![Diagnosis Of Active Stage
The rule for dx of active stage
Active phase arrest of cervical dilation
Spontaneous labor:
Cervical dilation 6 cm in a patient with ruptured membranes and
≥
No change in the cervix for 4 hours despite adequate contractions (defined
≥
as >200 Montevideo units [MVU])
No change in the cervix for 6 hours with inadequate contractions
≥](https://image.slidesharecdn.com/presentationabnormallabor-250611133514-5f62bf98/85/Presentation-Abnormal-labor-power-point-31-320.jpg)
Presentation (Abnormal labor). power point
- 1. Seminar Presentation Presenters: Shaban Naim Gatwech Chuol Mediator: Dr.
- 2. Abnormal Labor Outline • Introduction • Definition of abnormal labor (dystocia) • Etiologies of abnormal labor • Classifications of abnormal labor patterns • Evaluation for causes of abnormal labor • Management options of abnormal labor patterns • Summary
- 3. Introduction
- 4. Comparison of Labor curves
- 5. Definition An abnormal labor is any labor in which the pattern of labor progress is significantly different from accepted and recognized patterns of labor progress in terms of; cervical changes, decent of fetal presenting part or profile of uterine contractions Dystocia (difficult labor) is often used interchangeably to denote an abnormal labor pattern
- 6. The significance of abnormal labor High prevalence of abnormal labor one of the leading indications for primary caesarean section Abnormal labor is an important cause of maternal and perinatal mortality and morbidity. obstructed labor, obstetric fistula, uterine rupture, hemorrhage, sepsis and maternal death, fetal distress, asphyxia, and death Its appropriate diagnosis and management is one target area to decrease primary cesarean section rate Good management of labor may prevent problems associated with prolonged labor
- 7. Etiologies of Abnormal Labor • The 3 P’s Abnormalities of the Powers Primary power – uterine contraction Secondary power – maternal expulsive efforts Abnormalities of the Passages Contraction of the bony pelvis –inlet, mid-pelvic , outlet Soft tissue dystocia – tumor previa, vaginal septa etc Abnormalities of the Passenger, the fetus Size, Presentation, Position, Anomaly……… The other P’s (psyche, pain, provider…)
- 8. A) Abnormalities of the power Dysfunctional uterine contraction is any deviation of normal patterns of uterine contraction that affect the course of labor. This entity refers to uterine activity that is not sufficient to dilate the cervix and expel the fetus. It is the most common cause of protraction and/or arrest disorders in the first stage of labor. It occurs in 3 to 8 percent of parturient and has been defined as uterine contraction pressures less than 200 Montevideo units. Can be hypotonic or hypertonic uterine contraction
- 9. Hypotonic uterine dysfunction Characterized by contraction of the uterus with insufficient force, irregular or infrequent rhythm, or both. May occur at the onset or during labor. The cervix dilates slowly or not at all. The contractions are of normal polarity. Mostly seen in primigravida in the active phase of labor. Can be primary or secondary uterine inertia
- 10. √ is either a series of single contractions lasting 2 min.or more or contraction frequency of five or more in 10 min. √ Basal tone is elevated appreciably or √ The pressure gradient is distorted √ Asynchrony of the impulses originating in each corn • Hypertonic uterine dysfunction
- 11. Hypotonic uterine dysfunction ● Primary uterine inertia – abnormal uterine contraction frequencies, duration and intensity that is due to inherent myometrial dysfunction • Mainly affects primigravid labors without other additional factors ● Secondary uterine inertia – causes • Prolonged labor • Malpresentations/malpositions • Epidural analgesia • Uterine myomata • Dehydration and electrolyte imbalances • Fetopelvic disproportion • Abruptio placentae with couvaliare uterus
- 12. Classifications of abnormal labor patterns Latent phase Disorders Prolonged latent phase Active phase disorders Active-Phase Protraction (in cx dilatation or fetal descent) Active-Phase Arrest (in cx dilatation or fetal descent) Second stage disorders Protracted descent Arrest of descent Precipitous labor and delivery Precipitated dilatation Precipitated descent
- 13. Classifications of abnormal labor patterns Four Major Groups: Prolongation Disorders Protraction Disorders Arrest Disorders Precipitate Labor
- 14. Classification the abnormal labor patterns
- 15. Prolonged latent phase of labor: A latent phase lasting more than 14 hours in a multigravida and 20 hours in a primigravida Cervical dilation <4 cm after 8 hours of true labor Diagnosis: made retrospectively Mistaking false labor for the latent phase leads to unnecessary induction and unnecessary caesarean section. Prolongation disorders
- 16. Con’t.. What are the Causes? Those are the major causes of the prolongation disorders. •Dysfunctional uterine contraction • Unripe cervix •Scarred cervix •CPD •Malpresentation & malposition •False labor
- 17. Protraction Disorders Two protraction disorders: Protracted active phase cervical dilatation A cervical dilatation <1.2cm/hr in the nulliparous and <1.5cm/hr in the multiparous during active labor Protracted Descent ▪︎Descent of the fetal presentation is <1cm/hr in the nulliparous and <2cm/hr in the multiparous approximately 30 percent of women with protraction disorders had cephalopelvic disproportion (CPD)
- 18. Arrest Disorders Two arrest disorders: Active phase arrest of cervical dilatation absence of cervical change for 2 hours or more in the presence of adequate uterine contractions and cervical dilation of at least 4 cm. Active phase arrest of descent: Absence of descent for 1 hour or more 45% of women with arrest disorders had cephalopelvic disproportion, Freidman
- 19. Labor abnormalities in SSOL Protracted descent Arrest of descent Prolonged second stage
- 20. Labor abnormalities..cont’d A) Protraction of Descent Is defined as descent of the presenting part during the second stage of labor that occurs at:- less than 1 cm/hr in nulliparous women and less than 2 cm/hr in multiparous women.
