Abnormal delivery

Liu Yuling 刘玉凌 M.D.

Department Of Obstetrics & Gynecology
Renmin Hospital Wuhan University
Email: lyl2-2001@163.com
DYSTOCIA

 Definition ＆ Classification
 Abnormal Patterns of Labor
 Pathogenesis ＆ Treatment
Definition

 Dystocia is defined as difficult labor

 It may associated with various
abnormalities that prevent or deviate
from the normal course of labor and
delivery
 These abnormalities are classified
into 3 general categories that are often
interrelated
 A contracted pelvis may increase the
likelihood of fetal malpresentation
 Malpresentation or excessive fetal size
may be related to ineffective uterine action
 Disproportion between pelvic architecture
and the presenting part often accompanies
uterine dysfunction
Classification

I. Abnormalities of the Powers

II. Abnormalities of the Passage
III. Abnormalities of the Passenger
Abnormalities of the Powers
 Constitute uterine dystocia
 That is uterine activity that is in effective in eliciting
the normal progress of labor
 Characteristic of ineffective uterine action
 Hypertonic activity
 Hypotonic activity
 Discoordinated uterine activity
 Lack of voluntary expulsive effort during the
second stage may also impede the normal
course of delivery
Abnormalities of the Passage

 Constitute pelvic dystocia

That is aberrations of pelvic architecture and
its relationship to the presenting part
 Be related to
 Size or configurational alterations of the bony
pelvis
 Soft tissue abnormalities of the birth canal
 Reproductive tract masses or neoplasia
 Aberrant placental location
Abnormalities of the Passenger

 Be known as fetal dystocia

 That is that are caused by abnormalities of
the fetus.
 Common fetal abnormalities leading to
dystocia include
 Excessive fetal size
 Malposition
 Congenital anomalies
 Multiple gestation
Abnormal Patterns of Labor
 Prolonged latent phase
 Protraction disorders
 Protracted active-phase dilatation
 Protracted descent
 Arrest disorders
 Prolonged deceleration phase
 Secondary arrest of dilatation
 Arrest of descent
 Failure of descent
 Precipitate labor disorders
Abnormal Patterns
of Labor
 Labor
Labor is a dynamic process characterized by
uterine contraction that increase in regularity
intensity
duration
to cause progressive dilatation and effacement of the cervix
and permit descent of the fetus through the birth canal
Stages of labor

 1st stage of labor

begin of contraction to full cervical dilatation
 2nd stage of labor
from full dilatation to the birth of the baby
 3rd stage of labor
the time from the birth of the baby to the
expulsion of the placenta and membranes
 Labor
 Stage One
(Dilatation)
 Stage Two
(Expulsion)
 Stage Three
(Placental
Stage)
Evaluate the progress of labor

 Estimate of cervical dilatation

 Estimate of descent of the fetal
presenting part
 Pattern of Cervical Dilatation
2 phases of cervical dilatation
 latent phase
 Begins with the onset of regular uterine contractions
 Extends to the beginning of the active phase of cervical
dilatation(2cm )
 active phase
from a 2cm dilatation of the cervix
until the point when the cervix is fully dilated (approximately
10 cm)
 Acceleration phase
 Phase of maximum slope
 Deceleration phase
1st & 2nd stage of normal labor
Abnormal Patterns of Labor
 Prolonged latent phase
 Protraction disorders
 Protracted active-phase dilatation
 Protracted descent
 Arrest disorders
 Prolonged deceleration phase
 Secondary arrest of dilatation
 Arrest of descent
 Failure of descent
 Precipitate labor disorders
Prolonged latent
phase
 The duration of the latent phase
 average 6.4 hours in nulliparas
 average 4.8 hours in multiparas
Definition
 Prolonged Latent Phase
 The latent phase is abnormally prolonged
It lasts more than 20 hours in nulliparas
14 hours in multiparas
Causes
 Excessive sedation or sedation
given before the end of the latent phase
 The use of conduction or general anesthesia
before labor enters the active phase
 Labor that begins with an unfavorable or unripe
cervix, ie, one that is long, closed, rigid, and
thick ( a low Bishop score)
 Uterine dysfunction
 Fetoplevic disproportion
Treatment

