Dysfunctional labor

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Failure to progress
Dysfunctional labor
Prof.Aboubakr Elnashar
Benha University Hospital, Egypt Email
elnashar53_at_hotmail.com
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Stages of labor Stage I Latent phase
Active phase . Acceleration
. Maximum slope
. Deceleration Stage II Phase 1
Phase 2 Stage
III Stage IV
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Cervical dilatation (cm)
Friedman labor curve in nulliparous
2nd stage
1st stage
dec
max slope
acceleration
Active phase
Latent phase
Time (hours)
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Labor duration (Friedman,1978)
Variable Nulliparas
(h) Multiparas(h) Latent
phase mean
6.4 4.8
upper limit 20.1
13.6 Active phase
mean 4.6
2.4
dilatation rate(cm/h) 1.2
1.5 Second stage mean
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0.5 upper
limit 2.9
1.1
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Dysfunctional labor Definition Any deviation in
normal progress of labor , either in cervical
dilatation or in descent of the presenting part
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Etiology 1. Malfunction in the myogenic,
neurogenic, or hormonal mechanisms of uterine
activity. 2. Malpresentation, fetal anomalies,
uterine malformation, pelvic tumors,
overdistension of the uterus, CPD 3. Extrinsic
factors sedation, anxiety, anesthesia, supine
position, unripe cervix, chorioamnionitis
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• Classification
• Freidman (1989)
• 1. Prolonged latent phase
• 2. Protraction disorders1.Protracted active
  phase
• 2.
  Protracted descent
• 3. Arrest disorders1.2ndry arrest of cervical
  dilatation
• 2. Prolonged
  deceleration phase
• 3. Arrest of
  descent
• 4. Failure of
  descent

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• ACOG (1995)
• 1. Protraction disorders Slower than normal
• 2. Arrest disorders Complete cessation of progress

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• Fields
• 1.Hypotonic dysfunction
• a.Prolonged latent phase
• b.Prolonged active phase
• c. Prolonged deceleration phase
• d. Prolonged 2nd stage
• 2.Hypertonic dysfunction

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• Shifirin Cohen(1998)
• 1.Disorders of dilatation
• a. Prolonged latent phase
• b. Protracted active phase
• c. Secondary arrest
• 2.Disorders of descent
• a. Failure of descent
• b. Protracted descent
• c. Arrest of descent.

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• Philpott (1979)
• 1. Prolonged latent phase
• 2. Primary dysfunctional labor
• 3. 2ndry arrest of labor.

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Early diagnosis 1. Partogram In active
phase Alert line drawn from cervical dilatation
on admission ,at a rate of 1 cm /h Action line
drawn 2 h to the right of alert line
(Philpott,1972). 2. Nomogram (Studd,1973) labor
stencil a series of curves from patient
admission cervical dilatation to 10 cm.
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• Prevention
• O,Driscol method of active management of labor
  (1969)
• Diagnosis of labor
• 1 h ARM
• 2hcervical dilatation lt1 cm /h
• oxytocin drip