- 21. Labor abnormalities..cont'd B) Arrest of Descent I.e Failure descent It refers to no progress in descent. Both diagnoses require evaluation of five factors: •uterine activity, •maternal expulsive efforts, •fetal heart rate status, •fetal position, and •clinical pelvimetry Decisions then may be made regarding interventions(oxytocin, operative vaginal or cesarean delivery)
- 22. Prolonged Second stage of labor No universal definition ACOG: more than 2 hours without or 3 hours with epidural analgesia in nulliparous women, and More than 1 hour without or 2 hours with epidural in multiparous women 10% to 14% of nulliparous and 3% to 3.5% of multiparous women FMOH 2020 guideline More than 2 hours without or 3.5 hours with epidural analgesia in nulliparous women More than 1 hour without or 2.5 hours with epidural in multiparous women
- 23. Abnormal third stage of labor If placenta is not delivered by AMTSOL in 30 minutes/ 60 minutes by physiological maternal effect, retained placenta diagnosed. Risk: PPH Causes: Poor uterine contraction Closed cervix Early GA Scared uterus( c/s, abortion
- 24. Abnormal third stage of labor…cont’d Prevention and Management AMSOL is recommended for all Manual removal of the placenta High dose oxytocin Pathological adherence of the placenta: may need hysterectomy
- 25. Precipitated labor and delivery Precipitous labor and delivery is extremely rapid labor and delivery Precipitous labor terminates in expulsion of the fetus in less than 3 hours. Incidence: 3% in USA It may result from an abnormally low resistance of the soft parts of the birth canal, strong uterine and abdominal contractions, or rarely from the absence of painful sensations and thus a lack of awareness of vigorous labor Risks: Genital tract lacerations, uterine atony/PPH, AFE, adverse perinatal outcomes…
- 26. Precipitated labor and delivery… cont’d Precipitated cx dilatation: Active phase dilatation is >5cm/hr for NP Active phase dilatation is >10cm/hr for MP Precipitated descent: Active phase descent is >5cm/hr Active phase descent is >10cm/hr
- 27. Evaluation for causes of abnormal labor patterns Assessment of powers of labor • Palpation of uterine contractions • External tocodynamometer • Intrauterine pressure catheter monitoring • Maternal exhaustion, vital signs, blood glucose and evidence of dehydration Assessment of the passenger • Size, number, presentation, position and anomalies of the fetus by Leopold's palpations , Vaginal exam and ultrasonography Assessment of the passages • Bony pelvis – clinical pelvimetry • Soft tissue dystocia – vaginal exam Assessment of maternal emotional status and pain control
- 28. Management Options Power abnormalities • Uterine inertia – Augmentation • Secondary powers failure – operative vaginal delivery Passenger abnormalities • Often caesarean deliveries required • Destructive deliveries in cases of fetal deaths Abnormalities of the passages • Often Caesarean delivery • Episiotomy for perineal level obstruction
- 29. Labor Support Labor support is an essential component of labor management, especially protracted labor which leads to exhaustion, dehydration, starvation, psychological disturbances. Labor support improves contractions and accelerates progress. Emotional support and encouragement Encouraging walking, sitting and change position Giving abundant fluid either by mouth (or IV if indicated) Encouraging urination Managing labor pain as appropriate Encouraging the woman’s birth companion to give adequate support
- 31. Diagnosis Of Active Stage The rule for dx of active stage Active phase arrest of cervical dilation Spontaneous labor: Cervical dilation 6 cm in a patient with ruptured membranes and ≥ No change in the cervix for 4 hours despite adequate contractions (defined ≥ as >200 Montevideo units [MVU]) No change in the cervix for 6 hours with inadequate contractions ≥
- 32. Cont’d.. Active phase protracted cervical dilation; •The rate of active phase dilation was substantially slower than the standard rate derived from Friedman’s work, varying from:- 0.5 cm/h to 0.7 cm/h for nulliparous women and 0.5 cm/h to 1.3 cm/h for multiparous women Duration of second stage: allow a nullipara to push for at least 3 hours and a multipara to push for at least 2 hours as long as maternal and fetal status is reassuring
- 33. Summary The diagnosis of active phase protraction or labor arrest should not be made before 6 cm of dilation. Labor progresses more slowly than previously thought and that cervical dilatation accelerate as labor advances. Ineffective uterine contractions are the most common reason for slow progress of labor in a primigravida. A specific absolute maximum length of time spent in the second stage of labor beyond which all women should undergo operative delivery has not been identified.
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