2. Labour
• Series of events that take place in the genital organs in an
effort to expel the viable products of conception out of the
womb through the vagina into the outer world.
First stage
• start of the true labor pain to full dilatation of
the cervix (10 cm)
• latent phase (primi-8hrs, multi-4hrs) active
phase (primi-4hrs, multi-2hrs)
3. Second stage
from full dilatation of the cervix to the
expulsion of the fetus.
Propulsive phase
Expulsive phase
duration-
primi =2 hours
multi = 30 minutes
4. Third stage
from expulsion of the fetus to the expulsion
of the placenta
Phase of placental separation
Phase of placental descent
Phase of placental expulsion
Duration- 15 minutes (primi and multi)
5 minutes in active management
Fourth stage
Upto 1 hour of delivery of placenta
5. NORMAL LABOUR
• Defined as:
Presence of regular painful uterine contractions becoming
progressively stronger and more frequent accompanied by
effacement and progressive dilatation of the cervix and
decent of the presenting part.
• At its onset its usually accompanied by bloody
mucoid vaginal discharge called show.
• The process culminates in expulsion of the baby and
other products of conception.
7. 1.The 1st stage of labour
(a)the latent phase
This is the period from 0 – 3 cm
dilatation of the cervix.
Its duration can not be easily
determined but perhaps around 8
hrs.
8. (b) The active phase
This is the period from 3 – 10 cm (full dilatation)
dilation of the cervix.
In this stage the woman is said to be in established
labour.
The cervix dilates at the rate of about 1 cm/hour
It may be a little faster esp. in multiparous women or
little slower esp. in primigravida, giving an average
duration of labour of about 12 hrs.
9. 2.The 2nd stage of labour
•This is the stage from full dilatation of the
cervix to the delivery of the baby.
•It takes
•2 hours in primigravidas
•30 minutes in multigravidas
10. The 3rd stage of labour
This is the stage of labour after delivery of
the baby to the delivery of the placentaand
membranes.
•It usually takes 15 minutes
11. The 4th stage of labour
•This is the stage in the first 24 hours after
delivery
•This is the period where majority of
maternal deaths occurs
•It needs close monitoring of the mother in
the hospital esp. for PPH, Eclampsia etc..
13. DEFINITION:
Labor is said to be prolonged when the
combined duration of the first and second
stage is more than the arbitrary time limit of
18 hours.
According to WHO- labor is considered to be
prolonged when the cervical dilatation rate is
less than 1 cm/hr and descent of the
presenting part is <1 cm/hr for a period of
minimum 4 hours observation.
15. Prolonged latent phase
• Primi >20 hrs and multi >14 hrs
• Causes: unripen cervix, malposition
and malpresentation, CPD, PROM
• Worrisome to the patient but donot
endanger mother and fetus
16. Expectant management is usually done unless
there is any indication (for the fetus or mother) for
expediting the delivery.
Rest and Analgesic are usually given
When augmentation is decided, medical
methods ( oxytocin or prostaglandin) are
preferred.
Amniotomy is usually avoided.
Prolonged latent phase is not an indication for
cesarean section delivery.
18. Causes of prolonged labor
1. First stage
a. Fault in power
Abnormal uterine contraction (uterine inertia
or inco-ordinate uterine contraction)
b. Fault in passage
Contracted pelvis
Cervical dystocia
Pelvic tumor
Full bladder
19. c. Fault in the passenger
Malposition or malpresentation
Congenital anomalies of the fetus
(hydrocephalus)
d. Others – early administration of sedatives
and analgesics before active labor
21. 2. Second stage
a. Fault in the power
Uterine inertia
Inability to bear down
Epidural analgesia
Constriction ring
b. Fault in the passage
CPD, android pelvis, contracted pelvis
Undue resistance (spasm or old scarring)
Soft tissue pelvic tumor
22. c. Fault in the passenger
Malposition
Malpresentation
Big baby
Congenital malformation of the baby
23. Diagnosis
History:-
Age
Parity
Duration of labour
Duration of membrane rupture
Whether the patient was handle outside the
hospital
Whether she was treated with oxytocic drugs
outside the hospital
Previous history of difficult labour, instrumental
delivery or stillbirth.
