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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1
POOR PROGRESS OF LABOUR
Dr.M.ThirukumarConsultant obstetrician and GynaecologistTeaching Hospital Batticaloa
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2
What is the importance?
• 1/3 of caesarean section, mainly in nulliparous –due to poor progress of labour.
• Uncommon in multiparous- only in 2%
• The rates of dystocia differs among practitioners mainly due to difference in labour management.
• Success in decreasing the incidence of dystocia among nulliparous will have impact on overall rate of caesareans birth
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3
Labour• Regular, frequent uterine
contraction which leads to progressive cervical effacement and dilatation
to culminate progressive descend of fetus to have vaginal delivery.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4
Progress of Labour
• Effacement (thinning)• Dilatation (opening)• Descent (progress through the
birth canal)• Delivery of the baby and
placenta
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5
The Labour Curve
• First stage - A: latent phase; B + C + D: active phase; B: acceleration; C: maximum slope of dilation; D: deceleration; E: second stage.Adapted from: Friedman. Labor: Clinical evaluation and management, 2nd ed, Appleton, New York 1978.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6
Definition of the first stage
• Latent first stage of labour – when
-there are painful contractions, and
-there is some cervical change, including cervical effacement and dilatation up to 4 cm.
• Established first stage of labour – when:
regular painful contractions, and
progressive cervical dilatation from 4 cm.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7
Disorders of labour
• 3 major disorders
1)prolonged latent phase
2)primary dysfunctional labour
3)secondary arrest
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9
Latent Phase Labour• <4 cm dilated• Contractions may or may
not be painful• Dilate very slowly• Can talk or laugh through
contractions• May last days or longer• May be treated with
sedation, hydration, ambulation or rest.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10
• During latent phase changes occurs in
-collagen content of the cervix
-ground substance of the cervix
-hydration state of the cervix
so remodelling effacement of the cervix occur
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11
• Duration of latent phase
• Primi -20 hours(average-8.6 hours)
• Multi -14 hours(average 5.3 hours)
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12
Management of latent phase
• Reassurance
• Pain relief
• Mobilisation
• Augmentation with oxytocin increases
-caesarean rates by 10 fold
-3 fold increase in law apgar score
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13
Active Phase Labour
• At least 4 cm dilated• Regular, frequent, usually
painful contractions• Dilate at least 1.2-1.5 cm/hr• Are not comfortable with
talking or laughing during their contractions
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14
Duration of the first stage
• varies between women,
• first labours last on average 8 hours and are unlikely to last over 18 hours.
• Second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15
Definition of delay in the established first stage
• needs to take into consideration all aspects of progress in labour and should include:
• cervical dilatation of less than 2 cm in 4 hours for first labours
• cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16
• descent and rotation of the fetal head
• changes in the strength, duration and frequency of uterine contractions.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17
Primary dysfunctional labour
• Poor progress in active phase of labour(up to 7 cm dilation of the cervix)
• Affects 26% of nullipara
8% of multipara
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18
Causes of dystocia
• 1)inefficient uterine activity is a significant factor. Due to
-induction of labour
-inadequate stimulation of contraction
-failure of uterine response to stimulation
• 2) relative disproportion due to deflexion of the fetal head-OPP,asynclitism,inaduate cephalic flexion
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19
• 3) Cephalo pelvic dispropotion
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20
Possible outcome of primary dysfunctional labour
• It leads to-obstructed labour
- infection
- uterine rupture
-PPH
• 70% of nullipara and 80% of multipara will respond to oxytocin
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21
Secondary arrest
• Cessation of cervical dilation following a normal period of active phase dilatation.
i.e after 7 cm of cervical dilation
• Affects 6% of nulliparae and 2 % of multiparae
• CPD is more likely to be associated with it
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22
Assessment in secondary arrest
• 1) fetal size-fundal height >40 cm in this stage is due to large baby
• 2)degree of engagement(fifth palpable)
• 3)position of the presenting part
• 4)signs of obstruction
• 5)any pelvic mass
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23
• 6)descent of presenting part with contraction
• 7)contraction frequency
• 8)fetal well being
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 24
station
• SO assess following before any intervention
1)EFW-fundal height > 40 cm at this stage is large baby
2)Degree of engagement
3)Position of the presenting part
4)Evidence of obstruction
5)Any pelvic mass
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 25
Engagement• entrance of the largest diameter of the
presenting part into the true pelvis.
