DYSTOCIA abnormal labor

1. DYSTOCIAabnormal labor Supervised By: Prof. Faheem Zayed Done by: Mohammed Okour Mahmoud Maaitah Mohammed Semiran Ra’ad Jaradat

2. Normal labor Definition: the process by which regular, painful uterine contractions bring about the effacement and dilatation of the cervix and the descent of the presenting part, leading to the expulsion of the fetus and the placenta from the mother. Criteria of normal labor: Spontaneous onset Single cephalic presentation 37-42 weeks No artificial intervention Unassisted spontaneous vaginal delivery Reasonable duration Without complications to mother or fetus. A retrospective diagnosis

3. Stages of labor Normal labor consists of 4 stages , so any factor interfering with of these stages will result in abnormal labor. First stage: Starts with the onset of true labor pain and ending with cervical dilatation. It lasts from 5- 14 hour depending on the parity of the woman. Second stage: Starts with the full dilatation of the cervix until the complete expulsion of the fetus. Lasts between 1- 2 hours also depending on the parity.

4. Cont… Third stage: It is the stage if placental expulsion. Lasts for 15-30 minutes. Fourth stage: Early recovery of the patient starting after the placental expulsion. first 1-2 hours after delivery.

5. Definition 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 . When any thing interferes with the normal course of labor and delivery

6. Abnormal labor Induced labor. Multiple gestation. Malpresentation. Pre/Post term. Assisted delivery. Precipitous labor. Uterine scar. Poor progress or arrest.

7. Cont… Abnormal labor can be due to abnormalities in one or all of the following factors: 1- Power (efficiency of uterine contractions) 2- Passenger (fetus) 3- Passage (uterus, cervix and bony pelvis).

8. Risk factors for poor progress in labor: Risk factors for poor progress in labor: Small women ( less 1.52 m ) Large babies Malpresentation Malposition Early rupture of membranes Soft tissue/ pelvic malformations

9. The passenger Size of infant Presentation Position

10. Cont… Size of infant: Fetal macrosomia: - > 90th percentile of fetal weight, or > 4 kg for term - risk factors: DM, obesity, post-term, multiparity, etc. - complications: prolonged labor, instrumental delivery, shoulder dystocia ? abnormal labor Others: anomalies and other developmental abnormalities (including hydrocephalus, encephalocele, fetal goiter, cystic hygroma, hydrops, ascitis, organomegaly, meningocele, meningomyelocele

11. Cont… Presentation : any presenting part other than the vertex, i.e. breech, face, brow, shoulder, compound presentation

12. Cont… Position : Malposition: any position other than occipito-anterior. - Occipitoposterior, usually corrects spontaneously 90% of cases rotates to (OA) position - Possible causes: pendulous abdomen, anthropoid pelvis, ant. uterine wall placenta

13. The power Which means the uterine contractions that play the major role in cervical dilatation in addition to the descent of the fetus. Such contractions should be effective and adequate :- 1. duration 45-60 sec. 2. frequency every 2-3 min. 3. intensity >= 50mm hg (IUPC). 4. 4-5 per 10 min.

14. Criteria for Diagnosis of Abnormal Labor Due to Arrest or Protraction Disorders

15. Abnormal labor

16. 1st and 2nd stage abnormalities Prolonged labour: This term refers to prolongation of the first stage of labor only; because prolongation of following stages is considered a failure to progress. Prolonged latent phase: > 20 hr Nulliparous < 14 hr Multiparous A prolonged latent phase may result from over sedation or from entering labor early with a thickened or uneffaced cervix. Causes: 1- Power (Inefficient uterine contraction) a) Hypertonic uterine dysfunction b) Hypotonic uterine dysfunction 2- Excessive use of sedative or analgesia.

17. Cont… Hypertonic contractions are painful ineffective and associated with increased uterine tone. There is a high resting basal tone between contractions. Therefore, uterine circulation does not return to normal between contractions and consequently fetal distress is more common. Hypotonic contractions are less painful and characterized by easily indentable uterus during the contractions and occur more frequently during the active phase. They are considered as the most common cause of poor progress in labor. Risk factors: Extreme reproductive age (too young or too old). Primigravida. Unusually anxious women. Uterine over distention, e.g. multiple gestation, polyhydraminos. Minor degrees of cephalo-pelvic disproportion. Malposition of the fetal head. some patients who appear to be developing prolonged latent phase are shown eventually to be in false labor with no progressive dilatation of the cervix.

