Educational Materials

1. Abnormal Progress Of Labour
Associate Clinical Prof. Dr Aisha EL-Bareg, MD, PhD
Senior Consultant in ( Obs & Gyn/Reproductive Medicine)
Faculty of Medicine, Misurata University, LIBYA

2. Labor is defined as:
The onset of regular painful uterine contractions
with progressive cervical effacement and
dilatation of the cervix accompanied by descent
of the presenting part.
Definitions of labor

3. Stages of labor
Onset End Duration
1-First stage
Onset of true
labour pains
Full cervical
dilatation
Primi: 12-16
hrs
Multi: 6-8 hrs
2-Second stage
Full cervical
dilatation
Delivery of the
fetus
Primi: 1-2 hrs
Mutti: average
0.5 hrs
3-Third stage
After delivery
of the baby
Complete
expulsion of
placenta and
membranes
Up to 30
minutes
Fourth stage: 1- 2 hours after delivery
(observational)

4. Assessment & monitoring
 Maternal general condition, FHR
 Assessment of uterine contraction
 Clinical pelvimetry
 Evaluation of fetal presentation, position, station
 Estimation of fetal weight.

5. Always use partogram to
monitor labor

6. Partogram
 A graphical record of progress of labor, purpose:
 For early detection of abnormal progress of labor.
 Recognition of CPD
 Can allow time & discussion of further
management of labor
 Make observation & recording of fetomaternal
condition more objectively
 Prevention of feto-maternal problems &
complications.

7. Friedman labor curve in nulliparous - 1954

8. 0
2
4
6
8
10
12
2 4 6 8 10 12 14 16
Latent phase Active phase
2nd
stage
1st stage
max slope
acceleration
dec
Time (hours)
Cervicaldilatation(cm) Friedman labor curve in nulliparous
-3
-2
-1
0
+1
+2
+3

9. Normal progress in labor

10. Philpott and Castle - 1972
•Introduced the concept of
“ALERT” & “ACTION” lines.
•ALERT LINE – represent the
mean rate of slowest progress
of labor (1cm/hr)
•ACTION LINE – appropriate
action should be taken.
•Normal labor is plotted to the
left alert line

11. (1) FHR Chart:
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16Time (Hrs)
180
170
160
150
140
130
120
110
100
90
FHR

12. (2) UC, Caput, Molding, liquor & Memb:
5
4
3
2
1
Ut. Contra. per
10 Min.
Contra. Duran (Sec)
Membrane Status +/-
Weak
Mod
Good
Caput
Molding
Liquor C C C C M
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16Time (Hrs)
<20s
20-40s
>40s

13. (3) Cx dilatation & descent of head:
PP Position
CX Dilatn (Cm)10
9
8
7
6
5
4
3
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Time (Hrs)
HeadStation
-3
-2
-1
0
+1
+2
+3
Action lineLabor progress Alert line

17. Descent of the fetal head
 The rule of fifth BY abdominal examination

18. Assessing descent of the fetal PV;
0 station is at the level of the Ischial spine

19. Molding the fetal skull bones
 Increasing molding with the head high in the pelvis
is an ominous sign of Cephalopelvic disproportion.
 separated bones . sutures felt easily……..O
 bones just touching each other……………..+
 overlapping bones …………… ………….........++
 severely overlapping bones ( notable ) …+++

20. Abnormal labor
Precipitated labor
Prolonged labor
Obstructed labor

21. Prolonged labour (Dystocia)
Prolonged labour occurs when there is :
 Poor progress- delay in cervical dilatation
and/or delayed descent of the presenting
part.
 Fetus shows signs of compromise.

22. Criteria for diagnosis of abnormal labor

23. Incidence
Dystocia complicate 8% to 11% of vertex
deliveries in the 1st and 2nd stages of labor.
The leading indication for primary CS.
Recognition of risk factors and causes are
critical for proper treatment.
Appropriate management reduces maternal
and fetal morbidity and prevents
unnecessary CS.