24. General examination :-
• Height of patient
• Dehydration
• Acetone breath
• Pallor
• Raise in temperature
• Tachycardia
• Decrease in BP
25. Abdominal examination :-
Contour of the uterus
Presentation & position
Tenderness of uterus
Frequency, intensity &
duration of uterine
contraction.
Lower segment distended or
not.
Distension of the bladder.
Fetal heart sound.
26. Vaginal examination:-
- The vulva usually swollen and edematous.
- The vagina is dry, hot and occasionally offensive
and purulent discharge.
- The cervix is almost fully dilated or hanging like a
curtain.
- The presenting part is extremely moulded and
jammed in the pelvis.
- There is usually large caput formation.
27. Diagnosis cont..
Prolonged labor is not a diagnosis but it is the
manifestation of an abnormality.
• The cause of which should be detected by a thorough
abdominal and vaginal examination.
• During vaginal examination if the finger is accomodated in
between the cervix and the head during uterine
contraction pelvic adequecy can be reasonably
established.
• Intranatal imaging ( radiography, CT or MRI) is of help in
determining the fetal station and position as well as pelvic
shape and size.
28. FIRST STAGE
Duration is > 12 hours
Cervical dilatation rate < 1 cm/hr in primi and
< 1.5 cm/hr
Rate of descent of presenting part is < 1 cm/hr
in primi and < 2 cm/hr in multi
SECOND STAGE
Duration >2 hrs (nullipara), >1 hr (multipara)
[if regional analgesia is given then one hour is
permitted in both groups]
32. Prevention
Antenatal or early intranatal detection
Use of partograph
Selective and judicious augmentation
Change of posture in labor, avoidance of
dehydration in labor and use of adequate
analgesia for pain relief
33. ActualTreatment
Careful evaluation is to be done
Evaluate carefully to find out
Cause of prolonged labor (inadequate uterine
activity in nulliparous, primary dysfunctional labour;
cephalopelvic disproportion in multiparous)
Effect on the mother
Effect on the fetus
34. Preliminaries
Correct fluid and electrolyte imbalance
Correction of dehydration and ketoacidosis
by IV fluids in case of neglacted prolonged
labour
Control of infections (ampicillin,
metronidazole, ceftriaxone)
Emptying the bladder (catheterization)
Emptying the stomach
Blood cross matching
35. DEFINITIVETREATMENT
FIRST STAGE DELAY
IF only uterine activity is suboptimal,
• Amniotomy/ oxytocin infusion
• Effective pain relief
SECONDARY ARREST
• Careful use of oxytocin
• Cesarean section delivery
36. First stage delay
Vaginal examination and clinical pelvimetry done
Uterine activity suboptimal Secondary arrest
(Careful using oxytocin)
• Amniotomy and oxytocin infusion (5U in 500 ml RL
• Effective pain relief (im pethidine or RA)
• Cesarean section
37. SECOND STAGE DELAY
• Short period of expectant management is reasonable
provided the FHR is reassuaring and vaginal delivery
is imminent
• Otherwise, appropriate assisted delivery , vaginal
(forceps, ventouse) or abdominal (cesarean) should
be done.
Note: difficult instrumental delivery should be avoided
40. Obstructed labour
• Definition :- obstructed labour can be
defined as a labour where there is poor
or no progress of labour in spite of good
uterine contraction.
• Incidence :- 1 -2% of referral cases in
developing country.
41. Obstructed labor is one where in spite of good
uterine contractions, the progressive descent
of the presenting part is arrested due to
mechanical obstruction.
Result due to factors in the fetus or in the
birth canal or both
42. Causes:
a. Fault in the passage
Cephalopelvic disproportion
Contracted pelvis
Cervical dystocia
Cervical or broad ligament fibroid
Impacted ovarian tumor
Non gravid horn of bicornuate uterus
43. b. Fault in the passenger
Transverse lie
Brow presentation
Congenital malformations (hydrocephalus,
ascites, double monsters)
Big baby, occipitofrontal position
Compound presentation
Locked twins
44. Morbid anatomical changes
a. Uterus
Formation of bandl’s ring
Gradual increase in intensity, duration and
frequency of contraction.
