3. ⚫Any deviation from normal pattern of
uterine contractions affecting the normal
courseof labour is designated as disordered
orabnormal uterine contraction.
⚫Overall labourabnormalities occur in 25%
nulliparous and 10% multiparous.
5. First birth speciallywith advancing ageof the mother
Prolonged pregnancy
Overdistentionof the uterus
Psychological factor
Contracted pelvis, mal-presentationand deflexed
head
6. Injudicious administration of
sedatives, analgesicsand oxytocics
Prematureattemptatvaginal
delivery or attempted
instrumental vaginal delivery
under lightanesthesia
Cervical rigidity
Massivelyobeseclients
7. ⚫Weak, infrequent and ineffective uterine
contractions
⚫Intensity is diminished
⚫Duration is shortened
⚫Good relaxation in between contractions
and the intervals are increased.
8. 1. General factors:
⚫Primi-gravida especially elderly.
⚫Anemia, chronic illness, antepartum
hemorrhage
⚫Hypertensive states with pregnancy.
2. Local factors:
⚫Overdistension of the uterus
⚫Anomalies in developmentof the uterus
⚫Mal-presentations and mal-position
⚫Full bladderorrectum.
⚫Uterine fibroids
⚫Induction of premature labour.
10. ⚫Labor is prolonged
⚫On Examination:
⚫weak increase in the uterine tone
⚫uterine contractions in 10 minutes are less
than 3 contractions and each lasting less
than 30 seconds.
11. ⚫In the 1ststage: Nervousness, anxiety, exhaustion and
starvation ketoacidosis
⚫In the 2nd stage: Prolonged 2nd stage, increase liability
for instrumental deliveryand cesarean section.
⚫In the 3rd stage: Retention of the placentaand
postpartum hemorrhage.
⚫Sub-involutionof the uterus.
⚫Risksof abuseof uterinestimulants.
12. Properdiagnosis
Exclusion of cephalo-pelvic
disproportionand mal-presentations
Oxytocin stimulation:
• To increase thestrength, frequencyand
duration of the uterinecontractions.
Closeobservation of the mother & the
fetal well being.
Assessmentof efficiencyof uterine
contractions
13. Operative interference:
⚫ Artificial ruptureof the membranes
⚫ Operativedelivery indicated if labor is prolonged beyond
24hoursor if there is fetal distress at any time.
⚫ Oneof the following may be done:
o Vaginal delivery by forceps if thecervix is fullydilated
and theconditions are suitable forvaginal delivery
.
o Caesarean section: if fetal distress occurs before full
dilatationof thecervix.
14. It is defined as either a series of single
contractions lasting 2 minutes or moreora
contraction frequency of five or more in 10
minutes.
⚫Strong and painful uterinecontraction
⚫High frequency
⚫Slow cervical dilatation
⚫Two poleof uterus doesn’t functions
15. ⚫ Labour is prolonged
⚫ Uterine contractions are
irregularand more painful
⚫ High resting intrauterine
pressure in between uterine
contractions detected by
tocography
⚫ Slow cervical dilatation
⚫ Premature ruptureof
membranes
⚫ Fetal and maternal distress
16. ⚫ CPD, Fetal Distress- Caesarean
Section
⚫ Vital monitoring
⚫ I/V therapy: correction of
dehydrationand ketoacidosis
⚫ I/O charting
⚫ FSH every 15 min
⚫ Partograph
17. Uterine Contraction:
⚫ Fundal dominance is lacking
⚫ Reversepolarity
⚫ Lower segmentcontractions are
stronger
⚫ Inadequaterelaxation in between
thecontractions
⚫ Premature bearing down
⚫ Cervix loose, edematous, not well
applied to the presenting part
18. ⚫ Patient isagonywith unbearable pain referred to the back.
⚫ Bladder is frequentlydistended; distension of stomach and
bowels arevisible.
⚫ Premature attempts to beardown.
⚫ Abdominal palpation reveals:
⚫ Uterus is tenderand gentle manipulationexcites hardening of the
uterus with pain
⚫ Uterus remains tense evenaftercontraction passesoff and as
such
⚫ Palpation of the fetal parts is difficult
19. ⚫Internalexamination may reveal:
⚫ Cervix which is thick, edematous
hangs loosely likea curtain; not well
applied to the presenting part
⚫ Inappropriatedilatation of thecervix
⚫ Absenceof the membrane
⚫ Varying degree of caput
⚫ Meconium stained liquor amnii
⚫Effect on the Fetus: Fetal distress
appears early due to placental
insufficiencycaused by inadequate
relaxation of the uterus.
