Dystocia: August Gay C. Militante

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DYSTOCIA

August Gay C. Militante


Outline
I. Overview of Dystocia
II. Abnormal Labor
III. Partogram
IV. Abnormalities of Expulsive Forces (Power)
V. Abnormalities of the Birth Canal (Passageway)
VI. Abnormalities of the Fetus (Passenger)
DYSTOCIA: OVERVIEW
Difficult labor
Abnormally slow progress of labor
Incidence varies from 6-13% of pregnancies
Most common indication for primary Caesarean
section (43%)
Causes of Dystocia
1. Abnormalities of the expulsive forces.-Uterine
2. Abnormalities of presentation, position, or
development of the fetus.
3. Abnormalities of the maternal bony pelvis—that
is, pelvic contraction.
4. Abnormalities of soft tissues of the
reproductive tract that form an obstacle to fetal
descent
Forces Concerned in Normal Labor

1. Power - pushing the uterine contents downwards


Uterine contractions
Intra-abdominal pressure
2. Passenger (Fetus)
3. Passage (Birth Canal)
Bony structure
Soft tissues
4. Psyche
Common Clinical Findings in Women w/ Ineffective Labor
Inadequate Cervical Dilatation & Fetal Descent
- Protracted Labor or Slow Progress
- Arrested Labor or No Progress
- Inadequate Expulsive Effort or Ineffective
Pushing
Fetopelvic Dosproportion
- Excessive Fetal Size
- Inadequate Pelvic Capacity
 Malpresentation or Malposition of Fetus

Ruptured Membranes without Labor


Phases of Cervical Dilatation
Friedman’s Curve
Abnormal Labor Patterns
A. Prolonged Latent Phase
>20hrs for nulliparas (or primigravidas)
>14hrs for multiparas
Causes of Prolonged Latent Phase of Labor
1. Excessive sedation/early conduction of
anesthesia
2. Unfavorable cervix - cervix still thick &
uneffaced
3. False labor - most common cause
4. Uterine dysfunction
B. Protraction Disorders
1. Protracted Active Phase
Nulligravida: <1.2cm/hr
Multipara: <1.5 cm/hr
2. Protracted Descent
Nulligravida: <1cm/hr
Multipara: <2cm/hr
C. Arrest Disorders
1. Prolonged Deceleration
Primigravida: >3hrs
Multipara: >1hr
2. Secondary Arrest of Dilatation
>2 hrs
3. Arrest of Descent
>1hr
4. Failure of Descent
>1hr during deceleration phase of labor
Mechanism of Dystocia
ABNORMALITIES IN EXPULSIVE FORCES
(Power)
UTERINE DYSFUNCTION
inadequate uterine contractions
inadequate expulsive effort (push)
2 Types:
1. Hypotonic uterine dysfunction
- no basal hypertonus, uterine contractions have normal
gradient pattern
-pressure is insufficient to dilate the cervix
2. Hypertonic or incoordinated uterine dysfunction
- basal tone is elevated or pressure gradient is distorted
Causes of Uterine Dysfunction
Epidural anesthesia
Chorioamnionitis
Maternal Position during labor
Multiparity - hypotonic
Overdistention of uterus
- Polyhydramnios
- multiple pregnancy
- macrosomic baby
Tumors
- Fundal tumors (this may prevent the fundus from contracting; LUS contracts)
- may cause both types but more on hypotonic contractions
Cephalopelvic disproportion
- hypertonic
Complications of Uterine Dysfunction
Fetal and neonatal death
- injuries with prolonged labor
Intrauterine infection
- maybe from repeated IE
Maternal exhaustion
 Psychological effect on mother which may affect
future child-bearing
Management of Uterine Dysfunction
Hypertonic Dysfunction
Therapeutic rest by giving sedative
Rule out CPD - CPD is usually associated with
hypertonic
CS if with CPD or fetal distress
Hypotonic Dysfunction
Oxytocin
CS if oxytocin is contraindicated
Contraindication to Use of Oxytocin
Great multiparity
- Greater than gravida 5
Overdistended uterus - thinning uterus prone to
rupture
Previous uterine scar - Previous CS, previous
myomectomy
Abnormal fetal presentation
Any degree of fetopelvic disproportion
ABNORMALITIES OF THE BIRTH CANAL
(Passageway)
Fetopelvic disproportion
- diminished pelvic capacity
- excessive fetal size
BONY PELVIS
Pelvic Inlet
Midpelvis
Pelvic outlet
Inlet Contraction
Shortest AP diameter is <10 cm
Greatest transverse diameter is <12 cm
 Diagonal conjugate is <11.5 cm
 Diagnosis by Xray Pelvimetry can be done
Early spontaneous rupture of membrane more likely
Plays a role in production of abnormal presentation
Midpelvic Contraction
More common
Sum of the interischial spinous and posterior sagittal
diameters is 13.5 cm or below (normally 10.5 + 5= 15.5)
Interischial spinous diameter is less than 8 cm
Spines are prominent, pelvic sidewalls converge,
sacrosciatic nothch narrow
Contracted Outlet
Interischial tuberous diameter 8cms or less
Outllet contraction without concomittant midplane
contraction is rare
Perineal tears – risk of laceration
Pelvic Contraction (Clinical
measurement)
Easily reached sacral Short diagonal Inlet
promontory conjugate (thus, short
obstetrical conjugate)
Prominent Ischial spines Shorter diameter than Midpelvis
flattened ischial spines
Convergent sidewalls Must be parallel to a Midpelvis & outlet
certain extent to allow
passage of fetus
Straight sacrum Shorter AP diameter than Midpelvis
curved sacrum
Intertuberous dm less At least 8cm for NSVD Outlet
than 8cm
Narrow sub-pubic arch Must have a wide angle Outlet
Pelvimetry
Level Parameter Suspect contraction if
Inlet Diagonal conjugate < 11.5 cm

