Kazan State Medical University Department of Obstetrics

Kazan State Medical University Department of Obstetrics & Gynecology Abnormalities of Labor Activity Student – Abhinav Sumit Kumar Group - 1428

ABNORMAL LABOUR DYSTOCIA : - Difficulty in labour [ Discordination of labor activity ] Depends on Cervix contraction b/c of Trauma, Fibrosis 7 scars When there is poor progress or the foetus shows signs of compromise or malpresentation or uterine scar or labour is induced.

RF for abnormal labour: • Small women • Big baby • Mal presentation • Mal position • Early membrane rupture • Soft tissue/pelvic malformation

PATHOLOGICAL PRELIMINARY PERIOD OF CHILDBIRTH ( 1 ST PATHOLOGICAL CONDITION ) The pathological preliminary period of childbirth – the prolonged predrodovy preparatory period proceeding with the irregular painful contractions which are not leading to structural changes of a neck of uterus. The pathological preliminary period is characterized is long (over 6 -8 hours) the proceeding inefficient colicy pains which break the daily mode of wakefulness and the woman's dream, cause exhaustion of the woman in labor and increase risks of a Hypoxia.

REASONS OF THE PATHOLOGICAL PRELIMINARY PERIOD OF CHILDBIRTH: Disturbances of the preliminary period of childbirth are more often noted at pathology of a maternal organism: at pregnant women with a labile nervous system, neurosises, NTs. D; metabolic and endocrine disturbances (obesity, insufficient body weight, menstrual dysfunction, sexual infantility, etc. ); the accompanying somatic pathology (heart diseases, arrhythmia, arterial hypertension, diseases of kidneys, a liver, adrenal glands); inflammatory changes of a uterus (endometritises, tservitsita); a gestosis, dystrophic processes after the postponed abortions.

SYMPTOMS OF THE PATHOLOGICAL PRELIMINARY PERIOD OF CHILDBIRTH The pathological preliminary period passes or into a diskoordination of patrimonial activity, or into primary weakness of pains; quite often is followed by the expressed vegetative disturbances (perspiration, a sleep disorder, a neurangiosis). The pregnant woman complains of pains in the field of a sacrum and a waist, a bad dream, heartbeat, an asthma, the dysfunction of intestines increased and painful stir of a fruit.

DIAGNOSIS: Clinical and laboratory trials allowed to reveal disturbance of vegetative balance at these patients: increase in blood of level of adrenaline and noradrenaline, decrease in atsetilkholinesterazny activity of erythrocytes. intensity of exchange processes in a uterus (low level of activity glyukozo-6 -fosfatdegidrogenazy - G -6 -FDG, reduction of maintenance of proteinaceous and nonprotein SH-group), dominance of a glycoclastic way of metabolism of glucose.

Periods of Labor 1 st Period of Labor = Dilatation of Cervix 2 nd Period of Labor = Delivary Period [ its called Famous period ] 3 rd Period of Labor = Plasental Period Powerless Labor activity = separate into two parts 1. Primary powerless labor activity ( b/c of women may have large fetus & multiple pregnency ) 2. Secondary powerless labor activity ( Powerless Pushing activity = b/c of not enough contraction & dilatation of uterus )

Phases of labour

Poor Progress in 1 st Stage May be problems with: 1. The PASSENGER – size, presentation, position. 2. The PASSAGES – uterus, cervix, bony pelvis. 3. The PROPULSION – uterine power, uterine efficiency. Diagnosed when there is slow dilation of the cervix

Phrases Relating to Poor Prognosis in 1 st Stage Labour Prolonged latent phase: → A failure of thinning of the lower segment, effacement and dilation of the cervix despite several hours of painful contractions. Primary dysfunctional labour: → Most common in first labour. → Implies slow progress during the active phase of labour. → Usually asso. with inefficient uterine contractions.

