Abnormal labor: Protraction and arrest disorders

NORMAL LABOR
Labor refers to uterine contractions resulting in progressive dilation and effacement of the cervix, and accompanied by descent and expulsion of the fetus Friedman divided labor into three stages: First stage: time from the onset of labor until complete cervical dilatation Second stage: time from complete cervical dilatation to expulsion of the fetus Third stage: time from expulsion of the fetus to expulsion of the placenta

 About 20 percent of labors involve either protraction or arrest disorders A labor abnormality is the most common indication for primary cesarean birth

NORMAL LABOR
Labor refers to uterine contractions resulting in progressive dilation and effacement of the cervix, and accompanied by descent and expulsion of the fetus Friedman divided labor into three stages: First stage: time from the onset of labor until complete cervical dilatation Second stage: time from complete cervical dilatation to expulsion of the fetus Third stage: time from expulsion of the fetus to expulsion of the placenta

Prolonged latent phase

Definition : prolonged latent phase is defined as 20 hours for the nullipara and 14 hours for the multiparous woman ( def a) when latent phase lasts longer than 12hrs for nullipara and 6hrs for parous women (def b)
Latent phase longer than 8 hours (WHO definition)

Factor contributing
Prematurely admistered sedation and analgesia Poor cervical condition Myometrial dysfunction false labor

significance
Increased risk of subsequent labor abnormality Increased cesarean delivery rate Low APGAR score Increased perineal laceration febrile morbidity& intrapartum blood loss

Treatment
Adequate rest with therapeutic sedation /narcosis morphine /pethidine Augmentation with oxytocin less preferred option

Active phase abnormalities

25% of nulliparas &15% of multiparous womens develop active phase abnormalities. This makes it the commonest labor abnomality

Protraction disorders
Protracted active phase dilatation:defined as less than 1.2cm/hr & 1.5cm/hr of cervical dilatation for nullipara & multipara respectively <1cm/hr of cervical dilatation for a minimum of 4 hrs (WHO defn) Protracted descent: defined as < 1cm/hr of descent of fetal head for nullipara &<2cm/hr for multipara.

Arrest disorders
Arrest of cervical dilatation :no change in cervical dalitation for >2hrs period for both nulliparas &multiparas Arrest of descent : no demonstrable descent of the head for more than 1hr for both nulliparas & multiparous

Labor pattern

Diagnostic criteria for abnormal patterns in active labor

Nullipara Multipara 12.5 hours 14.9 hours <1.5 cm/h >2 h 61 minutes 131 minutes >2 h >1 h

First stage
Duration (no anesthesia) 16.6 hours Duration (anesthesia) Protracted dilation Arrested dilation 19.0 hours <1.2 cm/h >2 h

Second stage
Duration (no anesthesia) 132 minutes Duration (anesthesia) Arrest of descent (epidural) Arrest of descent (no epidural) 185 minutes >3 h >2 h

causes
CPD Inadequate uterine contraction Malpresentation & malposition

Management
Before making dx active phase abnormalities make sure that women is in active phase. Evaluate for CPD. 30% of protraction & 50% arrest disorders associated with CPD. If the cause is CPD do C/S Reevaluate for malposition & malpresentation &mange depending on types of malposition & malpresentation

Mx cont
Evaluate uterine function 1. If hypotonic dysfunction - <180 mv unit A. Amniotomy if the head is fixed &membrane is intact & observe for 3060minute B.if no improvement after Amniotomy initiate oxytocin augumentation

Mx cont.
2. Uncoordinated uterine action:-dx by internal monitoring Responds favorably for oxytocin augumentation In the absence of CPD

Poor progression in the second stage

Arrest of descent: no descent for > 2hr for primi & multi Protracted descent:< 1cm/hr in nullipara & <2cm/hr in multi NB the duration of second stage has no relationship to perinatal out come if fetal distress & traumatic deliveries are excluded

Mx
Depends on cause CPD :-C/s Inadequate uterine contraction:- oxytocin Malposition manage accordingly Inadequate maternal voluntary effort managed with appropriate encouragement & instruction.

references
Up To Date 19.1 version WHO guide line Addis Ababa university management protocol for labor & deliveries Williams text book of obstetrics