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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

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Abnormal labor

Managing Labor Using the Partograph 4

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)

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Factor contributing• Prematurely admistered sedation and

analgesia• Poor cervical condition • Myometrial dysfunction• false labor

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significance

• Increased risk of subsequent labor abnormality

• Increased cesarean delivery rate • Low APGAR score• Increased perineal laceration febrile

morbidity& intrapartum blood loss

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Treatment

• Adequate rest with therapeutic sedation /narcosis

morphine /pethidine• Augmentation with oxytocin less preferred option

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Active phase abnormalities

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

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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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Diagnostic criteria for abnormal patterns in active labor

Labor pattern Nullipara Multipara

First stageDuration (no anesthesia)

16.6 hours 12.5 hours

Duration (anesthesia) 19.0 hours 14.9 hours Protracted dilation <1.2 cm/h <1.5 cm/h

Arrested dilation >2 h >2 h

Second stageDuration (no anesthesia) 132 minutes 61 minutes Duration (anesthesia) 185 minutes 131 minutes Arrest of descent (epidural)

>3 h >2 h

Arrest of descent (no epidural)

>2 h >1 h 12

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 malposition &

malpresentation


Mx cont……

• Evaluate uterine function1.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


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

Managing Labor

Using the Partograph


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


WHO Partograph TrialWorld 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 hoursIf action line was reached during active phase,

considered:◦ Oxytocin augmentation◦ Cesarean section◦ Observation and supportive treatment

Managing Labor Using the Partograph 21WHO 1994.

WHO Partograph Trial (cont.)All Women Before

ImplementationAfter

Implementationp

Total childbirths 18,254 17,230Labor > 18 hours 6.4% 3.4% 0.002Labor augmented 20.7% 9.1% 0.023Postpartum sepsis 0.70% 0.21% 0.028

Normal WomenMode of childbirth

Spontaneous cephalicForceps

8,428 (83.9%)

341 (3.4%)

7,869 (86.3%)

227 (2.5%)

< 0.001

0.005

Managing Labor Using the Partograph 22WHO 1994.

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


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


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


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


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



The Modified WHO

Partograph

Sample Partograph for Normal Labor


Unsatisfactory Progress of Labor• Unsatisfactory progress of labor is defined as:

– 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


Prolonged Active Phase

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


Partograph Showing

Prolonged Active Phase


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


Management of Prolonged Active Phase: Cephalopelvic Disproportion

• 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: 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


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.

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


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

Rupture membranes and augment labor using oxytocinReassess 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

Partograph Showing

Inadequate Uterine Contractions

Corrected with Oxytocin


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