal head. because there
is a barrier preventing its descent despite
strong uterine contractions
Causes :
1-cephalopelvic disproportion
2-Abnormal presentation ( + position )
brow , shoulder , and chin posterior
3-fetal abnormalities : hydrocephalus .
4- Genital tract abnormalities : Pelvic
tumours ,stenosis of the cervix or vagina
 When do u have to Suspect obstructed
labor ?

• Cervix does not dilate in spite of good

contractions.

• Molding and caput increase , but baby’s head

doesn’t descend.
• Patient becomes anxious and restless and
exhausted.
• Patient develops hypertonic uterine
contractions, with poor relaxation in
between
• A cervix which is not well applied to the head

• When you diagnose obstructed labour, the

next critical question is: has her uterus
already ruptured???
• Bandl’s ring is a pathological retraction ring
A constriction located at the junction of the
thinned lower uterine segment with the thick
retracted upper uterine segment, resulting
from obstructed labour; this is one of the
classical signs of threatened rupture of the
uterus
Bandl’s ring is a late sign of obstructed labor , the
depression can be seen or on the abdomen at the
level of the umbilicus .. It signifies impending
rupture of the lower uterine segment.
 Signs on pelvic examination
• Vulvar edema .
• The cervix may or may not be fully dilated.
• A large caput succedaneum can be felt .
• Presentation can be assessed .
 Obstructed labor
• signs: bloody urine, unexpected easy
dislodgment of presenting part
followed by vaginal bleeding,
stretching & tenderness of the lower
segment of the uterus, Bandl’s ring
• The danger with obstruction is
uterine rupture.
 Uterine rupture s&S

• Severe lower abdominal pain.

• Cessation of contractions.
• Fetal distress. Fetal death
• Maternal tachycardia.
• Maternal shock.
 Uterine scar
• Usually due to a previous Caesarean section.
• 1 in 200 women with pre-existing uterine scar will
have uterine rupture during labor.
• Likely to occur late in the 1st stage of labor
• Risk increases with:
– Induced or augmented labor.
– Large babies
 Management of obstructed labor
• Caesarean section is the safest method of
delivery even if the baby is dead as labor must
be immediately terminated and any
manipulations may lead to rupture uterus.

Resuscitation .
Admission directly to operating room
 Management
 Correct dehydration, electrolyte deficit, and
acidosis.
 Cross match and prepare blood.
 Follow vitals.
 Patient is likely to go into septic shock, so start
prophylactic antibiotics
 As soon as the patient is stabilized perform
cesarean section
 Complications

• Pelvic floor injury

• pelvic organ prolapse .
 Intrapartum infection : maternal and fetal bacteremia and
sepsis..
 The more shoulder dystocia The higher the rate of perinatal
morbidity & mortality resulting from birth trauma.
THE END
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