Abnormal progress of labor for 4th year med.students
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
Onset of true
Multi: 6-8 hrs
Delivery of the
Primi: 1-2 hrs
of the baby
Up to 30
Fourth stage: 1- 2 hours after delivery
4. Assessment & monitoring
Maternal general condition, FHR
Assessment of uterine contraction
Evaluation of fetal presentation, position, station
Estimation of fetal weight.
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 &
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
12. (2) UC, Caput, Molding, liquor & Memb:
Ut. Contra. per
Contra. Duran (Sec)
Membrane Status +/-
Liquor C C C C M
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16Time (Hrs)
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 ) …+++
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
24. Risk factor
Obese women, Short maternal stature
Advanced maternal age
Infertility or nulliparity
Uterine (previous CS, fibroid, overdistension)
Contracted bony pelvis
25. Risk factors
Big baby (macrosomia)
Congenital fetal abnormalities
PROM or oligohydramnios
Previous perinatal death
26. Complication of prolonged labour
Increased incidence of CS
Birth canal injuries if forceps is used
PPH, Puerperal sepsis
Fetal distress, Chorioamnionitis, neonatal
ICH- if forceps is used
28. POWER ► Contractions + Maternal pushing
1. Initiate by pacemakers at uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward
Shortening of muscle fibers
intra uterine pressure
EXPULSION OF THE FETUS
Uterine overdistension- Twins, hydramnios.
APH- PP, AP
Contracted pelvis, malpresentation, macrosomia
abuse of oxytocin
Anemia & malnutrition
Maternal exhaustion and dehydration
Full bladder, rectum - Grand MP - idiopathic
33. Clinical picture
Mother and fetus are usually not seriously
Infrequent labour pain, prolonged labour.
Slow cx dilatation and descent of the head.
a. Exclude and manage
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
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
Common in PG.
Uterine exhaustion due to obstructed
CS is usually needed.
36. Incoordinate uterine dysfunction
Hypertonic LUS - due to reversed polarity
Colicky uterus- incoordinate leading to
irregular, asymmetrical contraction in part or all
of the upper uterine segment
Elderly PG - Maternal exhaustion
Dehydration - Abuse of oxytocin
Malpresentation - CPD
37. Clinical presentation
Continuous low backache even after contraction
Maternal and fetal distress are common
Hydration, sedation + analgeics
Pethidine or epidural analgesia
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
Unfavorable cervix, forced induction
14% will go into protracted active phase
Awaiting active labour- provided no indication
If delivery is indicated- Induction /
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
43. a. Protraction (primary dysfunctional labor)
Rate of dilation- <1.2 cm/hr in PG
Rate of dilation- < 1.5 cm/hr in MG
b. Secondary arrest of labor
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
Abnormal uterine contraction.
Mal-position (OP, OT), Mal-presentation (Brow)
Cephalo-pelvic disproportion (CPD): often
Idiopathic (early ARM), Excessive sedation.
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
• > 2 hrs without epidural anesthesia
• > 3 hr with anesthesia
• > 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
Evaluation of uterine activity
Evaluation of maternal expulsive efforts
FHR status every 5 min
Fetal position, Clinical pelvimetry
Re-estimation of fetal wt
Increasing or initiating oxytocin to improve
maternal expulsive effort
Operative vaginal delivery or CS.
50. Obstructed labour
Failure of vaginal delivery due to a mechanical
Malposition: persistent OP, deep transverse arrest
Malpresentation: brow, shoulder, arrested breech
Macrosomia, Congenital fetal malformation,
Soft tissue obstruction
Perineal, vaginal, cervical
Pelvic mass-uterine fibroid, ovarian mass
Secondary hypotonic inertia- in PG due to
Rupture of uterus- pathological retraction
ring- usually in MG
Clinical picture of impending rupture of uterus
Prolonged labour, excessive oxytocin use
Labour pain is frequent and strong, persists
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’
Tonic tender uterus, collapsed on the fetus-
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-
Definitive treatment- CS
55. Precipitate labour
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
Passage- lack of resistance in LUS & Cx, roomy
Perineal, vaginal, cervical injuries
PPH (atonic & traumatic)
Acute inversion of the uterus
Later- recurrence, prolapse, stress UI
Fracture of skull, avulsion of the UC
give analgesia up to tocolytics- ritodrine or Mg
EUA to exclude birth tract injury or uterine
Observation for PPH
Management of complication
Proper examination of the newborn for any
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.
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 in Pelvic bone :
Metabolic: rickets, osteomalacia
Trauma : fractures
62. Causes in spines:
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
Rickets: is expected if there is a history of delayed
walking and dentition.
Trauma or diseases: of the pelvis, spines or lower
Bad obstetric history: e.g. prolonged labor ended by;
difficult forceps, caesarean section or Still birth.
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
Bony abnormalities in other area of the body
Non-engagement of the head: in the last 3-4
weeks in primigravida.
Pendulous abdomen: in a primigravida.
Malpresentations: are more common.
•Internal plevimetry: by vaginal examination
•External pelvimetry: pelvimeter
66. 1 September 2017 66
May All Be Happy & Healthy
By vaginal examination
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.
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
69. • Symphysis : The height, thickness and inclination
• 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
•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.
If the sacrospinous ligament is
two and half fingers, the
sacrosciatic notch is considered
72. The outlet
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
•Anteroposterior diameter of the outlet: ≥ 11 cm
from the tip of the sacrum to the inferior edge of
74. Data Finding
pelvic brim Round.
Diagonal conjugate ≥ 11.5 cm.
Symphysis Average thickness, parallel
Sacrum Hollow, average inclin.
Side walls Straight.
Ischial spines Blunt.
Interspinous diameter ≥ 10.0 cm.
Findings indicating adequate pelvis