24. Risk factor
Maternal
Obese women, Short maternal stature
Advanced maternal age
Infertility or nulliparity
Maternal DM/Hypertension
Uterine (previous CS, fibroid, overdistension)
Cervical lesions.
Contracted bony pelvis
Regional anesthesia

25. Risk factors
Fetal
 Big baby (macrosomia)
 Congenital fetal abnormalities
 Malpresentation, mal-position
 PROM or oligohydramnios
 Chorioamnionitis
 Previous perinatal death

26.  Complication of prolonged labour
 Maternal
 Maternal exhaustion
 Increased incidence of CS
 Birth canal injuries if forceps is used
 PPH, Puerperal sepsis
 Fetal
 Fetal distress, Chorioamnionitis, neonatal
sepsis
 ICH- if forceps is used

27. Power
• Uterine contraction
• Maternal expulsive eff.
Passenger
•Macrocosmic fetus
•Malposition
•malpresentation
Passage
• Contracted maternal pelvis
• Soft tissue obstruction
Abnormalities in the 4 Ps
Patient
•Pain relief
•Hydration
•Sympathy & reassurance

28. POWER ► Contractions + Maternal pushing
Uterine contractions:
1. Initiate by pacemakers at uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward
 Shortening of muscle fibers
 Retractions
 intra uterine pressure
EXPULSION OF THE FETUS
forceAdditional
“maternal pushing”
Intra abdominal
pressure

29. Uterine contraction
Normal contraction
1. Frequency: (3-5/ 10 min)
2. Intensity ~ strong (> 50 mmHg)
3. Duration ~ 40 – 60 sec
Frequency in 10min X intensity= 200 mentovideos
Uterine
contractions

30. Abnormal uterine action
 Uterine under activity (hypotonic inertia)
 Uterine over-activity (hypertonic inertia)
 Without obstruction- precipitate labor
 With obstruction- obstructed labor

31. Hypotonic inertia
 Definition
Inefficient contraction - weak, infrequent, short
 Types
1. Primary hypotonic inertia
2. Secondary inertia

32.  Causes
 Local causes
 Uterine overdistension- Twins, hydramnios.
 APH- PP, AP
 Contracted pelvis, malpresentation, macrosomia
 abuse of oxytocin
 Uterine fibroids
 General causes
 Anemia & malnutrition
 Maternal exhaustion and dehydration
 Full bladder, rectum - Grand MP - idiopathic

33.  Clinical picture
 Mother and fetus are usually not seriously
affected.
 Infrequent labour pain, prolonged labour.
 Slow cx dilatation and descent of the head.
 Management
a. Exclude and manage
 Contracted pelvis
 Malpresentation
 Twins, polyhydramnios

34. b. Proper management of primary inertia
 Evacuation of the bladder
 Monitor the progress of labour using partogram
 Hydration, energy- IV dextrose
 Pain relief, Avoid straining
 ARM + Oxytocin (syntocinon)- Augmentation
 Guard against infection & Guard agianst PPH
 Operative
 Instrumental- ventous or forceps
 CS- failure of oxytocin, CI to vaginal delivery

35. C. Management of secondary inertia
 Hypotonic inertia after a period of good
uterine contraction.
 Common in PG.
 Uterine exhaustion due to obstructed
labour.
 CS is usually needed.

36. Incoordinate uterine dysfunction
‘Hypertonic inertia’
 Hypertonic LUS - due to reversed polarity
 Colicky uterus- incoordinate leading to
irregular, asymmetrical contraction in part or all
of the upper uterine segment
 Aetiology- unknown
 Elderly PG - Maternal exhaustion
 Dehydration - Abuse of oxytocin
 Malpresentation - CPD

37.  Clinical presentation
 Prolonged labour
 Continuous low backache even after contraction
 Maternal and fetal distress are common
 Management
 Hydration, sedation + analgeics
 Pethidine or epidural analgesia
 Close observation
 CS- if
Failure to respond to analgesia
Indication of CS- CPD, malpresentation

38. Pattern of abnormal progress of labour
Disorders of 1st stage of labour
1. Prolonged latent phase
2. Disorders of active phase

39. A. Prolonged latent phase
B. Prolonged active phase
C. Arrested active phase
Disorders of 1st stage of labor

40. Prolonged latent phase
 Causes:
 False labor
 Excessive sedation
 Unfavorable cervix, forced induction
 Outcome:
 14% will go into protracted active phase

41. Management
 Expectant
 Awaiting active labour- provided no indication
for delivery.
 Simple analgesics.
 Mobilization, reassurance
 Active
 If delivery is indicated- Induction /
augmentation labor
 Early ARM- increase risk of prolonged labour
with PPROM- risk of IU infection and neonatal
sepsis, risk of CS 10 folds.