Treatment should acknowledge that

 These patients tend to be physically
exhausted and emotionally
discouraged by their lack of progress
 They are suffering from fluid and
electrolyte imbalance
Prolonged Latent Phase

Treatment

Therapeutic Rest
Oxytocin Infusion
Regimen

Narcotic agent Hydration

Therapeutic Rest Regimen

A regiment of rest is recommended in the

absence of any risk factors
 Premature rupture of the membrane
 Amnionitis
 Pre-eclampsia
 eclampsia
Narcotic agent
Purpose
 to arrest uterine contractions temporarily
 to provide from 6 to 12 hours of rest

Methods
 morphine sulfate given subcutaneously
 given in doses large enough
an initial dose of 8-12 mg (depending in the patient’s
weight)
 given and additional 4 mg of morphine
 no cervical changes have occurred
 if uterine contractions persist after 20 minutes
Oxytocin Infusion

 Be recommended as the primary

treatment
 Disadvantage
 Decrease the time available
 To correct fluid and electrolyte imbalances
 To meet the patient’s psychological needs

 No opportunity to identify patients in false

labor
Oxytocin Infusion

 Advantage
To be treatment of choice
if immediately delivery is required
such as preeclampsia and amniotitis
Prognosis

The prognosis for vaginal delivery after these

therapeutic measures is excellent.
 Patients with a prolonged latent phase of labor
who respond to rest can be expected to delivery
vaginally in nearly all cases.

 After abnormalities in the latent phase have been

corrected, patients are not at any greater risk of
developing subsequent labor disorders than the
patients who have experienced a normal latent
phase.
Abnormal Patterns of Labor
 Prolonged latent phase
 Protraction disorders
 Protracted active-phase dilatation
 Protracted descent
 Arrest disorders
 Prolonged deceleration phase
 Secondary arrest of dilatation
 Arrest of descent
 Failure of descent
 Precipitate labor disorders
Protraction disorders

 Definition
 Causes
 Treatment
 Prognosis
Definition

 The protraction disorders are constituted

of
 Protracted active-phase dilatation
 Protracted descent of the fetus
 Common characteristics
 An abnormally slow rate for dilatation in the
active phase
 A abnormally slow rate of descent
(cm/hr) In nulliparas In multiparas
Protracted ≤1.2 ≤ 1.5
dilatation
Protracted descent ≤ 1 ≤ 2
Causes
 Fetopelvic disproportion
 This is encountered in about one-third of patients
 Minor malpositions (occiput posterior)
 Improperly administered conduction anesthesia
 Epidural anesthesia administered above
dermatome T10
 or given before the onset of the active phase
 or in the presence of other inhibitory factors
 Excessive sedation
 Pelvic tumors obstructing the birth canal
 Treatment
Evaluation
of
fetopelvic relationships

Physical examination
Possibly by x-ray examination

Fetoplevic disproportion Fetoplevic disproportion

is present is absence

Cesarean section Conservative Management

Conservative Management

 Supportive measure
 Inhibitory factors should be avoided
 Oxytocin infusion or other forms of
stimulation of labor
Supportive measure

 Special attention should be paid to

 fluid and electrolyte balance
 the patients’ emotional and physical needs
 It is possible to enhance uterine
contractility, progression of dilatation
may not improve
Inhibitory factors

 Inhibitory factors should be avoided

 Administering excessive sedation
 Regional block anesthesia
Oxytocin

 Patients experiencing protraction

disorders generally do not respond to
oxytocin infusion or other forms of
stimulation of labor if their contractions
are already adequate
 Other authorities recommend active
intervention with oxytocin in nulliparas
with protraction disorders, and equally
successful outcomes are reported
Prognosis