Bispinous diameter < 10 cm


Spines Prominent
Midplane
Sidewalls Convergent
Sacral inclination Anterior
Sacrosciatic notch Narrow

Outlet Bituberous diameter ≤ 8 cm


ABNORMALITIES OF THE FETUS
(Passenger)
Fetal size
Malposition (asynclytism, cciput posterior, face and
brow)
Shoulder dystocia
Shoulder Dystocia
-Most cases cannot be predicted
Techniques of delivery:
1. McRoberts maneuver
- flex legs
- Hyperflex the legs towards abdomen to enhance opening of pelvis
2. Suprapubic pressure
3. Woods corkscrew maneuver :
- rotate posterior shoulder
- turn baby like a corkscrew
4. Zavanelli maneuver
- technically difficult
- replace head into pelvis and do CS
5. Cleidotomy - cutting the clavicle
6. Symphysiotomy
Shoulder Dystocia
A Ask for help
L Lift/hyperflex both legs
A Anterior shoulder disimpaction
R Rotation and delivery of the posterior shoulder
M Manual removal of posterior arm
E Episiotomy
R Roll on all fours
Complications of Prolonged Labor
Maternal Complications
Maternal infection
Maternal exhaustion
Postpartum hemorrhage – from atony
Uterine rupture
- pathologic retraction ring of Bandl
Fistula formation
Pelvic floor injury – may lead to urinary incontinence,
pelvic organ prolapse
Postpartum lower extremity nerve injury
Fetal Complications
- nerve injury
- fractures
- cephalhematoma
Guidelines in the Management of
Abnormal Labor
Diagnosis of arrest disorder warrants CS
 Arrest disorders can be diagnosed only when the
cervix is 6cm or more and uterine contractions are at
least 200 MU
 Amniotomy should be done
 Oxytocin may be used
 Xray Pelvimmetry is NOT indicated
o H V.F. G1P0 Pregnancy Uterine 38 4/7 wks AOG,
x y cephalic in labor, Oligohydramnios
y o
Intraop findings:
t s
- LUS well-formed
o c R
-amniotic fluid clear and scanty
c i B X X -baby delivered full term
i n O
- baby boy
n e W
- birth weight 3900 g
X
- AS of 9,10
- CAOG of 37 weeks

* * *X -Caput 1x1 cm
- Placenta located anterofundally

X
X
* * - Both ovaries and fallopian tubes
grossly normal

1 2 3 4 5 6 7 8 9 10

G1P1 (1001) Pregnancy Uterine Delivered to a Live Term Baby Boy with BW 3900g AS 9, 10 CAOG 37 weeks in
cephalic presentation via Primary Low Segment Cesarean Section for failure of descent (midplane contraction)
under RA SAB
A.U. G1P0 Pregnancy Uterine 37 2/7 weeks Age of
Gestation Cephalic in Labor
o a h h
x m y y Intraop findings:
y n o o - LUS well-formed
t i s s -amniotic fluid clear and adequate
o o c c -baby delivered full term
c t i i -baby boy
i o n n -Occiput posterior position
n m e e - birth weight 4200g
y - AS of 9,10
* * ** * ** X X X X X X - CAOG of 39 weeks
-placenta located anterofundally
X
-Both ovaries and fallopian tubes normal
X
X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

G1P1 (1001) Pregnancy Uterine Delivered to a Live Term Baby Boy in Cephalic Presentation with BW 4200 g, AS
9,10,CAOG 39 weeks via Primary Low Transverse Segment CesareanSection under Spinal Anesthesia for Arrest of
Cervical Dilatation,
Recommendations
The diagnosis of any arrest disorders warrants CS
Before an arrest disorder can be diagnosed in the first
stage of labor, the latent phase should be completed,
with the cervix at least 4 cm dilated and the uterine
contraction pattern exceeds 200 Montevideo units for
2 hours without cervical change
It is more reasonable to wait until cervical dilatation
ceases after reaching 5-6 cm dilation before an arrest
disorder is diagnosed
Amniotomy should be done if rupture of membrane
has not occurred
Oxytocin should be used to achieve adequate
contraction before operative delivery is considered
X-ray pelvimetry alone as a predictor of dystocia has
not been shown to have benefit and therefore is not
recommended
The end

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