42. 2. Disorders of active phase
a. Protraction (primary dysfunctional labour )
b. Secondary arrest
a b

43. a. Protraction (primary dysfunctional labor)
Definition
 Rate of dilation- <1.2 cm/hr in PG
 Rate of dilation- < 1.5 cm/hr in MG
b. Secondary arrest of labor
Definition
 Cessation of previously normal active phase cx
dilatation for a period of 2 hrs or more or
descent of head for > 1 hr
2. Disorders of active phase

44.  Causes
 Abnormal uterine contraction.
 Mal-position (OP, OT), Mal-presentation (Brow)
 Cephalo-pelvic disproportion (CPD): often
relative .
 Idiopathic (early ARM), Excessive sedation.
 Outcome
 10-30 % will go into Secondary Arrest
 Secondary arrest will require LSCS. If protracted
deceleration beware of shoulder impaction

45. 3. Prolonged 2nd stage of labour
 Definition
• PG
• > 2 hrs without epidural anesthesia
• > 3 hr with anesthesia
• MG
• > 1 hr without epidural anesthesia.
• > 2 hrs with anesthesia

46. 1. Protraction of descent
 Descent of presenting part during the 2nd
stage of labor occuring at
 < 1cm/h in PG
 < 2cm/h in MG
2. Arrest (failure) of descent- no progress of
descent for < 2 hrs

3. Prolonged 2nd stage of labor

47.  Assessment
 Evaluation of uterine activity
 Evaluation of maternal expulsive efforts
 FHR status every 5 min
 Fetal position, Clinical pelvimetry
 Re-estimation of fetal wt
 Management
 Increasing or initiating oxytocin to improve
maternal expulsive effort
 Operative vaginal delivery or CS.

50. Obstructed labour
 Definition
 Failure of vaginal delivery due to a mechanical
obstruction
 Causes
 Fetal
 Malposition: persistent OP, deep transverse arrest
 Malpresentation: brow, shoulder, arrested breech
 Macrosomia, Congenital fetal malformation,
Conjoined twins

51.  Maternal
 Contracted pelvis
 Soft tissue obstruction
 Perineal, vaginal, cervical
 Pelvic mass-uterine fibroid, ovarian mass
 Outcome
 Secondary hypotonic inertia- in PG due to
uterine exhaustion
 Rupture of uterus- pathological retraction
ring- usually in MG

52.  Diagnosis
Clinical picture of impending rupture of uterus
 history
 Prolonged labour, excessive oxytocin use
 Labour pain is frequent and strong, persists
between contraction
 Rupture membranes since long time
 General examination- all sigs of maternal distress
 Irritable, exhausted, sweaty
 Signs of dehydration- UOP with ketosis

53.  Abdominal examination
 Rising retraction ring ‘pathological retraction ring’
‘Bandl’s ring’
 Tonic tender uterus, collapsed on the fetus-
drained liq
 Fetal parts not felt, FHS usually not heard
 Transverse lie or macrosomic fetus

54.  Pelvic examination
 Vulva is oedematous, Vagina is dry, hot and
ballooned, Cx is oedematous, fully dilated
 Presenting part: high, caput, moulding +3
 Picture of the cause- CP, prolapsed arm, brow-
 Management
 Prevention
 Definitive treatment- CS

55. Precipitate labour
 Definition
Labour which has started & completed in <3hrs
 Etiology- unknow but it is common in MG, requires
 Power- strong, frequent, well coordinated
 Passenger- small or average fetus with vertex
presentation
 Passage- lack of resistance in LUS & Cx, roomy
pelvis

56.  Complication
 Maternal
 Perineal, vaginal, cervical injuries
 PPH (atonic & traumatic)
 Acute inversion of the uterus
 AF embolism
 Puerperial sepsis
 Later- recurrence, prolapse, stress UI
 Fetal
 ICH
 Fracture of skull, avulsion of the UC

57.  Management
 During labour
 stop oxytocin,
 give analgesia up to tocolytics- ritodrine or Mg
SO4
 After delivery
 EUA to exclude birth tract injury or uterine
inversion
 Observation for PPH
 Management of complication
 Proper examination of the newborn for any
trauma

58. Cephalopelvic Disproportion (CPD)
CPD is obstructed labor resulting from disparity
between the size of the fetal head and maternal
pelvis: small pelvis, nongynecoid pelvis, large fetus,
or more commonly a combination of these factors.
True CPD is rare, 1 in 250 pregnancies.