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Prolonged latent phase Define Freidman gt 20 h in
PG, gt 14 h in MG from onset of labor (difficult
to determine) Philpottgt 6h in PG , gt 4h in MG
from admission in labor. Incidence PG 4
MG 1
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Etiology 1. Wrong diagnosis of labor
2.Excess sedation 3. An abnormal or high
presenting part 4. PROM
5.Idiopathic. Risks are
created by aggressive intervention. If membranes
are intact, no risk , only maternal anxiety.
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Treatment True labor or not PV, CTG, palpation
of the cervix reexamine after 4h 1.C stop or
no cx changes not in labor 2. C persist no
cervical changes sedation. 3. C. persist cx
changes ARM Syntocinon drip. A. In 85 labor
will progress rapidly . B.In 15
adequate C will not cause cx dilatation. If
after 4-8 h of syntocinon, the cervix is not
further dilated, CS.
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Primary dysfunctional labor Define Cx. Dil. lt
1cm/h before normal active phase has been
established Incidence PG 20
MG 8 Etiology 1. Inefficient
C. the commonest 2. CPD 1/ 3 3. Malpresentation
or malposition
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Risks 1. F. distress 2. Maternal fear anxiety
, dehydration acidosis 3. Incordinate u.
activity. Treatment Exclude CPD, ARM oxytocin
drip. 15 vag. Delivery 35 instrumental
delivery 50 CS for F. distress.
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2ndry arrest of labor Define Active phase started
normally( cervical dilatation reached 5-7 cm )
then cervical dilatation stop or slows
significantly within 2 h Incidence PG 6
MG 2 Etiology 1.CPD50
2. Malposition
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Risks F. distress rare Treatment Exclude CPD
, ARM Syntocinon drip No progress after 4 h
CS (15 ). O, Driscol advised oxytocin
regardless of pelvimetry.
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Cervical dilatation (cm)
Types of dysfunctional
Time (hours)
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Prolonged deceleration phase Define Arrest or
slow of cervical dilatation after 8 cm (PG gt 3h
, MG gt 1h) Etiology 1. CPD
2. Uterine exhaustion Risks 1. High
incidence of shoulder dystocia 2.
Forceps is difficult Treatment Syntocinon is not
helpful. C.S.
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Elnashar et al (2000) compared oxytocin infusion
alone with propranolol in the management of DL
(Primary DL 2ndry arrest). The study group (50
women) was given propranolol I.V. in a dose of 2
mg to be repeated after one hour if there was no
response in cervical dilatation. The control
group (50 women) the study group received
oxytocin infusion for at least 4 hours for
maximum of 6 hours if there was no response,CS
was done.    
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There were a significant differences in the drug-
delivery interval (2.2 vs 3.7 hours) CS rate
(20 vs 38 ) between the study the control
groups. Between the two groups, no statistically
significant differences were observed in low
Apgar scores or incidence of admissions to the
NICU. Conclusion Propranolol combined with
oxytocin infusion in management of DL safely
shortened the drug-delivery interval reduced CS
rate.    
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• Active management of labor
• Dr Aboubakr Elnashar
• First introduced by O, Driscol et al (1969) in
  Dublin.
• Many modifications

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Protocol 1.This approach to management is
confined to nulliparas. 2. Patient education
during pregnancy signs symptoms of
labor 3.Strict criteria for diagnosis of labor
painful uterine contractions as well as complete
effacement of the cervix, ruptured membranes or
passage of blood stained mucous The diagnosis of
labor is made within 1 hr of presentation.
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4.Each woman in labor is assigned to trained
professional companion. 5.Amniotomy within 1 hr
of admission. 6.Strict criteria for diagnosis of
abnormal labor progress. partogram or labor
graph. 7.Oxytocin high dose infusion if progress
of labor is lt 1 cm/h over 2 h. Oxytocin infusion
is begun at 6mu/min increased by 6 mu/min every
15 min until 7 C/15min. or 40 mu/min.
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8.Assess FHR by auscultation intermittently
Continuous electronic fetal heart rate monitoring
is used only if there is me conium stained
amniotic fluid 9.All methods of pain relief are
freely available. 10. C.S if no delivery12 hr
post admission or if fetal scalp ph sampling
revealed fetal compromise.
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Benefits 1.Prevention of dysfunctional
labor 2.Decrease the incidence of prolonged labor
from 30 to 7 (Boylan,1997) 3.Decrease
incidence of operative delivery. 4. Decrease
maternal infectious mrbidity 5.Decrease incidence
of C.S to 4.8 (Lopez-Zeno,1992). Some found no
decrease in CS rate (Fraser et al,1993) others
found an increase in CS rate (Boylan et al,1993).
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• Amniotomy for shortening spontaneous labour
• Fraser et al, The Cochrane Library, 2, 2001.
• Routine early amniotomy is associated with both
  benefits and risks.
• Benefits include a reduction in labor duration(
  between 60 and 120 minutes) and a possible
  reduction in abnormal 5-minute Apgar scores.

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• No support for the hypothesis that routine early
  amniotomy reduces the risk of CS. Indeed there is
  a trend toward an increase in CS. An association
  between early amniotomy and CS for fetal distress
  is noted in one large trial.
• This suggests that amniotomy should be reserved
  for women with abnormal labor progress.

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Thank you
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt Email
elnashar53_at_hotmail.com