Abnormal labor and

dystocia
By :
Norliana binti jaafar
 Normal labor
• 3 elements :
– Power
– Passage
– Passenger
Abnormal Labor : Dystocia
A. Prolonged labor
B. Obstructed labor
C. Shoulder dystocia
 World Health Organization
partograph
• The World Health Organization(WHO) has promoted a partograph in 1994
• To improve labor management
• In partograph:
– Active phase : starts with cervical dilatation of 3cm( 4cm in new WHO partograph)
– Cervical should dilated at least 1cm/hour in this active stage
– Cervical dilatation (cervicograph) rate is plotted in relation to alert line and action
line
– Alert line: starts at 3cm and ends with full dilatation of cervix (10cm) in 7 hours.
– Action line : is drawn 4 hours to the right of the alert lines.
– An interval of 4 hours is allowed to diagnosed delay in active phase and then
appropriate intervention is done
– Labor is considered abnormal when cervicograph crossed the alert line and falls on
zone 2
– Intervention is required when it crosses the action lines and falls on zone 3.
 A. Prolonged labor
Definition :
• The labor said to be prolonged when the
combined duration of the 1st and 2nd stage is
more than the arbitrary time limit of 18 hour
Or
• When the cervical dilatation rate is <1cm/hour
& the descent of presenting part is <1cm/hour
for a period of minimum 4 hours observation.
(WHO-1994)
• Active 1st stage of labor lasting longer than 12
hours (roughly equivalent to a rate of
dilatation of 0.5/hour). (NICE guidelines-
2007)
 Classification
• 1st stage of labor
i. Prolonged latent phase
ii. Primary dysfunctional labor
iii. Secondary arrest of dilatation
• Prolonged 2nd stage of labor
 i-Prolonged latent phase
• 1st stage of labor
• Latent phase of labor begin with onset of painful
regular uterine contraction.
• But can only be observed and monitored from the
time that the patient gets admitted.
• WHO(1994) reckoned a latent phase exceeding 8
hours (from admission) was abnormal
• Friedman(USA) defined prolonged latent phase as
> 20 hours in nullipara & >14 hours in multipara
• Recently, WHO has produced a simplified
partograph starting at 4cm to ensure more
correct diagnosis of dystocia before cesarean
delivery.
• Patient maybe worried regarding prolonged
latent phase but it does not endanger the
mother or fetus.
• Causes of prolonged latent phase
– Unripe cervix
– Malposition and malpresentation
– Cephalopelvic disproportion
– Premature rupture of membrane
• Management
– Expectant management
– Unless there is any indication (for the fetus or
mother) for expediting the delivery
– Rest and analgesic usually given
– When augmentation decided. Medical methods
(oxytocin / prostaglandins) are preferred.
– Not an indication for caesarean delivery
 ii -Primary dysfunctional labor

• 1st stage of labor

• When the active phase progresses at
<1cm/hour in a primi & <1.5cm/hour in multi
from the beginning of the active phase slope.
• The rate of descent of the presenting part is
<1cm/hour in a primi & <2cm in a multi
• Most common labor abnormality
iii - Secondary arrest of dilatation

• 1st stage of labor

• When the active phase commences normally
but cervical dilatation stops or slows
significantly prior to full dilatation.
 Causes of prolonged labor
• Fault in power- inefficient uterine contraction
– Hypotonic/inadequate uterine contraction;
contraction are weak & infrequent (< 40ses &/ <2
contraction/10 min.
– Hypertonic/ineffective uterine contractions;
contraction are irregular, in coordinate & high
resting basal tone between contraction
• Fault in the passage:
– Contracted pelvis
– Cervical dystocia
– Pelvic tumor
– Full bladder
• Fault in the passenger:
– Malposition and malpresentation
– Congenital anomalies of the fetus (e.g.:
hydrocephalus)
 Management
• Prevention: antenatal/early intranatal detection
• Use of partograph help early detection
• Change of posture other than supine
• Dehydration and electrolyte disturbances are corrected.
• Give antibiotic to prevent /treat infection
• Cephalopelvic disproportion:
– Abdominal examination: fetal head not engaged in the pelvic
– Vaginal examination: severe molding (3+ ) of the fetal skull
– Indication for cesarean section
• Fetal distress – indication for caesarean section.
• Selective and judicious augmentation
– Ineffective uterine contractions :Reassurance, analgesia(epidural/injection
pethidine/injection promethazine)
– Artificial rupture of membranes (if not ruptured yet)
– Follow by oxytocin infusion
 Prolonged second stage of labor

