Dysfunctional Labour by Abhishek Jaguessar

8/4/2019 Dysfunctional Labour by Abhishek Jaguessar

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Failure to progress


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Stages of labor

Stage I

Latent phase

Active phase: . Acceleration. Maximum slope

. Deceleration

Stage II

Phase 1 Phase 2Stage III

Stage IV


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0

2

4

6

8

10

12

2 4 6 8 10 12 14 16

Latent phaseActive phase

2ndstage1st stage

max slope

acceleration

dec

Time (hours)

Cervical dilatation

(cm)Friedman labor curve in nulliparous


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Labor duration (Friedman,1978)

Variable Nulliparas (h) Multiparas(h)

Latent phase

mean 6.4 4.8

upper limit 20.1 13.6

Active phase

mean 4.6 2.4

dilatation rate(cm/h) 1.2 1.5

Second stage

mean 1 0.5

upper limit 2.9 1.1


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Dysfunctional laborDefinition

Any deviation in normal

progress of labor , either incervical dilatation or in descent

of the presenting part


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Etiology

1. Malfunctionin 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


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ClassificationFreidman (1989) :

1. Prolonged latent phase2. Protraction disorders:1.Protracted active phase

2. Protracted descent

3. Arrest disorders:1.2ndry arrest of cervical dilatation2. Prolonged deceleration phase

3. Arrest of descent

4. Failure of descent


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ACOG (1995):

1. Protractiondisorders Slower thannormal2.Arrest disordersComplete cessation ofprogress


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e s1.Hypotonic dysfunctiona.Prolonged latent phaseb.Prolonged active phasec. Prolonged decelerationphased. Prolonged 2nd stage2.Hypertonic dysfunction


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r n o en :1.Disorders of dilatation:a. Prolonged latent phaseb. Protracted active phase

c. Secondary arrest2.Disorders of descent:

a. Failure of descentb. Protracted descentc. Arrest of descent.


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Philpott (1979)1. Prolonged latent

phase2. Primary dysfunctional

labor

3 2ndry arrest of labor


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Early diagnosis1. 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 alertline (Philpott,1972).

2. Nomogram (Studd,1973):labor stencil: a series of curves from patient

admission cervical dilatation to 10 cm.


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Prevention

O,

Driscol method of activemanagement of labor (1969)

Diagnosis of labor 1 h: ARM

2h:cervical dilatation


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Prolonged latent phaseDefine

Freidman: > 20 h in PG, > 14 h in MGfrom onset of labor(difficult to determine)

Philpott:> 6h in PG , > 4h in MG fromadmission in labor.

IncidencePG: 4% MG: 1%


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Etiology

1. Wrong diagnosis of labor

2.Excess sedation3. An abnormal or high presenting part

4. PROM5.Idiopathic.

Risks

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

maternalanxiety.


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TreatmentTrue 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 cxdilatation. If after 4-8 h of syntocinon, thecervix is not further dilated, CS.


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Primary dysfunctional laborDefine

Cx. Dil. < 1cm/h before normal active phase hasbeen established

Incidence

PG: 20% MG: 8%

Etiology

1. Inefficient C.: the commonest2. CPD: 1/ 3

3. Malpresentation or malposition


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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.


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2ndry arrest of laborDefine

Active phase started normally( cervicaldilatation reached 5-7 cm ) then cervical

dilatation stop or slows significantly within 2 hIncidence

PG: 6% MG: 2%

Etiology1.CPD:50%

2. Malposition


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Risks

F. distress: rareTreatment

Exclude CPD , ARM & Syntocinon dripNo progress after 4 h : CS (15% ).

O, Driscol advised oxytocinregardless of pelvimetry.

C i l dil t ti T f d f ti l


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0

1

2

3

4

5

6

7

1 4 71

0

1

3

1

6

1

9

Prolonged

latent phase

Primary

dysfunctionallabor

Secondary

arrest

Cervical dilatation

(cm)

Time (hours)

Types of dysfunctional


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Prolonged decelerationphaseDefineArrest or slow of cervical dilatation after 8 cm

(PG > 3h , MG > 1h)

Etiology1. CPD 2. Uterine exhaustion

Risks

1. High incidence of shoulder dystocia2. Forceps is difficult

Treatment

S ntocinon is not helpful. C.S.

El h t l (2000) d t i


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Elnashar et al (2000) compared oxytocin

infusion alone & with propranolol in the

management of DL (Primary DL & 2ndryarrest).

The study group (50 women) was given propranololI.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 groupreceived oxytocin infusion for at least 4 hours & for

maximum of 6 hours & if there was no response,CS

was done.

Th i ifi t diff i th d


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There were a significant differences in the drug-

delivery 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 safelyshortened the drug-delivery interval & reduced

CS rate.


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Activemanagement oflaborDr Aboubakr Elnashar

First introduced by O,

Driscolet al (1969) in Dublin.

Many modifications

P t l


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Protocol1.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 orpassage of blood stained mucous

The diagnosis of labor is made within 1 hr of

presentation.

4 E h i l b i i d t


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4.Each woman in labor is assigned to

trainedprofessional 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.


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8.Assess FHR by auscultation

intermittently Continuous electronic fetalheart rate monitoring is used only if there is

me conium stained amniotic fluid

9.All methods ofpain reliefare freelyavailable.

10. C.S if no delivery12 hr post admissionor if fetal scalp ph sampling revealed fetal

compromise.

B fit


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Benefits

1.Prevention ofdysfunctional labor

2.Decrease the incidence ofprolonged laborfrom 30% to 7% (Boylan,1997)

3.Decrease incidence ofoperative delivery.

4. Decrease maternalinfectious mrbidity5.Decrease incidence ofC.S to 4.8% (Lopez-

Zeno,1992).Some found no decrease in CS rate (Fraser et

al,1993) & others found anincrease in CS rate

(Boylan et al,1993).

A i t f h t i


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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-minuteApgar scores.

N t f th h th i th t ti


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No support for the hypothesis that routine

early amniotomy reduces the risk of CS.

Indeed there is a trend toward an increasein CS. An association between early

amniotomy and CS for fetal distress isnoted in one large trial.

This suggests that amniotomy should be

reserved for women with abnormal labor

progress.

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Dysfunctional Labour by Abhishek Jaguessar