 Depends on the presence or absence

of fetopelvic disproportion
Prognosis

 The prognosis for the fetus is closely

related to the quality of delivery
 These infants seem particularly sensitive
to instrumental vaginal delivery
 The most crucial factor favoring a good
outlook for the fetus
 Spontaneous vaginal delivery
 One achieved with minimal manipulation
Abnormal Patterns of Labor
 Prolonged latent phase
 Protraction disorders
 Protracted active-phase dilatation
 Protracted descent
 Arrest disorders
 Prolonged deceleration phase
 Secondary arrest of dilatation
 Arrest of descent
 Failure of descent
 Precipitate labor disorders
Arrest disorders

 Definition
 Causes
 Treatment
 Prognosis
 Characters of Arrest Disorders
Prolonged The deceleration phase lasts ≥ 3 hours in nulliparas
deceleration phase ≥ 1 hour in multiparas

Secondary arrest No progressive cervical dilatation in

of dilatation the active phase of labor ≥ 2 hours

Arrest of descent Descent fails to progress ≥ 1 hour

Failure of descent Descent during fails to occur

the deceleration phase of dilatation
and during the second stage
Causative factors
 About 50% patients demonstrate
fetopelvic disproportion
 Various fetal malpositions
 Occiput posterior
 Occiput transverse
 Face
 brow
 Inappropriately administered anesthesia
or excessive sedation
 Treatment
Thorough evaluation
of
fetopelvic relationships

Fetoplevic disproportion Fetoplevic disproportion

exits is absence

Oxytocin
Cesarean section
stimulation
Prognosis

 A poor prognosis for vaginal delivery

 Increased perinatal morbidity
Abnormal Patterns of Labor
 Prolonged latent phase
 Protraction disorders
 Protracted active-phase dilatation
 Protracted descent
 Arrest disorders
 Prolonged deceleration phase
 Secondary arrest of dilatation
 Arrest of descent
 Failure of descent
 Precipitate labor disorders
Precipitate labor disorders

 Definition
 Causes
 Treatment
 Prognosis
Definition
In primigravidas In multigravidas

Precipitate A maximum ≥ 5 cm/ h ≥ 10 cm/ h

dilatation slope

Precipitate Descent of the≥ 5 cm/ h ≥ 10 cm/ h

descent fetal
presenting
part
Causes

 Extremely strong uterine contraction

 Occasionally be associated with
administration of oxytocin
 May accompany abruption placentae
 Low birth canal resistance
Treatment

 oxytocin administration may be stopped

 Decrease the uterine contractions
 Parenteral epinephrine
 Magnesium sulfate
 Various tocolytic agents
Prognosis

Maternal Perinatal mortality

complications  Hypoxia
 Postpartum  Possible intracranial
hemorrhage hemorrhage
 Uterine rupture or  Unattended delivery
Lacerations of the
birth canal
 Antecedents of
maternal amniotic
fluid embolism
 Abnormal labor pattern
Labor pattern Diagnostic criteria
Nulliparas Multiparas
Prolongation disorder > 20 hr >14hr
(Prolonged latent phase)
Protraction disorders
1. Protracted active phase dilatation < 1.2 cm/hr < 1.5 cm/hr
2. Protracted descent < 1.0 cm/hr < 2 cm/hr
Arrest disorders
1.Prolonged deceleration phase > 3 hr > 1 hr
2. Secondary arrest of dilatation > 2 hr > 2 hr
3. Arrest of descent > 1 hr > 1 hr
4. Failure of descent No descent in deceleration
phase
or second stage

Precipitate labor disorders

Precipitate dilatation ≥ 5 cm/ h ≥ 10 cm/ h
Precipitate descent ≥ 5 cm/ h ≥ 10 cm/ h
Pathogenesis ＆ Treatment