18. Cont… The outcome of a prolonged latent phase is generally favorable for both fetus and mother provided that no other abnormalities of labor subsequently occur. Management depend on the cause : * excessive sedation or analgesia resolved spontaneously after their effect have disappeared. * hypertonic activity respond erratically to oxytocin but usually respond to therapeutic rest with 15-20mg morphine sulphate or pethidine * hypotonic activity respond well to IV(infusion) oxytocin. * ARM has been regarded as an effective method for management but this approach continues to be controversial , also it carries the added risk of intrauterine infection and may increases the possibility of poor progress later in the labor with increasing risk for caesarean section.

19. Cont… Protraction disorder of the active phase: cervical dilatation less than 1.2cm/hr for primi and less than 1.5cm/hr for multi. more common in multiparous women. Arrest disorder of stage 1 (active phase arrest) or stage 2 (arrest of descent): either no progression in cervical dilatation for at least 2 hrs in stage 1(usually after 7cm dilatation) or prolonged duration of at least 2 hrs in stage 2. In the absence of CPD , fetal malposition , those disorders caused by hypotonic uterine contractions , excessive sedation and conduction anesthesia. Management *generally these disorders don’t respond to oxytocin stimulation or therapeutic rest or ARM , they should be treated expectantly as long as the fetal HR is satisfactory and labor continues to progress. *if due to hypotonic activity it will respond to oxytocin. *over sedation , normal labor will resume if the effect of drug is allowed to wear off.

20. Active management of labor (Dublin protocol) Active management of labor has been associated with shorter labors and lower rates of intervention. Components & Criteria of protocol: 1- Nulliparaus pregnant patient with spontaneous labor and singleton fetus in cephalic presentation. 2- Prenatal education class. 3- Constant attendance during labor. 4- Peer review of all caesarian sections

21. Cont… 5- Nonadmittance to the labor unit without a clear diagnosis of labor; the presence of regular painful uterine contractions and at least one of the following: - bloody show - rupture of membranes. - complete cervical effacement. 6- Amniotomy on admission to labor and regular examination for progress in cervical dilatation. 7- Oxytocin augmentation of labor if dilatation <1cm/hr in 1st stage, or no descent for 1 hr in 2nd stage. If progress fails to occur over the next 4-6 hours? Caesarean will be necessary

22. Malpresentations

23. Malpresentations Definition: describes any presentation other than a vertex lying in close proximity to the internal Os of the cervix and includes: Breech Brow Face Shoulder Arm Compound

24. Causes of Malpresentation Maternal Multiparity Pelvic tumors Congenital uterine anomalies Contracted pelvis Fetal Prematurity Multiple pregnancy Intrauterine death Macrosomia Fetal abnormality Hydrocephalus Anencephaly Cystic hygroma

25. Causes of Malpresentation Other causes Placenta previa Polyhydramnios Amniotic bands

26. 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 position. By 34 weeks gestation, most fetuses have assumed the vertex presentation position.

27. Types of Breech Extended breeches (70%) Presenting part is the buttocks Complete (Flexed) breeches (15%) Both buttocks and feet are presenting Footling breeches (15%) One leg flexed and one extended

29. Etiology and Associations of Breech Presentation The major factor predisposing to breech presentation is prematurity Idiopathic Previous breech presentation Uterine abnormalities ( fibroids, bicornuate uterus) Placenta previa, obstructions to pelvis Fetal abnormalities (6%) Multiple gestations Polyhydramnios

30. Diagnosis of Breech Presentation Examination: Lie is longitudinal Head palpated at the fundus Presenting part is not hard Fetal heart is best heard high up on the uterus Vaginal examination may reveal one or both feet Investigations Ultrasound confirms dx and should also asses growth and anatomy due to associations with fetal abnormalities

31. Cesarean Delivery Cesarean section delivery is currently preferred for both term and preterm breech infants In 2000 a large multicenter randomized trial (“Term Breech Trial”) compared elective c/s and planned vaginal delivery in term singeltons. No difference in mortality b/w the groups was seen, but an increase in short term morbidity was noted in those babies delivered vaginally.

