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ABNORMAL LABOR
AND
FETOPELVIC DISPROPORTION
Dystocia literally, difficult labor abnormally slow progress of labor m/c contemporary indication of primary c/sec
Abnormalities of the expulsive forces Uterine forces insufficiently strong or inappropriately coordinated to efface & dilate the cervix (uterine dysfunction) Inadequate voluntary muscle effort during the second stage of labor Abnormalities of presentation, position, or development of the fetus Abnormalities of the maternal bony pelvis Abnormalities of the reproductive tract that form an obstacle to fetal descent
Dystocia
Today, expression such as cephalopelvic disproportion and failure to progress are often used to describe these dysfunctional labor when cesarean delivery is necessary Cephalopelvic disproportion (CPD)
Disparity between the dimensions of the fetal head and maternal pelvis to preclude vaginal delivery True CPD is rare and most CPD are due to malposition of the fetal head : asynclitism or extension of the bony diameters of the fetal head Inability to achieve vaginal delivery after reaching complete dilatation is a significant marker of true dystocia because it is likely to recur
Dystocia
Failure to progress
This term include lack of progressive cervical dilatation or lack of descent The CPD and failure to progress are not precise terms and we should use more Practical terms, such as protraction or arrest The woman must be in the active phase of labor to diagnose either of these disorders Active phase arrest in 5 % of term nulliparas, this incidence has not changed since the 1950s ( Freidman 1978, Handa and Laros 1993) Inadequate uterine contractions ( < 180 Montevideo units ) were diagnosed in 80 % of women with active-phase arrest
Overdiagnosis of dystocia
CPD (cephalopelvic disproportion) Most disproportions are due to malposition of fetal head, or to ineffective uterine contracture Factors leading to increased use of c/sec for dystocia Incorrect diagnosis of dystocia Epidural analgesia Fear of litigation Obstetrician convenience
Variability in the criteria for diagnosis major determinant Almost 25% of the c/sec performed annually in the USA for the lack of progress were in women with cervical dilatation of only 0 to 3 cm
Labor Diagnosis
The strict definition of labor - uterine contractions that bring about demonstrable effacement and dilatation of the cervix Recognizing its start to instruct the woman to quantify contractions for some specified period define labor onset as the clock time when painful contractions become regular : very subjective to define the onset of labor to begin at the time of admission to the labor unit Admission criteria ( by National Maternity Hospital in Dublin ) painful uterine contractions accompanied by any one of the following ; ruptured membranes bloody show complete cervical effacement : in US, 3-4 cm or greater
Normal labor
Preparatory division latent & acceleration phases sensitive to sedation & conduction analgesia little cervical dilatation occurs, but considerable changes take place in the ground substance of cervix (collagen & other connective tissue component) Dilatational division phase of maximum slope of cervical dilatation most rapid rate of dilatation occur unaffected by sedation or conduction analgesia Pelvic division deceleration phase & second stage cardinal fetal movements in the cephalic presentation take place principally during this phase
Normal labor
Pattern of Cervical Dilatation ; 2 phases of cervical dilatation Latent phase subject to sensitive changes by extraneous factors (sedation prolongation, myometrial stimulation shortening) Active phase Acceleration phase usually predictive of the outcome of a particular labor Phase of maximum slope good measure of the overall efficiency of the machine Deceleration phase more reflective fetopelvic relationship 2nd stage of labor commences after complete cervical dilatation only progressive descent of fetal presenting part is available to assess the progress of labor
Latent Phase
commences with maternal perception of regular contractions accompanied by progressive & slow cervical dilatation and ends at between 3 and 5 cm of dilatation Prolonged latent phase > 20 hr in the nullipara and > 14 hr in the parous woman Factors that affect duration of the latent phase excessive sedation or conduction analgesia poor cervical condition false labor Management : rest and strong sedatives -> 85 % begin active labor -> 10 % cease contractions -> 5 % recur an abnormal latent phase -> oxytocin stimulation Amniotomy was discouraged during this phase Fetal and Maternal Effect of prolongation : not influence morbidity and mortality
Active Labor
