Professional Documents
Culture Documents
By Dr. Burhan F MD
objectives
At the end of this presentation students will able to: Define Abnormal labor: Protraction and arrest disorders. Describe causes of Protraction and arrest disorders. Explain management of Protraction and arrest disorders. Use partograph for management of labor.
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NORMAL LABOR
Labor refers to uterine contractions resulting in progressive dilation and effacement of the cervix, and accompanied by descent and expulsion of the fetus Friedman divided labor into three stages: First stage: time from the onset of labor until complete cervical dilatation Second stage: time from complete cervical dilatation to expulsion of the fetus Third stage: time from expulsion of the fetus to expulsion of the placenta
Abnormal labor
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Factor contributing
Prematurely admistered sedation and analgesia Poor cervical condition Myometrial dysfunction false labor
significance
Increased risk of subsequent labor abnormality Increased cesarean delivery rate Low APGAR score Increased perineal laceration febrile morbidity& intrapartum blood loss
Treatment
Adequate rest with therapeutic sedation /narcosis morphine /pethidine Augmentation with oxytocin less preferred option
Protraction disorders
Protracted active phase dilatation:-defined as less than
1.2cm/hr & 1.5cm/hr of cervical dilatation for nullipara & multipara respectively <1cm/hr of cervical dilatation for a minimum of 4 hrs (WHO defn) Protracted descent: defined as < 1cm/hr of descent of fetal head for nullipara &<2cm/hr for multipara.
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Arrest disorders
Arrest of cervical dilatation :no change in cervical dalitation for >2hrs period for both nulliparas &multiparas Arrest of descent : no demonstrable descent of the head for more than 1hr for both nulliparas & multiparous
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Labor pattern
First stage
Duration (no anesthesia) Duration (anesthesia) Protracted dilation Arrested dilation 16.6 hours 19.0 hours <1.2 cm/h >2 h 132 minutes 185 minutes >3 h 12.5 hours 14.9 hours <1.5 cm/h >2 h 61 minutes 131 minutes >2 h
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Second stage
Duration (no anesthesia) Duration (anesthesia) Arrest of descent (epidural)
causes
CPD Inadequate uterine contraction Malpresentation & malposition
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Management
Before making dx active phase abnormalities make sure that women is in active phase. Evaluate for CPD. 30% of protraction & 50% arrest disorders associated with CPD. If the cause is CPD do C/S Reevaluate for malposition & malpresentation &mange depending on types of
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Mx cont
Evaluate uterine function 1.If hypotonic dysfunction - <180 mv unit A. Amniotomy if the head is fixed &membrane is intact & observe for 30-60minute B. If no improvement after Amniotomy initiate oxytocin augmentation
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Mx cont.
2. Uncoordinated uterine action:dx by internal monitoring Responds favorably for oxytocin augumentation In the absence of CPD
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Mx
Depends on cause CPD :-C/s Inadequate uterine contraction:oxytocin Malposition manage accordingly Inadequate maternal voluntary effort managed with appropriate encouragement & instruction.
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Partograph
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The Partograph
The partograph is used to assess:
Fetal well being:
Fetal heart rates and pattern Degree of molding, caput Color of amniotic fluid
Progress of labor:
Cervical dilatation Descent of presenting part Duration and frequency of contractions
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WHO 1994.
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WHO 1994.
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Cervical dilatation: Assess at every vaginal examination, mark with cross (X) Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour Action line: Parallel and 4 hours to the right of the alert line
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Oxytocin: Record amount per volume IV fluids in drops/minute every 30 minutes when used Drugs given: Record any additional drugs given
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If less than three contractions in 10 minutes, each lasting less than 40 seconds, suspect inadequate uterine activity If three contractions or more in 10 minutes, each lasting more than 40 seconds, suspect cephalopelvic disproportion, obstruction, malposition or malpresentation
General methods of labor support may improve contraction and accelerate progress
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Diagnose cephalopelvic disproportion if there is secondary arrest of cervical dilatation and descent of presenting part in presence of good contractions If cephalopelvic disproportion is confirmed, deliver by cesarean section If fetus is dead, deliver by craniotomy or cesarean section
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If fetus is alive, the cervix is fully dilated and the head is at 0 station or below, deliver by vacuum extraction
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Diagnose inadequate uterine activity if there are less than three contractions in 10 minutes, each lasting less than 40 seconds If contractions are inefficient and cephalopelvic disproportion and obstruction have been excluded, the most probable cause of prolonged labor is inadequate uterine activity
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Rupture membranes and augment labor using oxytocin Reassess progress by vaginal examination 2 hours after good contraction pattern with strong contractions is established:
If there is no progress between examinations, deliver by cesarean section If progress continues, continue oxytocin infusion and re-examine after 2 hours. Continue to follow progress carefully
Inefficient contractions are less common in a multigravida than in a primigravida. Hence, every effort should be made to rule out disproportion in a multigravida before augmenting with oxytocin
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references
Up To Date 19.1 version 2011 WHO guide line Addis Ababa university management protocol for labor & deliveries Williams text book of obstetrics