32. Other Presentations

33. Face Presentation Fetal head is hyper extended such that the fetal face, between the chin and orbits is the presenting part Incidence 1:500 deliveries Diagnosis is made by VE during labor, when soft tissues of fetal mouth and nose are felt. Confirmed with U/S. Factors associated with face presentation: extreme prematurity, high maternal parity, cong. anomalies such as fetal goiter, cystic hygroma, anencephaly

34. Face Presentation cont. Mentoanterior in 60% can be delivered vaginally and/or with forceps. Vacuum contraindicated. If mentum rotates posteriorly, cesarean section must be carried out. (Fetal head will be unable to extend farther to complete the birth process) Approximately 50% of mentoposterior and mentotransverse presentations spontaneously rotate to MA position. When delivered by spontaneous vag. delivery or with forceps, perinatal morbidity and mortality for face presentations are similar to those for vertex presentations.

36. Brow Presentation The head occupies a position midway between full flexion (vertex) and full extension (face). 1 in 1400

37. Brow presentation cont. Diagnosis Diagnosed in advanced labor Head does not descend below ischial spines VE is diagnostic as the frontal sutures, anterior fontanelle, orbital ridges and root of nose are palpable. 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 occipitomental diameter (13.5cm) ? Cesarean section

38. 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

39. Compound Presentation Fetal extremity (hand) prolapses alongside the presenting part (the head) and both parts enter the maternal pelvis at the same time. Premature gestations 1 in 700 Usually the prolapsed part does not interfere with labor.

40. Position The relation of an arbitrary chosen point of the fetal presenting part to the right or left side of the maternal birth canal Affected by the passage (pelvis)

42. Gynecoid: Classic type, 50% of women, it has a spacious cylindrical shape and is most favorable. Fetal head usually assumes an occipito-anterior position in this type.

43. Android: Typical male pelvis 30% of women, limited space at inlet and becomes narrower (funneling). Forces the head into occipito-posterior position causing deep transverse arrest of descent is common at midpelvis.

44. Anthropoid: Resembles that of the anthropoid ape, 20% of women. Allows fetal head to engage in AP diameter, and does so in the occipito-posterior position.

45. Platypelloid: A flattened gynecoid pelvis. 3% of women. Oval shaped inlet with wide transverse diameter. A gentle curve throughout. Fetal head must engage in the transverse diameter ? obstructed labour

46. CPD A disproportion between the size of the fetus relative to the maternal pelvis, due to large baby or small pelvis or both of them. BUT 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 CPD is one of the most common reason for doing a cesarean section due to failure to progress. Types of pelvis : gynecoid,android,anthropoid,and patypelloid.

48. Abnormalities of the passages Maternal causes of cephalo-pelvic disproportion: Suspected fibroids of lower uterine segment. Cervical dystocia. Abnormal shapes of the pelvis. Pelvic tumors Previous pelvic trauma and previous surgeries.

49. Diagnosis Of CPD When to suspect CPD in labor? -Progress is slow or arrested despite efficient uterine contractions. -The fetal head is not engaged. -Vaginal examination shows severe moulding and caput formation. -The head is poorly applied to the cervix.

50. Diagnosis of CPD History: Rickets Osteomalacia Trauma or diseases : of the pelvis, spines or lower limbs. Bad obstetric history Indicators of a large baby Any patient in labor is at risk for abnormal labor regardless of the number of previous pregnancies or the seemingly adequate dimensions of the pelvis. Examination: General examination: Gait: abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs. Stature: women with less than 150 cm height usually have contracted pelvis. Manifestations of rickets as: 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

51. Cont… 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.

52. Cont… Clinical pelvimetry -it is not possible to assess all pelvic dimensions clinically. - Early Vs. Late assessment of pelvic dimensions -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.

53. Cont… Vaginal examination to determine the diagonal conjugate

54. Cont…

55. Cont… Imaging pelvemitry Transvaginal ultrasound pelvimetry X-ray CT, 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.

56. 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. Warning signs: Bandl’s ring and tenderness of the lower segment of the uterus. The danger with obstruction is uterine rupture.

57. Cont… Bandl’s ringis 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.

58. Cont…

59. Cont… Suspect obstructed labor when: Cervix does not dilate in spite of good contractions. Moulding 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 Other signs are: s?tretched lower segment, bloody urine, unexpectedly easy dislodgement of the presenting part followed by a gush of vaginal bleeding . When you diagnose obstructed labour, the next critical question is: has her uterus already ruptured

60. Cont… Management 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. Patient usually in hypovolemic shock, so resuscitation must be rapid, because delivery is urgent. Admit her directly to operating room, This will allow you to operate as soon as she is in an optimal condition. 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

61. Uterine ruptureSigns and symptoms Severe lower abdominal pain. Cessation of contractions. Fetal distress. Maternal tachycardia. Maternal shock. Fetal death.