21. ⚫It is a persistent localized annularspasm of thecircular
uterine muscles .
22. ⚫ It occurs at any part of the uterus but usuallyat junction of the
upperand lower uterinesegments around aconstricted part of the
fetus usuallyaround the neck in cephalic presentation.
⚫ It can occurat theany stage of labourand is usually reversible and
complete.
23. Etiology is unknown but the predisposing
factors are:
⚫ Malpresentationsand malpositions
⚫ Premature ruptureof membrane
⚫ Premature attemptof instrumental delivery
⚫ Intrauterine manipulations under light
anesthesia.
⚫ Improper use of oxytocin e.g. use of
oxytocin in hypertonic inertia or IM
injection of oxytocin.
24. ⚫Maternal condition notaffected.
⚫Fetal distress mayoccur
⚫Ring is not palpable during perabdomen
⚫Felt into first stage during – Caesarean
Section
⚫Second stage – Forcepsapplication
⚫Third stage – Manual removal of
placenta.
25. Diagnosis is
difficult.
More common in primi gravida and
frequently preceded bycolicky uterus
The exact diagnosis is achieved only by
feeling the ring with a hand introduced into
the uterine cavity.
26. Prolonged 1st
stage
• if the ring
occursat the
level of the
internal Os.
Prolonged 2nd
stage
• if the ring
occurs around
the fetal neck.
Retained placenta
and postpartum
hemorrhage
• if the ring
occurs in the
3rd stage
27. 3rd stage: Deep general anesthesiaand amyl nitrite inhalation
followed by manual removal of the placenta.
ring is relaxed, delivery by
forceps
ring does not relax,
caesarean section
1st stage: Pethidine morphine
2nd stage: Deepgeneral anesthesiaand amyl nitrite
Exclude malpresentations,
malposition and
disproportion
28. ⚫This typeof uterinecontraction is predominatelydue to
obstructed labor.
⚫Physiological Retraction Ring: It is a line of demarcation
between the upperand loweruterine segment presentduring
normal labourand cannot usually be feltabdominally
.
⚫ As a result of lower segment thinning and concomitant upper
segment thickening.
29. Pathological Retraction Ring : It is the rising upretraction ring
during obstructed labour due to marked retraction and
thickening of the upper uterine segment while the relatively
passive lower segment is markedly stretched and thinned to
accommodatethe fetus.
Contraction increases in intensity ,durationand frequency
with decreased relaxation in between.
Retractioncontinues
Progressive thinning & elongation of loweruterinesegment
Developmentof circulargroove between upperand lower
segment-called BANDL’S RING.
30.
31.
32. Continuouspain, discomfort, restlessness.
Featuresof exhaustionand ketoacidosis
Abdominal palpation reveals:
• Upperuterine segment is tenderand hard. Lower uterine
segmentdistended and tender.
• Groove is seen between the umbilicusand symphysis pubis
and rises upwards in course of time.
• Fetal part may not be well defined.
• F.H.S. is usuallyabsent.
Internalexaminationreveals:
• Vagina-dry and hot and thedischarge - offensive.
• Cervix fullydilated.
• Membranes are absent.
• Causeof obstructed labour is revealed.
33. ⚫Correction of dehydrationand keto-acidosis by
infusionof Ringer's solution.
⚫Adequatepain relief.
⚫Parenteralantibiotic isgiven.
⚫Caesareandelivery is done in majorityof thecases.
⚫ Ruptureof uterus must be excluded before attempting
destructiveoperation.
34.
35. 1. Organic (secondary)
Due to:
⚫ Cervical stances as a sequel to
previousamputation, cone biopsy,
extensivecauterizationor
obstetrictrauma.
⚫ Excessivescarring orrigidityof
cervix frompreviousoperationor
disease.
⚫ Postdelivery.
⚫ Organic lesionsas cervical myoma
orcarcinoma.
2. Functional (primary):
In spiteof the absenceof any
organic lesion and the well
effacementof thecervix, the
external Os fails todilate.
Due to:
⚫ lack of softening of the cervix
during pregnancyorcervical
spasm resulted fromoveractive
sympathetic toneorexcessive
fibrous tissue.
⚫ Insufficientuterinecontraction.
⚫ Malpresentationand
malposition.
Failure of the cervix to dilate within a reasonable
time in spite of good regular uterine contractions
36. If only thin rim of cervix left behind- it is pushed up
manually during contraction.
