Dysfunctional labor

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Dysfunctional labor

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  • 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 Aboubakr Elnashar
  • Normal labor Aboubakr Elnashar
  • Stage I Latent phase Active phase: . Acceleration . Maximum slope . Deceleration Stage II Phase 1 Phase 2 Stage III Stage IV Aboubakr Elnashar
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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 Aboubakr Elnashar
  • Aboubakr Elnashar
  • Dysfunctional labor Aboubakr Elnashar
  • Definition Any deviation in normal progress of labor, either in cervical dilatation or descent of the presenting part, despite the presence of uterine contraction Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • Fields 1.Hypotonic dysfunction a.Prolonged latent phase b.Prolonged active phase c. Prolonged deceleration phase d. Prolonged 2nd stage 2.Hypertonic dysfunction Aboubakr Elnashar
  • 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. Aboubakr Elnashar
  • Philpott (1979) 1. Prolonged latent phase 2. Primary dysfunctional labor 3. 2ndry arrest of labor. Aboubakr Elnashar
  • Diagnosis 1. Partogram: Recording of the condition of the mother, the condition of the fetus, and the progress of labour Aboubakr Elnashar
  • 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) Aboubakr Elnashar
  • 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 (40 sec, strong). Aboubakr Elnashar
  • C. CONDITION OF THE MOTHER I. Medications: Oxytocin, Drugs, IV Fluids II. V/S: B.P, P, T. III. Urine: Vol, alb, ketones Aboubakr Elnashar
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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. Aboubakr Elnashar
  • Aboubakr Elnashar
  • Aboubakr Elnashar
  • 2. Nomogram (Studd,1973): labor stencil: a series of curves from patient admission cervical dilatation to 10 cm (not the patient onset of labour) Aboubakr Elnashar
  • Aboubakr Elnashar
  • 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% Aboubakr Elnashar
  • Etiology 1. Wrong diagnosis of labor 2. Excess sedation 3. An abnormal or high presenting part 4. PROM 5.Idiopathic. Aboubakr Elnashar
  • Risks If membranes are intact, no risk , only maternal anxiety. Risks are created by aggressive intervention. Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • Primary dysfunctional labor Define Cx. Dil. < 1cm/h before normal active phase has been established Poor progress during active phase of labour: cervical dil 3h , MG > 1h) Etiology 1. CPD 2. Uterine exhaustion Risks High incidence of shoulder dystocia Treatment Syntocinon is not helpful. C.S. Aboubakr Elnashar
  • Stage II Labor Assessment at least every 30 minutes x2: 1. Descent of the fetus (>1 cm/h). 2. Rotation of the fetus. Aboubakr Elnashar
  • 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. Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • Prevention O,Driscol method of active management of labor (1969) Diagnosis of labor 1 h: ARM 2h: cervical dil