Relaxation becomes less and less
Ultimately, a state of tonic contraction develops
45. b. Bladder
Becomes abdominal organ
Compression of urethra b/w presenting part and
symphysis pubis→urinary retention
Trauma→blood stained urine
Pressure necrosis of the bladder and urethra→
genitourinary fistula
46. Diagnosis
• Partograph will recognize impending
obstruction early. If the labour is slow to
progress, careful general, abdominal and
vaginal examination is necessary.
• Woman gives the history of:-
- prolong labour and
- the labour pain become severe and frequent
48. Clinical features
Maternal condition
Mother is in agony, exhausted, sepsis appear
early
Abdominal examination
• Uterus tense and tender
• Fetal parts easily felt
• Distended bladder due to retention or edema
• Retraction Ring may be felt
• FHS usually absent
• “Three tumor abdomen” evident
51. Vaginal examination
• Lower segment pressed by forcibly driven
presenting part
• Edematous vulva (cannula sign) and cervix
• Severe caput and moulding
• Ring not felt vaginally
• Descent of presenting part absent
52. Anticipation of Obs. Labor during
ANC
Short stature particularly in primi <150 cm
Large fetus >4 kg
Obvious pelvis/spinal deformities
Gynetresia (at least one pelvic exam be done
at ANC)
Uterine myomas in lower segment or cervix
Abnormal lie
Severe degree of overlap at pelvic brim
54. b. Remote
Genitourinary fistula or rectovaginal fistula
Variable degree of vaginal atresia
Secondary amenorrhea
2. Fetus
a. Asphyxia
b. Acidosis
c. Intracranial hemorrhage
d. Infection
56. Principles
To relieve the obstruction at earliest by a safe delivery
procedure
Pain relief
Tocombat dehydration and ketoacidosis
Tocontrol sepsis
Correct hypoglycemia
Correct electrolyte imbalance
57. 1. Prevention
Same as prolonged labor
2. Initial assessment of the patient
Pallor, pulse, blood pressure, dehydration
Fundal height, fetal lie, presentation and heart
rate, state of the uterus and bladder
Level of presenting part, cervical dilatation, caput
formation and moulding
Do pelvic assessment and note the measurement
and the presence of infected liquor
Access urine
Blood group and cross matching
58. 3. Resuscitate the patient
IV fluids at least 3 litres
Give dextrose saline for hypoglycemia initially
then ringers lactate
Oxygen if fetal distress or maternal distress
4. Control infection
Give broad spectrum IV antibiotics
Stat dose of Ampicillin 1g and Chloramphenicol
59. 5. Check if the fetus is alive and decide mode of
delivery
6. Empty bladder with self retaining catheter
60. Obstetric management
No place of “wait and watch”, neither any scope of
using oxytocin to stimulate uterine contraction.
Before proceeding for definitive operative
treatment, rupture of the uterus must be
excluded.
Decide best method to relieve the obstruction with
least hazards to the mother.
61. Vaginal delivery
If baby dead, destructive operation (craniotomy,
decapitation, evisceration and cleidotomy) is
best choice
If baby living and head is low down and vaginal
delivery not risky→forceps extraction
After delivery, explore uterus and lower genital
tract to exclude uterine rupture or tear
62. Cesarean delivery
Done if the case is detected early with good fetal
outcome.
In late case, desperate attempt to do a C/S to save
the morbidund baby more often leads to
disastrous consequents.
Symphysiotomy
Alternate to risky cesarean
In case of established obstruction due to outlet
contraction with vertex presentation having good
FHS
63. Post delivery care
Continue monitoring of temperature, pulse, BP,
urine output and colour
Monitor abdominal distension
Continue antibiotics
Continuous bladder drainage for at least 10
days
Check for perineal nerve damage and
rehabilitate accordingly
Bear in mind, possibility of secondary PPH
Counseling for future pregnancies and deliveries