A rapid change in the slope of cervical dilatation between 3 & 4 cm the mean duration of active phase labor in nulliparas was 4.9 hours the rate of dilatation 1.2 cm/hr is the minimum normal rate in the nullipara 1.5 cm/hr is the minimum normal rate in the multipara active labor phase abnormalities m/c abnormalities of labor incidence : in nullipara, 25% vs in multipara, 15% classification : protraction, arrest (Friedman 1972) associated factors of active labor phase abnormalities . excessive sedation or conduction analgesia . fetal malposition (e.g., persistent occiput posterior)
The majority of active phase disorders did not result in cesarean delivery -only about 2 % of the 500 women studies (Friedman 1955)
> 20 hr
>14hr
1.Prolonged deceleration phase 2. Secondary arrest of dilatation 3. Arrest of descent 4. Failure of descent
begin when cervical dilatation is complete and ends with fetal expulsion median duration : in nulliparas - 50 min, in multiparas - 20 min average second stage labor was lengthened about 25 minutes by regional analgesia limit of the length of the second stage in nulliparas : 2 hrs & extended to 3 hrs when regional analgesia in multiparas : 1 hr & extended to 2 hrs with regional analgesia The relationship between the duration of second stage labor and pregnancy outcome maternal effects : postpartum hemorrhage & infection increased but incidence is quite small infant effects They concluded that there is no compelling reason to intervene with a possibly difficult forceps or vacuum extraction but after 3 hours in the second stage, delivery by cesarean or other operative method increased
Inadequate labor
Uterine dysfunction
Fetopelvic disproportion
Uterine Dysfunction
Characterized by lack of progress In the latent phase, the diagnosis is difficult One of the most common errors is to treat women for uterine dysfunction who are not yet in active labor There have been three significant advances in the treatment of uterine dysfunction:
improvement of perinatal morbidity and mortality dilute intravenous infusion of oxytocin more frequent use of cesarean delivery rather than difficult midforceps delivery
Uterine Dysfunction
The lower limit of contraction pressure required to dilate the cervix is 15 mmHg (Caldeyro-Barcia, 1950) Normal spontaneous contractions often exert pressures of about 60 mmHg (Hendricks,1959) Two types of uterine dysfunctions
There is no basal hypertonus Uterine contractions have a normal gradient pattern (synchronous) The slight rise in pressure during a contraction is insufficient to dilate the cervix.
Basal tone is elevated appreciably the pressure gradient is distorted perhaps by contraction of the midsegment of the uterus with more force than the fundus by complete asynchronism of the impulses originating in each cornu a combination of these two
Fetopelvic disproportion
This arises from either diminished pelvic size, excessive fetal size, or more usually, a combination of both. Pelvic capacity Any contraction of the pelvic diameters that diminishes the capacity of the pelvis can create dystocia Contractions of the pelvic inlet, the midpelvis, the pelvic outlet and combinations of these.
Fetopelvic disproportion
Contracted Pelvic Inlet Definition AP diameter < 10 cm or transverse diameter < 12 cm Diagonal conjugate < 11.5 cm Both AP diameter (< 10cm) and transverse diameter (< 12cm) are contracted -> dystocia is much greater Cervical dilatation is facilitated by hydrostatic action of the unruptured membranes or, after their rupture, by direct application of the presenting part against the cervix. In contracted pelvis, however, when the head is arrested in the pelvic inlet, the entire force exerted by the uterus acts directly upon the portion of membranes that overlie the dilating cervix. Consequently, early spontaneous rupture of the membranes is more likely to result. Fetal presentation and position face and shoulder presentation ( x3) & cord prolapse ( x4-6)
Fetopelvic disproportion
Average midpelvis measurements Transverse (interspinous) 10.5cm Anteroposterior (from the lower border of the symphysis pubis to the junction of the fourth and fifth sacral vertebrae) 11.5cm Posterior sagittal (from the midpoint of the interspinous line to the same point on the sacrum) 5cm Contracted Midpelvis Definition The interischial spinous diameter + posterior sagittal diameter < 13.5 cm The interischial spinous diameter < 8 cm
Suggestive findings The ischial spines are prominent The pelvic side walls converge The sacrosciatic notch is narrow
Fetopelvic disproportion
Contracted Pelvic Outlet Definition The interischial tuberous diameter < 8 cm Outlet contraction without concomitant midplane contraction is rare.
