Failure to progress
Benha University Hospital, Egypt
Aboubakr Elnashar
Is Dysfunctional Labour important?
Primary indication of CS
UK, 2001
%
Fetal distress 22
Failure to progress 20
Repeat CS 14
Breech 11
Maternal request 7
Others 25
Proper understanding of the pathophysiology &
appropriate treatment, is important for reduction
CS rate Aboubakr Elnashar
•Normal
labour
Stages
Duration
•Dysfunctional
labour
Definition
Etiology
Classification
Diagnosis
Types
Prevention
•Active management of
labour
Protocol
Benefits
•Recommendations
OUTLINE
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Normal labor
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Stage I Latent phase
Active phase: . Acceleration
. Maximum slope
. Deceleration
Stage II
Phase 1 Phase 2
Stage III
Stage IV
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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
labor
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Definition Any deviation in normal progress of
labor, either in
cervical dilatation or
descent of the presenting part,
despite the presence of uterine
contraction
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Etiology
•Power: Dysfunctional uterine activity: 75% (Steer et al, 1985)
Malfunction in the myogenic, neurogenic, or hormonal mechanisms of uterine
activity.
•Passenger:
Malpresentation, malposition, fetal anomalies
•Passages:
-Uterine malformation, pelvic tumors, uterine over distension,
cervical stenosis from previous surgery
-CPD
•Extrinsic factors:
Patient not in labor, sedation, anxiety, anesthesia, supine position,
unripe cervix, chorioamnionitis Aboubakr Elnashar
Classification
• Freidman (1989)
1. Prolonged latent phase
2. Protraction disorders: a. Protracted active phase
b. Protracted descent
3. Arrest disorders: a. 2ndry arrest of cervical dilatation
b. Prolonged deceleration phase
c. Arrest of descent
d. Failure of descent Aboubakr Elnashar
• ACOG (1995)
1. Protraction disorders Slower than normal 2. Arrest disorders Complete cessation of progress
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•Fields 1.Hypotonic dysfunction a.Prolonged latent phase b.Prolonged active phase c. Prolonged deceleration phase d. Prolonged 2nd stage 2.Hypertonic dysfunction
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•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.
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•Philpott (1979)
1. Prolonged latent phase
2. Primary dysfunctional labor
3. 2ndry arrest of labor.
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Diagnosis
1. Partogram: •Recording of the condition of the mother,
the condition of the fetus, and
the progress of labour
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A. CONDITION OF THE FETUS I. FHR.
II. Memb & Liq: I= intact, C= clear, M= meconium
B= blood, A= abscent
III. Moulding: 0 (separated); + (touching);
++(overlap); +++ (severe overlap)
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B. PROGRESS OF LABOUR I. Cervical dilatation (cm). Plot x
In active phase
Alert line: drawn at a rate of 1 cm /h cervical dil
The mean rate of the slowest 10% of normal PG Action line: drawn 4 h to the right of alert line. Intervention should take place
II. Descend: Plot O (amount of head palpable above
pelvic brim) and Position
III. Contractions: Frequency/10 m, Duration &
Intensity:
stippled (<20 sec, weak);
striped (20-40 sec, moderate);
complete (>40 sec, strong).
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C. CONDITION OF THE MOTHER I. Medications: Oxytocin, Drugs, IV Fluids
II. V/S: B.P, P, T.
III. Urine: Vol, alb, ketones
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WHO partogram, 2002
Simple & easy to use.
The latent phase has been removed .
Plotting on begins in the active phase when the cervix is
4 cm dilated.
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2. Nomogram (Studd,1973): labor stencil: a series of curves from patient admission
cervical dilatation to 10 cm (not the patient onset of
labour)
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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. (8 & 6)
Incidence PG: 4%
MG: 1%
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Etiology 1. Wrong diagnosis of labor
2. Excess sedation
3. An abnormal or high presenting part
4. PROM
5.Idiopathic.
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Risks If membranes are intact, no risk , only maternal
anxiety.
Risks are created by aggressive intervention.
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Management •Oxytocin augmentation: does not increase vaginal delivery rate, 10 fold increase
in CS rate
increase in low Apgar score (WHO, 1994) {Ib}
•Careful explaination •Adequate analgesia
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Primary dysfunctional labor Define
•Cx. Dil. < 1cm/h before normal active phase has
been established
•Poor progress during active phase of labour:
cervical dil <1 cm/h for 2 consecutive hrs.
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Primary
dysfunctional
labour
Prolonged active phase of labour
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Primary dys labour
[inadequate uterine
contractions} corrected
with oxytocin
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Incidence PG: 25%
MG: 8%
Etiology 1. Poor/inco-ordinate C: the commonest
2. CPD: 1/ 3
3. Malpresentation or malposition
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Risks 1. F. distress 2. Maternal fear & anxiety, dehydration & acidosis
3. Obstructed labour, maternal infection, uterine
rupture & pph {II}.
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Management •Exclude CPD, ARM + oxytocin drip.