• Considered prolonged if it last for more than

2hours in primi and 1hour in multi
• Diagnostic features
– Sluggish or non descent of the presenting part even
after full dilatation of the cervix (protraction of
descent)
– Variable degree of molding and caput formation in
cephalic presentation
 Causes of prolonged labor
• Fault in power:
– Uterine inertia
– Inability to bear down
– Epidural analgesia
– Constriction ring
• Fault in passage:
– Cephalopelvic disproportion, android pelvic, contracted pelvic
– Undue resistance of the pelvic floor/perineum due to spasm or old scaring
– Soft tissue pelvic tumor
• Fault in passenger:
– Malposition (occipital posterior)
– Malpresentation
– Big baby
– Congenital malformation of baby
 Management
• Short period of expectant management is
reasonable provided the FHR is reassuring and
vaginal delivery is imminent
• Otherwise – appropriate assisted delivery
vaginal ( ventous/forceps) or abdominal
(caesarean) should be done.
 B. Obstructed labor
• When in spite of good uterine contraction, the
progressive descent of the presenting part is
arrested due to mechanical obstruction.
• Incidence 1-2% in referral hospital
 Causes
• Fault in the passage:
– Bony: contracted pelvis and cephalopelvic
disproportion (common causes)
– Soft tissue: cervical dystocia due to prolapsed
/previous operative scarring, cervical/broad
ligament fibroid, impacted ovarian tumor/non-
gravid of a bicornuate uterus below the presenting
part.
• Fault in the passenger:
– Transverse lie
– Brow presentations
– Congenital malformation of the fetus:
hydrocephalus (commonest) ,fetal ascites
– Big baby, occipito-posterior position
– Compound presentation
– Locked twins
 Course of labor
• During the labor uterine contractions increase in strength and
frequency to overcome the obstruction.
• With each contraction there is some myometrial
shortening(retraction) so that the upper active segment
becomes progressively thicker and shorter
• The passive lower uterine segment becomes progressively
stretched and thinner
• The junction between the two segment stands out as a
pathological retraction or Bandl’s ring.
• This is sometimes confused with a distended bladder, but
oblique line is diagnostic.
• Primigravida -> secondary inert & stop
contracting
• Multiparous -> uterus continues to contract
vigorously -> Bandl’s ring may climb upwards
-> rupture of uterus.
• VE :
– Edematous vulva
– A hot dry bruised vagina
– Fully dilated cervix
– In vertex presentation
– Marked molding & caput formation
– Hand prolapsed in shoulder presentation
 Management
• Should be urgent and carried out in a 1st referral
unit only
• Dehydration is rapidly corrected with 1-3L
normal saline/ringer’s lactate solution
• Broad spectrum antibiotic parenterally to
counteract sepsis
• Blood requisition : to anticipate atonic/traumatic
post partum haemorrhage
• Oxytocin is contraindicated
• The mode of delivery:
– Alive: immediate cesarean section
– Dead :
• destructive operations (craniotomy/decapitation/evisceration for
transverse lie)
• Cesarean section
• After every case of operative vaginal delivery:
– Exclude rupture of uterus
– Give oxytocin
– Put continous blader catheterization (10days) to prevent
vesico vaginal fistula which can occur due to ichemia.
C. Shoulder dystocia
• Failure to deliver fetal anterior shoulder on gentle
downward traction
• An obstetric emergency
• Risk factors
– Maternal obesity
– Previous shoulder dystocia
– Big baby/macrosomia
– Prolonged 1st and/or 2nd stage of labor
– Small mother
– Post maturity
• Often arise unexpectedly
• Quick action is needed to prevent neonatal morbidity &
mortality
Method to identified big baby
• Clinical evaluation : risk assessment &
physical examination
• Ultrasonography to estimate fetal weight
 Recognition
• The baby's body does not emerge with
standard moderate traction and maternal
pushing after delivery of the fetal head.
• Loss of restitution
• The "turtle sign“ -
 Shoulder dystocia drill
• Call for help (call for experienced doctor/senior
obstetrician/ midwife and pediatrician)
• Intravenous access should be secured
• Patient is placed in lithotomy position and generous
episiotomy.
Techniques to reduced the impacted shoulder:

