Failure to progress

Stages of labor Stage I

Latent phase Active phase: . Acceleration . Maximum slope . Deceleration

Stage II
Phase 1 Phase 2

Stage III Stage IV

Cervical dilatation (cm)

Friedman labor curve in nulliparous

2nd dec stage max slope

12 10 8 6 4 2 0 2 4 6 8 10 12 14 16
Time (hours)
acceleration Active phase Latent phase 1st stage

Labor duration (Friedman,1978)

Variable Latent phase mean upper limit Active phase 6.4 20.1 4.8 13.6 Nulliparas (h) Multiparas(h)

mean
dilatation rate(cm/h) Second stage mean upper limit

4.6
1.2

2.4
1.5

1 2.9

0.5 1.1

Dysfunctional labor Definition Any deviation in normal progress of labor , either in cervical dilatation or in descent of the presenting part

Etiology

1. Malfunction in the myogenic, neurogenic, or hormonal mechanisms of uterine activity.

2. Malpresentation, fetal anomalies, uterine malformation, pelvic tumors, overdistension of the uterus, CPD 3. Extrinsic factors: sedation, anxiety, anesthesia, supine position, unripe cervix, chorioamnionitis

Classification
Freidman (1989) : 1. Prolonged latent phase 2. Protraction disorders:1.Protracted active phase 2. Protracted descent 3. Arrest disorders:1.2ndry arrest of cervical dilatation 2. Prolonged deceleration phase 3. Arrest of descent 4. Failure of descent

ACOG (1995): 1. Protraction disorders Slower than normal 2. Arrest disorders Complete cessation of progress

Fields 1.Hypotonic dysfunction a.Prolonged latent phase b.Prolonged active phase c. Prolonged deceleration phase nd stage d. Prolonged 2 2.Hypertonic dysfunction

Shifirin & Cohen(1998): 1.Disorders of dilatation: a. Prolonged latent phase b. Protracted active phase c. Secondary arrest 2.Disorders of descent: a. Failure of descent b. Protracted descent c. Arrest of descent.

Philpott (1979)

1. Prolonged latent phase 2. Primary dysfunctional labor 3. 2ndry arrest of labor.

Early diagnosis 1. Partogram: In active phase Alert line: drawn from cervical dilatation on admission ,at a rate of 1 cm /h Action line: drawn 2 h to the right of alert line (Philpott,1972). 2. Nomogram (Studd,1973):
labor stencil: a series of curves from patient admission cervical dilatation to 10 cm.

Prevention ,Driscol method of active O management of labor (1969) Diagnosis of labor 1 h: ARM 2h:cervical dilatation <1 cm /h: oxytocin drip

Prolonged latent phase

Define Freidman: > 20 h in PG, > 14 h in MG from onset of labor (difficult to determine) Philpott:> 6h in PG , > 4h in MG from admission in labor. Incidence PG: 4% MG: 1%

Etiology 1. Wrong diagnosis of labor 2.Excess sedation

3. An abnormal or high presenting part 4. PROM 5.Idiopathic.

Risks
are created by aggressive intervention. If membranes are intact, no risk , only maternal anxiety.

Treatment
True labor or not: PV, CTG, palpation of the cervix & reexamine after 4h:
1.C stop or no cx changes: not in labor 2. C persist & no cervical changes: sedation. 3. C. persist & cx changes : ARM + Syntocinon drip. A. In 85% labor will progress rapidly . B.In 15% adequate C will not cause cx dilatation. If after 4-8 h of syntocinon, the

cervix is not further dilated, CS.

Primary dysfunctional labor Define Cx. Dil. < 1cm/h before normal active phase has been established Incidence PG: 20% MG: 8%

Etiology 1. Inefficient C.: the commonest 2. CPD: 1/ 3 3. Malpresentation or malposition

Risks 1. F. distress 2. Maternal fear & anxiety , dehydration &

acidosis

3. Incordinate u. activity. Treatment Exclude CPD, ARM + oxytocin drip.

15%: vag. Delivery 35%: instrumental delivery 50%: CS for F. distress.