If cervix is thinned out but only half dilated –
Duhrssens’s incision isgiven at 2’oclock and 10 o’clock
position followed by forceps orventouse extraction.
37. Organicdystocia:
• Caesarean section is the managementof choice.
Functional dystocia:
• Pethidineand antispasmodics: may beeffective.
Caesarean section: if medical treatment fails or
fetal distress developed.
38. Pronounces retraction occurs involving whole of the uterus up
to the level of internal Os.
No physiological differentiationof theactiveuppersegment
and the passive lowersegment of the uterus.
No thinning of the lowersegment, there is no chance of
ruptureof the uterus.
The uterine contraction ceases and the whole uterus
undergoes a sort of tonic muscularspasm holding the fetus
inside (active retention of the fetus).
39. Failure toovercome theobstruction by
powerful contractions of the uterus.
Injudicious administration of oxytocics
Irritation caused by repeated unsuccessful
attempt of instrumental delivery.
40. ⚫The patient is in prolonged labor having severeand
continuous pain.
⚫PER ABDOMINAL EXAMINATION
⚫ Uterus is smaller in size, tense, tender
⚫ Fetal parts are not palpable
⚫ Fetal heart sounds not audible
⚫PER VAGINAL EXAMINATION
⚫ Dryand edematousvagina
⚫ Jammed head with a big caput
41. ⚫Correction of dehydration and ketoacidosis: by rapid
infusionof Ringer’s solution
⚫Antibiotics : To control infection
⚫Adequatepain relief
⚫Tocolyticagents fore.g terbutalin 0.25mg S.C : to
manage hypercontractility (tachysystole) induced by
oxytocics.
⚫Caesarean delivery is done in majorityof cases.
42.
43. Precipitate labourrefers to a labour pattern that
progresses rapidlyand ends with deliveryoccurring in less
than 3 hours is typically less than 5 hours after the onset
of uterineactivity.
It is due tostrong coordinate uterinecontractions in
absenceof obstruction in the birth canal, and resistance
of the soft tissues.
The patientdoes not feel contractionsexcept the last
contractionsduring theexpulsionof the fetus.
44. 1
• Maternal multi parous status.
2
• Small fetus
3
• Relaxed pelvicand vaginal musculature
4
• History of rapid labors with previous deliveries
5
• A particularly efficient uterus which contracts
with great strength
45. A sudden onsetof intense, closely timed contractions
with little opportunity for recovery between
contractions.
The sensation of pressure including an urge to push
that comes on quicklyand withoutwarning.
Often times this symptom is notaccompanied by
contractionsas the cervixdilatesvery quickly.
46. ⚫It is a retrospectivediagnosisas the patient is usually
seen in the 2nd or 3rdstagesof labor.
⚫ If seen during the first stage of the labor, the
Partograph will show rapid progress of cervical
dilatationand effacement.
47. FOR MOTHER
⚫Increased risk of tearing and laceration of thecervix and
vagina
⚫Predisposing topostpartum hemorrhage and sepsis
⚫Atonic Uterus: due to uterineexhaustion
⚫Hemorrhaging from the uterusorvagina
⚫Shock following birth which increases recovery time
⚫Delivery in an unsterilized environment such as the caror
bathroom
48. FOR BABY
⚫Risk of infection from unsterilized delivery
⚫Potential aspiration of amniotic fluid
⚫Intracranial hemorrhage: due to rapid compression
and decompression of the fetal head during delivery.
⚫Fetal injuries
⚫Avulsion (forcible separation) of thecord
⚫Neonatal sepsis
49. BEFORE DELIVERY
A patientwith past historyof precipitate laborshould be admitted to
the hospital at the first perception of laborpains.
DURING DELIVERY
Rarely if the patient is seen during delivery, general anesthesia
(inhalation by nitrous oxideand oxygenorsedation) may be given to
slow down thecourseof delivery to prevent forcible bearing down.
AFTER DELIVERY
⚫ If the patient is seenafterdelivery: exploration of the birth canal for
any injuryand manageaccordingly
.
⚫ Prophylactic antibiotics if deliveryoccurred in unsuitable
conditions.
⚫ Properexaminationof the fetus fordetection of anycomplications.
⚫ Continuous assessment of maternal and fetal status.
50.
51. Preterm labor is defined as the presence of
contractions of sufficient strength and
frequency toeffect progressive effacement
and dilatation of thecervix between 20 and
37 weeks’ gestation.