– 1: Mc Robert’s maneuver:
• hip flexion and slight abduction
will reduce the angle of pelvic
inclination
• This will help the movement of
the posterior shoulder over the
sacrum and inlet
• Maternal lordosis will be
straightened
• The overall result will be a
more spacious pelvis
– 2 :“directed” suprapubic pressure
may help to dislodge the anterior
shoulder. Fundal pressure should
be avoid
– 3: If fails, rotate the
anterior shoulder :
• By pressure with the two
fingers on the fetal scapula
so that the shoulders come
to lie in the broader oblique
diameter of pelvis
• Gentle traction of the head
may result in delivery of
anterior shoulder.
– 4: Rubin (1964) recommended two maneuvers.
• First, the fetal shoulders are rocked from side to side by
applying force to the maternal abdomen.
• If this is not successful, the pelvic hand reaches the
most easily accessible fetal shoulder, which is then
pushed toward the anterior surface of the chest.
• This maneuver most often results in abduction of both
shoulders, which is turn produces a smaller shoulder-to-
shoulder diameter and displacement of the anterior
shoulder from behind the symphysis pubis
– 5: Wood’s method:
• by progressively
rotating the posterior
shoulder 180 degrees in
a corkscrew fashion,
the impacted anterior
shoulder could be
released.
• This is frequently
referred to as the Woods
corkscrew maneuver
– 6 : If fails, an attempt is made to deliver the
posterior arm first:
• Pressure on the antecubital fossa of the posterior arm
(transvaginally) will flex the arm bringing the hand with
in the operators grasp
• The arm is pulled across the chest and the posterior arm
and the shoulder are delivered
• The anterior shoulder will then slip beneath the
symphysis.
– 7 : When all fails, used Zavanelli maneuver:
• Cephalic replacement
• Immediate cesarean delivery.
 Complication of shoulder dystocia

• Asphyxia
• Erb’s palsy
• Fracture of clavicle or humerous
• High perinatal morbidity and mortality
• Postpartum hemorrhage from the trauma to the
genital tract or uterine atony
• Increased operative delivery and morbidity.
 Dangers abnormal labor/dystocia.
Maternal Fetal
• Exhaustion • Hypoxia
• Dehydration, acidosis, • Acidosis
electrolytes imbalance • Fetal distress
• Infection • Stillbirth
• Increased operative delivery • Asphysia neonatorum
• Post partum haemorrhage • Infection
• Trauma to genital tract • Intracranial injuries
including ruptured uterus
• Operative delivery
• Increased maternal mortility
• Increased perinatal mortality
rate
rate
Remote
Remote
• Vesicovaginal fistula
• Delayed milestone
• Chronic pelvic infection
• Pelvic floor muscle and
 Assessment
• History
– Past pregnancy outcome
– Present pregnancy: labor onset, membrane rupture, interference
• General examination
– Mental state
– Dehydration
– Anemia
• Abdominal examination
– Uterine contractions
– Station
– Bladder/bowel
– Bandl’s ring
• Fetal heart sound
• Vaginal examination
– Malposition/mal presentation
– Caput/molding
– Color of liquor