Abnormal labour:

Labour becomes abnormal when there is poor progress (as evidenced by a

delay in cervical dilatation or descent of the presenting part) and/or the
fetus shows signs of compromise.
Risk factors for poor progress in labour:
• Small woman
• Big baby
• Dysfunctional uterine activity
• Malpresentation
• Malposition
• Early membrane rupture
• Soft-tissue/pelvic malformation
 Poor progress in labour:

Poor progress in the first stage of labour

Prolonged latent phase occurs when the latent phase is longer
than the arbitrary time limits discussed previously. It is more
common in primiparous women and probably results from a
delay in the chemical processes that occur within the cervix
which soften it and allow effacement. It is best managed away
from the labour suite with simple analgesics, mobilization and
reassurance.
 Primary dysfunctional labour
Poor progress in labour has been defined already as cervical dilatation of
less than 2 cm in 4 hours, usually associated with failure of descent and
rotation of the fetal head.
Progress in labour is dependent on three variables:
1. The powers, i.e. the efficiency of uterine contractions,
2. The passenger, i.e. the fetus (with particular respect to its size,
presentation and position),
3. The passages, i.e. the uterus, cervix and bony pelvis.
Abnormalities in one or more of these factors can slow the normal progress
of labour. Plotting the findings of serial vaginal examinations on the
partogram will help to highlight poor progress during the first stage of
labour.
 Dysfunctional uterine activity:

This is the most common cause of poor progress in labour. It is more common in
primigravidae and perhaps in older women and is characterized by weak and infrequent
contractions. The assessment of uterine contractions is most commonly carried out by
clinical examination and by using external uterine tocography. However, this can only
provide information about the frequency and perhaps duration of contractions.
Intrauterine pressure catheters are available and these do give a more accurate
measurement of the pressure being generated by the contractions, but they are rarely
necessary. A frequency of four to five contractions per 10 minutes is usually considered
ideal. Fewer contractions than this does not necessarily mean progress will be slow, but
more frequent examinations may be indicated to detect poor progress earlier. Women
should be offered hydration, good pain relief and emotional support. When poor
progress in labour is suspected it is usual to recommend repeat vaginal examination 2,
rather than 4, hours after the last.
• If delay is confirmed, the woman should be offered
artificial rupture of membranes (ARM) and, if there is still
poor progress in a further 2 hours, advice should be sought
from an obstetrician regarding the use of an oxytocin
infusion to augment the contractions. The infusion is
commenced at a slow rate initially, and increased carefully
every 30 minutes, according to a well-defined protocol.
Continuous EFM is necessary as excessively frequent and
augmented contractions may cause fetal compromise.
 Cephalopelvic disproportion
Cephalopelvic disproportion (CPD) implies anatomical disproportion between the fetal
head and maternal pelvis. It can be due to a large head, small pelvis or a combination
of the two. Women of small stature (_1.60 m) with a large baby in their first pregnancy
are likely candidates to develop this problem. The pelvis may be unusually small
because of previous fracture or metabolic bone disease. Rarely, a fetal anomaly will
contribute to CPD. Obstructive hydrocephalus may cause macrocephaly, and fetal
thyroid and neck tumours may cause extension at the fetal neck. Relative CPD is more
common and occurs with malposition of the fetal head. The occipito-posterior position
is associated with deflexion of the fetal head and presents a larger skull diameter to the
maternal pelvis.
 Cephalopelvic disproportion is
suspected in labour if

• • progress is slow or actually arrests despite efficient uterine contractions;

• • the fetal head is not engaged;
• • vaginal examination shows severe moulding and caput formation;
• • the head is poorly applied to the cervix.
• Oxytocin can be given carefully to a primigravida with mild to moderate
CPD as long aas the CTG is reactive. Relative disproportion may be
overcome if the malposition is corrected (i.e. conversion to a flexed OA
position). Oxytocin must never be used in a multiparous woman where CPD
is suspected.

•
 Malpresentations
• Vital to good progress in labour is the tight application of the fetal
presenting part on to the cervix. Face presentations may apply
themselves poorly to the cervix and the resulting progress in labour may
be poor, although vaginal birth
• is still possible. Brow presentations are associated with the mento-
vertical diameter, which is simply too large to fit through the bony
pelvis unless flexion occurs or hyperextension to a face presentation.
Brow presentation therefore often manifests as poor progress in first
stage, often in a multiparous woman. Shoulder presentations cannot
deliver vaginally and once again poor progress will occur.
Malpresentations are more common in women of high parity and some
carry a risk of uterine rupture if the labour is allowed to continue.
 Abnormalities of the birth canal (the ‘passages’):

• The bony pelvis may cause delay in the progress of labour as

discussed above (CPD). Abnormalities of the uterus and cervix can
also delay labour. Unsuspected fibroids in the lower uterine segment
can prevent descent of the fetal head. Delay can also be caused by
‘cervical dystocia’, a term used to describe a non-compliant cervix
which effaces but fails to dilate because of severe scarring, usually as
a result of a previous cone biopsy. Caesarean section may be
necessary. It is rare for the soft tissues of the pelvic floor to cause
significant delay in labour.
 Poor progress in the second stage of labour:

• Birth of the baby is expected to take place within 3 hours of the start of the active
second stage (pushing) in nulliparous women, and 2 hours in parous women. Delay is
diagnosed if delivery is not imminent after 2 hours of pushing in a nulliparous labour
(1 hour for a parous woman). The causes of second-stage delay can again be
classified as abnormalities of the powers, the passenger and the passages. Secondary
uterine inertia is a common cause of second stage delay, and may be exacerbated by
epidural analgesia. Having achieved full dilatation, the uterine contractions become
weak and ineffectual and this is sometimes associated with maternal dehydration and
ketosis. If no mechanical problem is anticipated, the treatment is with rehydration and
intravenous oxytocin, if the woman is primiparous. Delay can also occur because of a
persistent OP position of the fetal head. In this situation, the head will either have to
undergo a long rotation to OA or be delivered in the OP position, i.e. face to pubes.
• Delay in the second stage can also occur because of a narrow
mid-pelvis (android pelvis), which prevents internal rotation of
the fetal head. This may result in the arrest of the descent of the
fetal head at the level of the ischial spines in the transverse
position, a condition called deep transverse arrest
• Instrumental birth should be considered for prolonged second
stage. This may be safely performed in the labour room, or may
be more safely carried out in theatre with easy recourse to
Caesarean delivery if the attempt is unsuccessful.
 Patterns of abnormal progress in labour
•
:
The use of a partogram to plot the progress of labour improves the detection of poor
progress. Indeed, three patterns of abnormal labour are commonly described.
• Prolonged latent phase:
• It is more common in primiparous women.
• Results from a delay in the chemical processes that occur within the cervix which soften it
and allow effacement.
• Primary dysfunctional labour: is the term used to describe poor progress in the active
phase of labour (_2 cm cervical dilatation/4 hours). More common in primiparous women.
• Inefficient uterine contractions (most common).
• CPD and malposition of the fetus.
• Secondary arrest: occurs when progress in the active phase of fi rst stage is initially good
but then slows, or stops altogether, typically after 7 cm dilatation. Most common in
multiparous women.
• Malpositions, malpresentations and CPD (most common)
• Inefficient uterine contractions.