2. NORMAL LABOUR
• Defined as:
Presence of regular painful uterine contractions becoming
progressively stronger and more frequent accompanied by
effacement and progressive dilatation of the cervix and decent
of the presenting part.
• At its onset its usually accompanied by bloody mucoid
vaginal discharge called show.
• The process culminates in expulsion of the baby and other
products of conception.
4. 1. The 1st stage of labour
(a)the latent phase
This is the period from 0 – 3 cm
dilatation of the cervix.
Its duration can not be easily
determined but perhaps around 8
hrs.
5. (b) The active phase
This is the period from 3 – 10 cm (full dilatation)
dilation of the cervix.
In this stage the woman is said to be in established
labour.
The cervix dilates at the rate of about 1
cm/hour
It may be a little faster esp. in multiparous women or
little slower esp. in primigravida, giving an average
duration of labour of about 12 hrs.
6. 2. The 2nd stage of labour
•This is the stage from full dilatation of the
cervix to the delivery of the baby.
•It takes
•1 hour in primigravidas
•30 minutes in multigravidas
7. The 3rd stage of labour
This is the stage of labour after
delivery of the baby to the delivery
of the placenta and membranes.
•It usually takes 15 minutes
8. The 4th stage of labour
•This is the stage in the first 24 hours after
delivery
•This is the period where majority of
maternal deaths occurs
•It needs close monitoring of the mother in
the hospital esp. for PPH, Eclampsia etc..
9. PROLONGED LABOUR
•Labour is said prolonged when it has lasted
for over 12 hours since its establishment.
•However since it may not be possible to
know exactly when it started in a particular
women, failure to progress may be more
significant than the actual duration.
11. Passenger
infant size and fetal presentation,
e.g., in cephalic-occiput anterior or
occiput posterior vs. breech or
transverse)
12. passage
• Pelvis size and adequacy of the bony pelvis as
well as soft tissues
• Conditions associated with faulty passage or
passenger will usually lead to mechanical
obstruction due to disproportion btw foetus
and the maternal pelvis.
16. Power
•Faulty powers means that the
expulsive forces are ineffective to
overcome the normal resistance of
the birth canal.
17. OBSTRUCTED LABOUR
Failure of progressive descent of the
presenting part , despite adequate uterine
contractions.
•It implies mechanical obstruction
•Cervical dilatation is usually arrested or
occurs much slower.
23. ANTICIPATION OF OBSTRUCTION DURING
LABOR
Close surveillance of a woman in labor
will identify obstruction before it
advances to cause maternal and/or fetal
complications
24. The following parameters should raise
suspicion
• Failure of progressive descent of the presenting part and/ or
stagnation or slow dilatation of the cervix
• Cervix that is poorly applied to the fetal presenting part
• Incoordinate uterine action
• Early rupture of membranes
• Reduced pelvic diameters
• Diagonal conjugates of less than 11cm
• Flat sacral curve
• Prominent ischial spine
• Narrow subpubic angle or pubic arc.
25. NEGLECTED OBSTRUCTED LABUR
•When labour is obstructed the uterus continues
to contract long after.
•In neglected obstruction the duration of labour
will be prolonged
•First stage will have lasted for many hours above
the average of 12 hours and/or the second stage
will have lasted for over an hour
26. • Most of the complications we encounter in
obstructed labor are a result of neglects
• The obstruction is prolonged resulting in short and
long term complications.
• The major immediate causes of death in obstructed
labour are sepsis, and haemorrhage from uterine
rupture.
• Sepsis is more common in primigravida women,
and uterine rupture in parous women.
27. • in primigravida women, the uterus probably stops
contracting because of myometrial acidification. This
acidification results from local myometrial energy
depletion, anaerobic metabolism, and systemic ketosis.
• In parous women, perhaps the myometrium becomes
tolerant to the effects of acidification by an unknown
mechanism and does not stop contracting. Continued
contractions in the presence of myometrial energy
depletion and hypoxia are likely to lead to myometrial
oedema and necrosis contributing to uterine rupture.
