Abnormal labor: Protraction and arrest disorders

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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Prolonged latent phase

Definition : prolonged latent phase is defined as 20 hours for the nullipara and 14 hours for the multiparous woman ( def a) when latent phase lasts longer than 12hrs for nullipara and 6hrs for parous women (def b)
Latent phase longer than 8 hours (WHO definition)

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

Active phase abnormalities

25% of nulliparas &15% of multiparous womens develop active phase abnormalities. This makes it the commonest labor abnomality

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

Diagnostic criteria for abnormal patterns in active labor

Nullipara Multipara

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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Poor progression in the second stage

What is prolonged second stage of labor? Arrest of descent: no descent for > 2hr for primi & multi Protracted descent:< 1cm/hr in nullipara & <2cm/hr in multi NB the duration of second stage has no relationship to perinatal out come if fetal distress & traumatic deliveries are excluded

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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

Maternal well being:

Pulse, temperature, blood pressure, respiration Urine output, ketones or protein in urine

Progress of labor:
Cervical dilatation Descent of presenting part Duration and frequency of contractions

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WHO Partograph Trial

World Health Organization (WHO) evaluated impact of partograph on labor management and outcome Conducted randomized, multi-center trial in hospitals in Indonesia, Malaysia and Thailand No intervention in latent phase until after 8 hours If action line was reached during active phase, considered:
Oxytocin augmentation Cesarean section Observation and Labor Using the Partograph treatment supportive Managing

WHO 1994.

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WHO Partograph Trial (cont.)

All Women Total childbirths Labor > 18 hours Labor augmented Postpartum sepsis Normal Women Mode of childbirth
Spontaneous cephalic Forceps

Before Implementation 18,254 6.4% 20.7% 0.70%

After Implementation 17,230 3.4% 9.1% 0.21%

0.002 0.023 0.028

8,428 (83.9%) 341 (3.4%)

7,869 (86.3%) 227 (2.5%)

< 0.001 0.005

WHO 1994.

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Using the Partograph

Patient information: Name, gravida, para, hospital number, date and time of admission, and time of ruptured membranes Fetal heart rate: Record every half hour Amniotic fluid: Record the color at every vaginal examination:
I: membranes intact C: membranes ruptured, clear fluid M: meconium-stained fluid B: blood-stained fluid
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Using the Partograph (cont.)

Molding:
1: sutures apposed 2: sutures overlapped but reducible 3: sutures overlapped and not reducible

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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Using the Partograph (cont.)

Descent assessed by abdominal palpation: Part of head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis

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Using the Partograph (cont.)

Hours: Time elapsed since onset of active phase of labor (observed or extrapolated) Time: Record actual time Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds
Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds:

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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Using the Partograph (cont.)

Temperature: Record every 2 hours Pulse: Record every 30 minutes and mark with a dot () Blood pressure: Record every 4 hours and mark with arrows Protein, acetone and volume: Record every time urine is passed

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The Modified WHO Partograph

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Sample Partograph for Normal Labor

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 Unsatisfactory progress of labor is defined as:

Unsatisfactory Progress of Labor

Latent phase longer than 8 hours Cervical dilatation to the right of the alert line on partograph Woman has been experiencing labor pain for 12 hours or more without delivery

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Prolonged Active Phase

Diagnose prolonged active phase if cervical dilatation is to the right of the alert line on the partograph

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Partograph Showing Prolonged Active Phase

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Management of Prolonged Active Phase of Labor

If no signs of cephalopelvic disproportion or obstruction and membranes are intact, rupture membranes Assess uterine contractions:

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

Management of Prolonged Active Phase: Cephalopelvic Disproportion

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Management of Prolonged Active Phase: Obstruction

Diagnose obstruction if there is secondary arrest of cervical dilatation and descent of presenting part with:
large caput third degree moulding cervix poorly applied to presenting part edematous cervix ballooning of lower uterine segment formation of retraction band or maternal and fetal distress

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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Management of Prolonged Active Phase: Obstruction (cont.)

If fetus is alive, the cervix is fully dilated and the head is at 0 station or below, deliver by vacuum extraction If fetus is alive but the cervix is not fully dilated or if the fetal head is too high for vacuum extraction, deliver by cesarean section If fetus is dead deliver by craniotomy or cesarean section Rupture of an unscarred uterus is usually caused by obstructed labor.

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Management of Prolonged Active Phase: Inadequate Uterine Activity

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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Management of Prolonged Active Phase: Inadequate Uterine Activity (cont.)

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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Partograph Showing Inadequate Uterine Contractions Corrected 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

Thank you for your Attention