• In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station.
• Once engaged, fetus does not go back up. Prior to engagement occurring, the fetus is said to be "floating" or ballottable.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 26
Position of the presenting part
• Determine by COUNTING SUTURE TECHNIQE
• Junction of 3 suture lines is posterior fontanel
• Junction of 4 suture lines-anterior fontanel
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 27
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 28
Occiput transverse positions
Occiput anterior positions
Fetal position
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 29
Degree of flexion/Attitude
• If only posterior fontanel is felt-it is well flexed fetal head. Here the cervix is regularly dilated
• If only anterior fontanel is felt-It is deflexed head(face /mento vertex presentation)
• If both fontanels are felt .-it is partially deflexed head. Here the cervix is also irregularly dilated
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 30
Types of attitude
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 31
Complete flexion-
• (a) normal attitude in cephalic presentation. "chin is on his chest." This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 32
Moderate flexion
• (b) - head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 33
DEGREE OF FLEXION
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 34
Poor flexion or marked extension
• . it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 35
Hyperextended• . In reference to the cephalic position, the
fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 36
Asynclitism
• One parietal bone presents at a higher plane than other ,with the head in the transeverse position as it enters the pelvis.
• Anterior asynclitism –physiological
• Posterior asynclitism is unfavourable and may indicate dispropotion
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 37
ASYNCLITISM
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 38
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 39
Management of poor progress in labour
• Decide whether it is safe to continue the labour
• If obstruction of labour / fetal distress-need operative delivery
• decide whether expectant policy is appropriate
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 40
Management of poor progress in labour
(1)One to one care
- it decreases the likelihood of medication for pain relief, instrumental delivery,C/S,
APGAR <7in 5 minutes
-encourage to adopt whatever the position comfortable-sitting, reclining,lateral semi recumbent position
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 41
(2) Maternal hydration and pain relief
-40 % of nulliparous will respond to normal saline infusion
-edidural or narcotics
(3) Mobilization
(4) Amniotomy –if not done earlier
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 42
• If delay in the established first stage of labour is suspected, amniotomy should be considered for all women with intact membranes.
• perform a vaginal examination 2 h .and if progress is less than 1 cm a diagnosis of delay is made.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 43
• When delay in the established first stage of labour is confirmed the use of oxytocin should be considered
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 44
5) Oxytocin for augmentation
-evaluate clinical situation i.e exclude obstructed labour and fetal distress .also consider maternal wishes in decision making.
-for poor progress due to inefficient/ in coordinate uterus contraction.
-60-80% of patients will respond to oxytocin by improving cervical dilation.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 45
• perform a vaginal examination 4 hours after commencing oxytocin in established labour. If there is less than 2 cm progress after 4 hours of oxytocin, further obstetric review is required to consider caesarean section. If there is 2 cm or more progress, vaginal examinations should be advised 4-hourly.
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 46
• Titrate every 30 minutes till 4 contraction for 10 min with each last 40 seconds.
• Moniter continuously –CTG
• If augmentation exceeds 8 hours duration it is unlikely to result in successful vaginal delivery
• 8% of muliparae and 22% of nulliparae -fail to respond to oxytocin
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 47
Ways to reduce the poor progress of labour
• Correct diagnosis of labour.(Pay attention on effacement of the cervix)
• Good midwifery care in labour room.
• Sustaining the morale of the woman and her partner
• Maintain hydration well
• Provide adequate analgesia
• maintain the partogram
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Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 48
THANK YOU