29. Other features
• Maternal exhaustion
• Fever
• tachycardia
• Fetal distress and/or IUFD
• Formation of bandl’s ring or peanut shaped uterus
• Tonic inertia of the uterus
• Excessive Caput formation
• Excessive molding
• Vulvae oedema
32. MANAGEMENT OF OBSTRUCTED
LABOUR
(a)initial assessment of the patient
• Pallor, pulse, blood pressure, dehydration
• Fundal height, foetal lie, foetal presentation, foetal heart rate, state of
the uterus and bladder.
• Level of presenting part, cervical dilatation, caput formation and
moulding.
• Do pelvic assessment and note the measurements and the presence
of infected liquour.
• Access urine
• Blood group and Xmatch
33. (b) resuscitate the patient
• IV fluids at least 3L stat.
• Give dextrose saline for hypoglycemia initially then ringers lactate
(c) control infection
• Give broad spectrum IV antibiotics
• Stat dose of Ampicillin 1g and chloramphenicol 1g IV
(d) check if the foetus is alive and decide mode of delivery
(e) empty bladder with self retaining catheter
34. Principles of management
• Relieve the obstruction the earliest
• Pain relief
• Combat dehydration
• Prevent sepsis.
• Correct hypoglycemia
• Correct electrolyte imbalance.
35. MODE OF DELIVERY
(a) If the foetus is alive delivery should be accomplished by
caesarean section.
• Swab of the amniotic fluid should be taken for
bacteriological analysis
• If the head is deep in the pelvis it should be pushed up from
the vagina by an assistant after opening of the uterus.
(b) If the foetus is dead and the cervix is fully dilated a
destructive procedure may be fully undertaken. However if
the cervix is not fully dilated C/S should be done
36. Post delivery care
• Continue monitoring of temperature, pulse, Bp urine output and
color
• Monitor abdominal distension
• Continue antibiotics
• Continuous bladder drainage for at least 10days
• Check for perineal nerve damage and rehabilitate accordingly
• Bear in mind possibility of Secondary PPH
• Counseling for future pregnancies and deliveries
37. anticipation of obs labor during ANC
• Short stature particularly in primes <150cm
• Large fetuses >4.0 kg
• Obvious pelvic/spinal deformities
• Gynetresia.(at least one pelvic exam be done at ANC
• Uterine myomas in lower segment or Cervix
• Abnormal lie
• Severe degree of overlap at pelvic brim
38. PROLONGED LABOUR DUE TO FAULTY
POWERS
• The expulsive force during labour is comprised of:
• Uterine contractions
• Maternal efforts
• As reflex action coinciding with contractions
• As a deliberate effort by the mother to bear down
• When the normal expulsive forces are too weak to overcome
the normal resistance from the birth canal labour fail to
progress and becomes prolonged.
39. • Normal myometrial contraction and retraction leads
to stretching of the lower segment and thickening of
the upper segment.
• This coordination leads to fundal dominance and a
resultant downward force during the process of child
birth.
• Lack of coordination of the upper segment and lower
segment leads to lack of fundal dominance hence
abnormal uterine action.
40. Three types of abnormal uterine
action have been recognized.
1. Incoordinate action
2. Uterine hypotonia (primary/
secondary)
3. Hypertonic dysfunction
41. Incoordinate action
Diagnosis
• Infrequent irregular contractions
• Cervix fails to dilate or stagnates
• Severe colicky pain persisting even after the contraction have
passed
• High intrauterine pressure >24 mmHg (persistently) leading
to interference with placental circulation and causes foetal
hypoxia and distress
42. Uterine hypotonia
• Urine contractions are of insufficient force and
infrequent.
• There could be complete inertia
• Common causes include:
• Over sedation
• Overdistention of the uterus eg. In multiple pregnancy,
polyhaydromnious and big baby.
• Secondary inertia in primigravidae could be due to
obstructed labour.
43. Treatment
• In both incoordinate dysfunction and uterine
hypotonia, as long as obstruction is ruled out give:
• Dilute IV oxytocin e.g.:
• 5 IU in 500 mls. of normal saline (20,30,40,50,60 drops/min)
• Care must be taken with oxytocin in multiparous
women as the response of oxytocin might violent
enough to cause uterine rupture
44. Complications of prolonged labour without
obstruction
1. Sepsis – both maternal and foetal
2. Maternal exhaustion
3. Fetal hypoxia or distress
4. PPH – both primary and secondary