Secondary arrest: → Implies appropriate progress of labour in the initial phase, but arrest of cervical dilation typically after 7 cm. → Usually assoc. with malpresentation and cephalo-pelvic disproportio

1. Inefficient uterine action: Most common cause. RF: o Extremes of reproductive age. ○ Primigravidae. o Unusually anxious women. ○ Uterine overdistension e. g. twins. Inefficient uterine action is divided into one of two: o Hypotonic inertia: Contractions are weak and infrequent. There is normal uterine tone between contractions. Treatment: rupture of membranes ± iv oxytocin

o Hypertonic inertia: Contractions are irregular. High resting basal tone between contractions. Uterine circulation does not return to normal between in contractions → Foetal distress more likely. Treatment: Epidural analgesia with iv oxytocin.

Indication Nullipara Multipara Prolonged latent phase >20 h >14 h Prolonged second stage without (with) epidural >2 h (>3 h) >1 h (>2 h) Protracted dilatation < 1. 2 cm/h < 1. 5 cm/h Protracted descent < 1 cm/h < 2 cm/h Arrest of dilatation* >2 h Arrest of descent* >2 h >1 h Prolonged third stage >30 min *Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours. (Please refer to the Pathophysiology information regarding adequate contractions. )

2. Cephalopelvic disproportion (CPD) Implies anatomical disproportion between the foetal head and maternal pelvic. Cause: large head, small pelvis, combination of the two OR relative CPD can occur with malposition of the head. RF: primigravida women of small stature (<1. 60 m) with a large baby. CPD suspect in labour if: • Progress slow/stopped despite efficient uterine contractions.

• Foetal head not engaged. • Vaginal examination shows severe moudling and caput formation. • Head is poorly applied to the cervix Treatment: Oxytocin – for primigravida women – as long as no foetal distress

3. Abnormalities of passages: Cause – abnormality of: » Bony pelvis. » Maternal soft tissues. » Uterus. » Cervix. Treatment: » Normal delivery. » C-Section. conditions: may be » Fibroids. » Severe scarring of cervix from ops e. g. LLETZ – scar tissue does not dilat

Delay in 2 nd Stage 1. Secondary uterine inertia: Having achieved full dilation the uterine contractions become weak and ineffectual ± maternal dehydration and ketosis. May be exacerbated by epidural analgesia. RF: Treatment (if no mechanical problem anticipated): Rehydration and iv Oxytocin.

2. Persistent occipitoposterior position of the foetal head: Treatment: Head will have to undergo long rotation of occiput-anterior OR deliver in occiputo-posterior position i. e. face to pubes AND/OR iv Oxytocin

3. Narrow mid-pelvis: This prevents internal rotation of the foetal head – results in arrest of foetal head at level of the ischial spines in transverse position – condition called ‘Deep Transverse Arrest’. Treatment: Delivery by rotational forceps (Kjelland’s) OR ventouse extraction OR C-Section.

Management of Poor Progress in Labour Management of poor progress: - One-to-one care - Early detection of poor progress - Pain relief -Oxytocin augmentation of abnormal labour Nulliparous woman: If no foetal problems do early artificial rupture of membranes (ARM) – if still poor progress then give iv Oxytocin.

Oxytocin: • Will make contractions more efficient AND/OR stronger + more frequent. • Do not give if suspicion of foetal distress. • Carries a risk of uterine rupture. • Monitor with CTG throughout administration. • Vaginal examination 2 hrs post administration. Assessment of uterine contractions: clinical examination and uterine tocography. Major degree of caput and moulding suggests that there is a mechanical obstruction. If strong contractions but little progress it suggests CPD – Treat with C-Section.

Women with a Uterine Scar Usually due to C-Section due to risk of rupture of scar. Likely to occur: → Late in 1 st stage of labour. → Induced or accelerated labour. → Large baby. Early signs of uterine rupture: → Severe lower abdo pain. → Cessation of contractions. → Signs of foetal distress. → Maternal tachycardia.

It is not advisable for a woman to labour if she: → Has two or more previous CSection scars. → Has a high head at term. → Requires induction of labour

Complications of abnormal labour MATERNAL COMPLICATIONS 1. Obstructed labour 2. Sepsis. 3. Ruptured uterus. 4. Increased risk of operative delivery 5. Increased risk of anaesthesia 6. Increased risk of PPH 7. Vesicovaginal fistula(Following Obstructed labour)

Complications of abnormal labour FETAL COMPLICATIONS 1. 2. 3. 4. 5. Birth asphyxia Still birth Neonatal sepsis Cephalhaematoma Skull fractures

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