(AmericanCollegeof Obstetriciansand Gynecologists, 2003)
54. The two most promising markerscurrentlyavailableare:
1. Fetal fibronectin levels
2. Ultrasound assessmentof cervical length.
Fetal fibronectin (fFN) testing:
⚫It is an extracellularglycoprotein secreted by thechorionic
tissueat maternal-fetal interface.
⚫Itacts as a biological gluewhich binds blastocyst to
endometrium.
⚫Itcan be normally present in cervico-vaginal secretions up
to 20-22 wks. Thus, presence of fFN between 27 to 34
weekscan provide important markerof preterm labour
55. SAMPLE : Sample is taken from the posteriorfornixof
thevagina.
VALUES: A cut-off of 50 ng/ml is considered positive.
Length of cervix:
⚫Cervix can beassessed digitallyor by ultrasound.
⚫A reduction in cervical length of >6mm between 2
ultrasounds have higher risk.
56. PRIMARY PREVENTION :
⚫ Smoking cessation .
⚫ Nutritional counseling .
⚫ Lower workload forwomen with stressful jobs
SECONDARY PREVENTION :
⚫ Self-measurementof thevaginal pH for B.V.
⚫ Cervix length measurement by TVS .
⚫ Theaccepted cutoff value forcervix length is ≤ 25 before GW
24 ).
⚫ Cerclage and completeclosure of the birth canal.
⚫ Progesteronesupplementation.
57. ⚫ Inhibition of uterinecontractions with tocolysis.
⚫ Corticosteroids to induce fetal lung maturation.
⚫ Treatment of infectionwith antibiotics.
⚫ Bed rest and hospitalization.
INTRAPARTUM MANAGEMENT
1. Monitoring: The preterm fetusshould be monitored closely
forsigns of hypoxiaduring labour, preferably by continuous
electronic fetal monitoring.
2. Antibiotic prophylaxis
3. Delivery: Delivery must be conducted in the presence of
expert neonatologistcapableof dealing with complications
of prematurity.
* Ventouse is contraindicated in preterm deliveries.
1. Caesarean section: only forobstetric indications.
58.
59. The labour is said to be prolonged when the combined
duration of the first and second stage is more than the
arbitrary time limitof 18 hrs.
Latent Phase: Latent phase is the preparatory phaseof the
uterusand thecervix before the actual onsetof labour.
Normal latentphase is about 8 hours in primi gravida & 4
hours in multi gravida.
Prolonged Latent Phase: A latent phase that exceeds 20
hrs in primi gravidaor 14 hrs in multi gravida is abnormal.
60. Unripe cervix
Malposition and malpresentation
Cephalopelvic disproportion
Premature rupture of the membranes
Abnormal uterine contraction
Contracted pelvis
Congenital malformation of the baby
61. FIRST STAGE: First stage of
labour is considered
prolonged when the
duration is more than 12
hrs.
⚫The rate of cervical dilatation is < 1 cm/hr in
primi and < 1.5
cm/hr in multi.
⚫The rate of descent if the presenting part
is < 1 cm/hr in primi and < 2 cm/hr in
multi.
SECOND STAGE:The 2nd stage isconsidered prolonged
if it lasts for more than 2 hrs in primi, and 1 hr in multi.
The diagnostic featuresare:
⚫Sluggish or non descent of the presenting
part even after full dilatation of thecervix.
⚫Variable degreesof molding and caput
63. ⚫ Antenatal or early intranatal detection of the factors likely to
produce prolonged labour (big baby, malpresentation or position).
⚫ Useof partograph helpsearlydetection.
⚫ Selectiveand judiciousaugmentation of labour by low ruptureof
membranes followed byoxytocin drip.
⚫ Changeof posture in labourother than supine to increase the
uterinecontractions.
⚫ Avoidance of labourdehydration. Useof adequateanalgesia for
pain relief.
64. First Stage Delay
⚫ Vaginal examination isdone toverify the fetal presentation,
positionand station.
⚫ Clinical pelvimetry isdone, if only uterineactivity is sub-
optimal.
⚫ Amniotomyand/ oroxytocin infusion isadequate.
⚫ Effective pain relief is given by IM Inj: Pethidine or by regional
analgesia.
⚫ Caesarean section isdone when vaginal delivery is unsafe.
65. Second Stage Delay
⚫Short period of expectant management is reasonable
provided the FHR is reassuring and vaginal delivery is
imminent.
⚫Otherwise appropriate assisted delivery vaginal
(forceps,ventouse) orabdominal (caesarean) should
bedone.