CS: No progress for 2 to 4 h (regardless of oxytocin
dosage or duration of oxytocin) after adequate
contraction pattern has been achieved on maximum
oxytocin dose (NCH,2004)
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2ndry arrest of labor
Define •Cessation of cervical dilatation following a normal period of
active phase dilatation
•Active phase started normally( cervical dilatation reached 5-7
cm ) then cervical dilatation stop or slows significantly within 2 h
Incidence PG: 6%
MG: 2%
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Etiology Any factor implicated in PDL
1.CPD: 50%
2. Malposition
Risks F. distress: rare
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Management
•Exclude CPD, ARM & Syntocinon drip
CS: No progress after 4 h
O, Driscol advised oxytocin regardless of pelvimetry.
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SECONDARY ARREST
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0
1
2
3
4
5
6
7
1 4 7 10 13 16 19
Prolongedlatent phase
Primarydysfunctionallabor
Secondaryarrest
Cervical dilatation
(cm)
Time (hours)
Types of dysfunctional
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Prolonged deceleration phase
(secondary arrest in declarative phase) Define
Arrest or slow of cervical dilatation after 8 cm
(PG > 3h , MG > 1h)
Etiology 1. CPD 2. Uterine exhaustion
Risks High incidence of shoulder dystocia
Treatment Syntocinon is not helpful. C.S.
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Stage II Labor
• Assessment at least every 30 minutes x2:
1. Descent of the fetus (>1 cm/h).
2. Rotation of the fetus.
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• If no progress in Stage II: (NCH, 2004)
1. Evaluation of mat position & f position.
2. Change mat position
3. Evaluation of fluid balance
4. Oxytocin augmentation unless contraindicated
5. When the above measures fail: operative vaginal
delivery (vacuum extraction or mid/low forceps)
unless contraindicated.
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Contraindications of Vacuum extraction:
Presenting part is too high
Doctor is inexperienced
F distress with inability to do timely operative
vaginal delivery
Patient refuses
When using vacuum extraction or forceps application with a suspected macrosomic infant, be aware of the risk of shoulder dystocia.
6. CS
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Prevention O,Driscol method of active management of
labor (1969) • Diagnosis of labor
• 1 h: ARM
• 2h: cervical dil <1 cm /h:
oxytocin drip
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Active
management of
labor
•First introduced by O, Driscol et al (1969) in Dublin.
•Many modifications
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Protocol 1.This approach to management is confined to
nulliparas.
2. Patient education during pregnancy: signs &
symptoms of labor
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3.Strict criteria for diagnosis of labor:
• Painful ut contractions as well as
complete effacement of the cervix,
ROM or
passage of blood stained mucous
The diagnosis of labor is made within 1 hr of presentation. Spontaneous contractions at least 2/15 min & at least 2 of the following:
Complete effacement of cervix Cervical dilation 3 cm or greater SROM (NGC,2004)
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4.Each woman in labor is assigned to trained
professional companion.
5.Amniotomy within 1 hr of admission.
Contraindications (NGC,2004): Presentation unknown, floating or unstable Cervix dilated <3 cm Patient refuses
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6.Strict criteria for diagnosis of abnormal labor
progress: partogram or labor graph.
Cervical checks should indicate at least 1 cm/h.
{Frequent cervical checks afford the best opportunity
for prevention of failure to progress}.
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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 FHR monitoring is used only
if there is meconium stained AF.
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9.All methods of pain relief are freely available.
•Parenteral analgesics:
nalbuphine hydrochloride [Nubain],
butorphanol tartrate [Stadol],
meperidine [Demerol], or
Hydroxyzine hydrochloride [Vistaril]
•Epidural or intrathecal narcotics for patients in active
progressing labor
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10. C.S:
a. No delivery12 hr post admission
b. Fetal scalp ph sampling revealed fetal
compromise.
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Benefits 1.Prevention of dysfunctional labor.
2.Decrease the incidence of prolonged labor from 30%
to 7% (Boylan,1997)
3. Decrease mat infectious morbidity
4. Decrease incidence of operative delivery. Not
confirmed by other studies
4. Decrease incidence of C.S to 4.8% (Lopez-Zeno,1992).
Some found no decrease (Fraser et al,1993)
others found an increase (Boylan et al,1993).
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Recommendations
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The Cochrane Library (Fraser et al, 2001)
Routine early amniotomy
• Reduction in:
1. Labor duration (between 60 and 120 min)
2. Use of oxytocin
3. Abnormal 5-min Apgar scores.
• Increase in:
CS for fetal distress
Amniotomy should be reserved for women with
abnormal labor progress.
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NICE (Sept, 2007) • Active management of labour (one-to-one
continuous support; strict definition of established
labour; early routine amniotomy; oxytocin if labour
becomes slow) should not be offered routinely.
•In normally progressing labour, amniotomy should
not be performed routinely.
•Combined early amniotomy with use of oxytocin
should not be used routinely.
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Aboubakr Elnashar
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