2ndry arrest of labor Define Active phase started normally( cervical dilatation reached 5-7 cm ) then cervical
dilatation stop or slows significantly within 2 h

PG: 6%

Incidence MG: 2% Etiology

1.CPD:50% 2. Malposition

Risks F. distress: rare

Treatment
Exclude CPD , ARM & Syntocinon drip

No progress after 4 h : CS (15% ). , Driscol advised oxytocin O regardless of pelvimetry.

Cervical dilatation 7 (cm)

Types of dysfunctional

6 5 4 3 2 1 0
10 13 16
Time (hours)

Prolonged latent phase Primary dysfunctional labor Secondary arrest

19

Prolonged deceleration phase Define Arrest or slow of cervical dilatation after 8 cm (PG > 3h , MG > 1h) Etiology 1. CPD 2. Uterine exhaustion Risks 1. High incidence of shoulder dystocia 2. Forceps is difficult

Treatment Syntocinon is not helpful. C.S.

Elnashar et al (2000) compared oxytocin infusion alone & with propranolol in the management of DL (Primary DL & 2ndry arrest).
The study group (50 women) was given propranolol I.V. in a dose of 2 mg to be repeated after one hour if there was no response in cervical dilatation. The control group (50 women) & the study group received oxytocin infusion for at least 4 hours & for maximum of 6 hours & if there was no response,CS was done.

There were a significant differences in the drugdelivery interval (2.2 vs 3.7 hours) & CS rate (20 vs 38 %) between the study & the control groups.

Between the two groups, no statistically significant differences were observed in low Apgar scores or incidence of admissions to the NICU.

Conclusion: Propranolol combined with oxytocin infusion in management of DL safely shortened the drug-delivery interval & reduced CS rate.

First introduced by et al (1969) in Dublin. Many modifications

Dr Aboubakr Elnashar
, O

Active management of labor

Driscol

Protocol
1.This approach to management is confined to nulliparas. 2. Patient education during pregnancy: signs & symptoms of labor 3.Strict criteria for diagnosis of labor: painful uterine contractions as well as complete effacement of the cervix, ruptured membranes or passage of blood stained mucous The diagnosis of labor is made within 1 hr of presentation.

4.Each woman in labor is assigned to trained professional companion.

5.Amniotomy within 1 hr of admission. 6.Strict criteria for diagnosis of abnormal labor progress. partogram or labor graph. 7.Oxytocin high dose infusion: if progress of labor is < 1 cm/h over 2 h. Oxytocin infusion is begun at 6mu/min & increased by 6 mu/min every 15 min until 7 C/15min. or 40 mu/min.

8.Assess FHR by auscultation intermittently Continuous electronic fetal heart rate monitoring is used only if there is me conium stained amniotic fluid 9.All methods of pain relief are freely available.
10. C.S if no delivery12 hr post admission or if fetal scalp ph sampling revealed fetal compromise.

Benefits 1.Prevention of dysfunctional labor 2.Decrease the incidence of prolonged labor from 30% to 7% (Boylan,1997) 3.Decrease incidence of operative delivery. 4. Decrease maternal infectious mrbidity 5.Decrease incidence of C.S to 4.8% (LopezZeno,1992). Some found no decrease in CS rate (Fraser et al,1993) & others found an increase in CS rate (Boylan et al,1993).

Amniotomy for shortening spontaneous labour

Fraser et al, The Cochrane Library, 2, 2001.

Routine early amniotomy is associated with both benefits and risks. Benefits include a reduction in labor duration( between 60 and 120 minutes) and a possible reduction in abnormal 5-minute Apgar scores.

No support for the hypothesis that routine early amniotomy reduces the risk of CS. Indeed there is a trend toward an increase in CS. An association between early amniotomy and CS for fetal distress is noted in one large trial.

This suggests that amniotomy should be reserved for women with abnormal labor progress.