 Abnormalities of the Powers

 Abnormalities of the Passage
 Abnormalities of the Passenger
Abnormalities of the
Powers
Normal Uterine Activity in
Labor
 Fundal dominance
 The relative intensity of contractions is greater in
the fundus than in the midportion or lower uterine
segment
 The value of the intensity of contractions
 The average value of the intensity of contractions
is more than 24 mmHg
 In the active phase of labor. Pressures often
increase to 40 – 60 mmHg
 Contractions are well synchronized in different
parts of the uterus
Normal Uterine Activity in
Labor
 The basal resting pressure of the uterus is
between 12 and 15 mmHg
 The frequency of contractions progresses
from 1 every 3 – 5 minutes to 1 every 2 – 3
minutes during the active phase
 The duration of effective contraction in active
labor approaches 60 seconds
 The rhythm and force of contractions
areregular
Abnormalities of the Powers

 Abnormal Uterine Activity

 Hypotonic dysfunction
 Hypertonic and uncoordinated dysfunction
 Inadequate Expulsive Efforts
Hypotonic dysfunction

 Uterine activity characterized by

 contraction of the uterus with insufficient
force (<24 mmHg)
 irregular of in frequent rhythm or both
Causative factors

 Excessive sedation
 Early administration of conduction
anesthesia
 Twins
 Polyhydramnios
 Overdistention of the uterus
Management

 Rule out abnormalities of the passage

or passenger requiring cesarean section
 Physical examination
 Ultrasonography
 Sometimes x-ray
Oxytocin

 Pure hypotonic patterns may be effectively

treated with oxytocin augmentation of
labor
 Intravenous administration of a dilute
oxytocin solution through an in fusion pump
 A used dilution is 10 U of oxytocin per liter of
balanced salt solution.
 The in vivo half-life of oxytocin is about 5
minutes.
Oxytocin
 With intravenous administration, a steady-
state plasma level is achieved 40-60
minutes
 The response of each patient to a given
dosage is unpredictable and must be
titrated
 Overzealous administration may lead to
hypertonic uterine action, precipitate labor,
fetal distress or hypoxia, or uterine rupture
Protocols for administration
of oxytocin
 A starting dose of 1 -2 mU/min
 Increasing in fractional fashion every 15
minutes to achieve the desired response
Seitchik and Castillo(1983)

recommend a lower dosage of oxytocin and report

similar efficacy
 starting doses of 1 mU/min
 be increased at intervals of not less than 30
minutes
 satisfactory cervical dilatation in more than 90%
of patients at dosage of 4 mU/min or less
 with fewer adjustments for hypertonic patterns
of fetal distress
Hypertonic and
uncoordinated dysfunction
 Be less common than hypotonic
dysfunction
 Often occur together
 Be characterized by
 elevated resting tone of the uterus
 dyssynchronous contractions with elevated
tone in the lower uterine segment
 frequent intense uterine contractions
Causative factors

 abruptio placentae
 overzealous use of oxytocin
 cephalopelvic disproportion
 fetal malpresentation
 the latent phase of labor
Manifestation

 Constant pain when the resting tone

of the uterus is 25 mmHg or more
 The uterus is generally painful to
palpation
 A constriction ring may develop at
the level of the isthmus and further
obstruct the progress of labor
Treatment

 Oxytocin administration is generally

of no value
 Sedation is generally effective in
converting hypertonic contraction
normal labor patterns
Prognosis

 Precipitate labor disorders

 Fetal intracranial hemorrhage
 Fetal distress
 Neonatal injury or depression
 Birth vaginal lacerations from rapid
deliver
Inadequate Expulsive Efforts

 Inadequate pushing in the second stage

of labor is common
Causative factors

 conduction anesthesia
 oversedation
 exhaustion
 neurologic dysfunction such as
paraplegia or hemiplegia of various
causes
 psychiatric disorders
Treatment

 Mild sedation or a waiting period to

permit analgesic or anesthetic agent to
wear off may improve expulsive effort.
 Outlet forceps delivery may be affected
in selected cases.
THANKS