59. 1 September 2017 59
Ischial
Spine

60. Various Planes

61. Contracted pelvis
 The pelvis in which one or more of its main
diameters are reduced to the extent that interferes
with the normal mechanism of labor .
 Causes
 Causes in Pelvic bone :
 Developmental
 Metabolic: rickets, osteomalacia
 Trauma : fractures
 Neoplastic: osteoma

62.  Causes in spines:
 Lumber kyphosis
 Lumber scoliosis
 Spondylolisthesis
 Causes in the lower limbs
 Dislocation of one or both femurs
 Atrophy of one or both lower limbs
 Disease, fractures or tumours affecting one side.

63. Diagnosis of contracted pelvis
 History:
 Rickets: is expected if there is a history of delayed
walking and dentition.
 Trauma or diseases: of the pelvis, spines or lower
limbs.
 Bad obstetric history: e.g. prolonged labor ended by;
difficult forceps, caesarean section or Still birth.

64.  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.
 Spines and lower limbs: may have a disease or
lesion.
 Bony abnormalities in other area of the body

65.  Examination
 Abdominal Examinations
Non-engagement of the head: in the last 3-4
weeks in primigravida.
Pendulous abdomen: in a primigravida.
Malpresentations: are more common.
•Pelvimetry:
•Internal plevimetry: by vaginal examination
•External pelvimetry: pelvimeter

66. 1 September 2017 66
Pelvimetry
ClinicalRadiological
May All Be Happy & Healthy
Internal pelvimetry
By vaginal examination
External pelvimetry
By pelvimeter

67.  contracted if Transverse diameter <12cm
AP diameter <10 (true conjugate)
Palpation of the pelvic brim:
The index and middle fingers are moved along the
pelvic brim. Note whether it is round or angulated.
The inlet

68. Diagonal conjugate:
Insert two fingers into the vagina until they reach
the sacral promontory. Normally, > 11.5 cm and
cannot be reached. If it is felt the pelvis is
considered contracted and the true conjugate can be
calculated by subtracting 1.5 cm from the diagonal
conjugate .This assessment is not done if the head is
engaged.

69. • Symphysis : The height, thickness and inclination
The cavity
• Hollow of the sacrum: The anterior surface of the
sacrum is palpated from below upward and its
vertical and lateral curvatures noted.
• In normal pelvis, only the
last three sacral vertebrae
can be felt without
indenting the perineum

70. •Side walls: straight, convergent or divergent
The cavity
•Ischial spines: Whether it is
blunt, prominent or very
prominent. Ischial prominence
narrows the transverse
diameter of the pelvis.

71. • Interspinous diameter:
By using the 2 examining fingers, if both spines can be
touched simultaneously, the interspinous diameter is
9.5 cm i.e. inadequate for an average-sized baby.
•Sacrosciatic notch:
If the sacrospinous ligament is
two and half fingers, the
sacrosciatic notch is considered
adequate.
The cavity

72. The outlet
•Bituberous diameter:
Normally, it admits the
closed fist of the hand
= (4 knuckle >8cm).
•Subpubic angle : Normally, it
admits 2 fingers (90◦). Angle ≤
90 degrees suggests contracted
transverse diameter in the
midplane and outlet.

73. •Mobility of the coccyx: by pressing firmly on it
while an external hand on it can determine its
mobility.
•Anteroposterior diameter of the outlet: ≥ 11 cm
from the tip of the sacrum to the inferior edge of
the symphysis.
The outlet

74. Data Finding
pelvic brim Round.
Diagonal conjugate ≥ 11.5 cm.
Symphysis Average thickness, parallel
to sacrum.
Sacrum Hollow, average inclin.
Side walls Straight.
Ischial spines Blunt.
Interspinous diameter ≥ 10.0 cm.
Findings indicating adequate pelvis

75. Data Finding
Sacrosciatic notch 2.5 -3 finger - breadths.
Subpubic angle 2finger - breadths.
Bituberous diameter 4 knuckles (> 8.0 cm).
Coccyx Mobile.
Antero-posterior
diameter of outlet
≥11.0 cm.
findings indicating adequate pelvis

76. External pelvimetry

77. MRI Pelvimetry:
1 September 2017 77May All Be Happy & Healthy