62. Precipitate labor Definition: 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. Risk factors: Strong uterine contractions. Small sized fetus. Minimal soft tissue resistance. Previous history of precipitate labor.

63. Precipitate labor Complications: Maternal: Laceration: Cervix, vagina, and perineum. Uterine inversion – postpartum hemorrhage Uterine atony – postpartum hemorrhage Amniotic fluid embolism Fetal: Intracranial hemorrhage Fetal distress Delivery in inappropriate place

64. Precipitate labor Management: Stop oxytocin infusion (if used). Tocolytics (Mg sulfate, terbutaline). Episiotomy to avoid fetal and birth canal injuries. Observe for PPH. Observe fetus fro injuries.

65. 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.

66. Trial of labor A woman with known complications, for example a previous Caesarean birth, 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 Ensure that conditions are favorable for trial of labor: The previous surgery was a low transverse caesarean incision The fetus is in a normal vertex presentation Emergency caesarean section can be carried out immediately if required. If these conditions are not met or if the woman has a history of two lower uterine segment caesarean sections or ruptured uterus, deliver by cesarean section.

67. Cont… Monitor progress of labor using a partograph. If labor crosses the alert line of the partograph, diagnose the cause of slow progress and take appropriate action. If there is slow progress in labor due to inefficient uterine contractions , rupture the membranes and augment labor with oxytocin. If there are signs of cephalopelvic disproportion or obstruction deliver immediately by cesarean section. If there are signs of impending uterine rupture, deliver immediately by cesarean section. If uterine rupture is suspected, deliver immediately by cesarean section and repair the uterus  or perform hysterectomy

68. The larger the fetus the more the following may happen: The longer the labour. The greater the chance for midforceps operation. The more shoulder dystocia The higher the rate of perinatal morbidity & mortality resulting from birth trauma.

69. Partogram partogram is a graphical representation of the changes that occur in labour, including cervical dilatation, fetal heart rate, maternal pulse, blood pressure, and temperature; it also shows a numerical record of features such as urine output and the volume and type of intravenous infusions (including oxytocin drips). It is therefore possible at a glance to identify deviations from normal in any of these variables

70. Philpott & Castle (1972) Partogram

71. Partogram Used in established labour to check progress Plots cervical dilatation. Alert and action lines Maternal T, P, BP, urine, contractions. Fetal heart rate, descent, moulding & caput. Liquor Fluids & drugs.

75. Primary arrest

76. Secondary arrest

77. Arrest in Second Stage

78. Fetal observations Admission CTG to check well being Intermittent monitoring by listening in after contractions

79. Cardiotocograph Assessed by: Baseline rate between 110 – 160 bpm Baseline variation: Beat to beat variability between 5 – 25 bpm Reactive: two acceleration of at least 15 bpm over the baseline, lasting for at least 15 seconds within 20mins No decelerations

80. Classification of CTG: Normal CTG where all four features fall into the reassuring category. Suspicious CTG whose features fall into one of the non-reassuring categories and the remainder of the features are reassuring. Pathological CTG whose features fall into two or more non-reassuring categories or one or more abnormal categories.

81. Types of decelerations: Early Decelerations: Normal, due to head compression during contractions. (? vagal tone) Onset, peak, and end coincides with the timing of the contraction (mirror image).

83. Variable Decelerations Abnormal (mild, moderate or severe depending on duration), due to cord compression. Can occur at any time, and pattern change from one contraction to another. If they are repetitive, suspicion is high for the cord to be wrapped around the neck or under the arm of the fetus.

84. Intervention: Change maternal position to the lateral recumbent position. Give oxygen by face mask. Stop oxytocin (Pitocin) infusion. Provide an IV fluid bolus. Give an IV tocolytic drug (MgSO4). Monitor maternal blood pressure. If persist longer than 30 minutes, fetal scalp blood pH should be obtained and C-section considered.

85. From: the Royal Women’s hospital clinical practice guidelines (Australia).

86. Fetal scalp pH When CTG is non-reassuring, it can be done to confirm hypoxia and acidosis (rem: Hypoxia ? anaerobic metabolim ? lactic acid ? acidosis). Done through a small incision in the scalp through which a small amount of blood is drawn. If pH > 7.25 : reassuring pH 7.20-7.25 pH <7.20 : non-reassuring Blood should not be contaminated with amniotic fluid which is basic.

87. Auscultation of fetal heart Done through hand-held doppler. Performed intermittently during labor.

88. Thank you