Prognosis Diminution in the intertuberous diameter with consequent narrowing of the anterior triangle must inevitably force the fetal head posteriorly. Depend on the size of the posterior triangle on the interischial tuberous diameter& posterior sagittal diameter of outlet Production of perineal tears
Fetopelvic disproportion
Trauma from automobile collisions: most common cause of pelvic fractures Bilateral fractures of the pubic rami :compromise of birth canal capacity by callus formation or malunion Careful review of previous of previous x-ray and possibly computed tomographic pelvimetry later in pregnancy, unless c/sec is performed for another reason. Rare pelvic contraction : dwarfs, poliomyelitis, kyphoscoliosis
Clinical estimation Narrow pelvic arch (<90 degrees) : narrow pelvis Unengaged fetal head -> excessive fetal head size or reduced pelvic inlet capacity X-ray pelvimetry 5 factors that determines successful vaginal deliveries. size and shape of the bony pelvis size of fetal head force of uterine contractions moldability of the fetal head presentation and position of the fetus Indications for X-ray pelvimetry for trial of vaginal delivery in case of breech presentation and previous injury or disease likely to affect bony pelvis
Computed tomographic scanning Advantages Reduction in radiation exposure Greater accuracy Easier to perform Comparable cost Magnetic resonance imaging Advantages Lack of ionizing radiation Accurate pelvic measurements Complete fetal imaging Providing the potential for evaluating reasons for soft tissue dystocia
Thus, fetopelvic disproportion usually is not associated with excessive fetal size.
Clinical estimation - Muller method In an occiput presentation, the brow and the suboccipital region are grasped through the abdominal wall with the fingers and firm pressure is directed downward in the axis of the inlet. Fundal pressure by an assistant usually is helpful. The effect of the forces on the descent of the head can be evaluated by concomitant vaginal examination. No disproportion -> the head readily enters the pelvis, and vaginal delivery can be predicted. Inability to push the head into the pelvis does net necessarily indicate that vaginal delivery is impossible. Flexed fetal head that overrides the symphysis pubis -> presumptive evidence of disproportion No relation between dystocia and failure of descent of the head
The cesarean delivery rate was almost tripled in women undergoing labor induction ( Duff 1984 ) In contrast, there was no advantage to delaying intervention because of neonatal infections ( Wagner 1989 ) Prostaglandin E2 to reduce the admission-to-delivery interval in non-laboring women after membrane rupture at term (Chua 1995, Mahood and Dick 1995) Labor induction with intravenous oxytocin was the preferred management (Hannah 1996)
Active-phase disorders : neither failure to progress nor cephalopelvic disproportion are precise terms (ACOG, 1995) A more practical classification is to divide labor abnormal into either slower-than-normal (protraction disorder) or complete cessation of progress (arrest disorder). The woman must be the active phase of labor (cervix dilated 3 to 4 cm or more) to diagnose either these. Active-phase arrest( no dilatation for 2 hours or more) in 5 percent of term nulliparas. Inadequate uterine contractions, defined as less than 180 Montevideo units were diagnosed in 80 percent of women with active-phase arrest. A labor management in which protraction is defined as less than 1cm/hr cervical dilatation for a minimum of 4 hours. (WHO,1994)
To effectively induce or augment labor with oxytocin, 90 percent of women achieve 200 to 225 Montevideo units, and 40 percent achieve at least 300 Montevideo units. Before the diagnosis of arrest during first stage labor is made, both of these criteria should be met :
The latent phase has been completed, with the cervix dilated 4cm or more.
A uterine contraction pattern of 200 Montevideo units or more in a 10-minute period has been present for 2 hours without cervical change
2-hour rule on the grounds that a longer time, i.e., at least 4 hours, is necessary before concluding that the active phase of laber has failed.
Thus, lack of engagement at the onset of labor, although a statistical risk factor for dystocia, should not be assumed to necessarily predict fetopelvic disproportion
Second-stage disorder
With achievement of full cervical dilatation, the great majority of women cannot resist the urge to bear down or push each time the uterus contract Coaching women to push forcefully, compared with letting them follow their own urge to bear down, has been reported to offer no advantage (Parnell , 1993)
Maternal effects
Intrapartum infection Uterine rupture Pathological retraction ring Fistula formation due to pressure necrosis Pelvic floor injury
During active labor, uterus differentiates into 2 distinct parts Upper segment actively contracting , becomes thicker as labor advances quite firm or hard on abdominal palpation1 Lower segment relatively passive develops into a much thinly walled passage for the fetus much less firm on abdominal palpation Physiologic retraction ring : As labor progresses -> thinning of the lower uterine segment and the concomitant thickening of upper segment -> the boundary between the two is marked by a ridge on inner uterine surface Pathologic retraction ring (the ring of Bandle) In obstructed labor -> lower uterine segments extreme thinning -> the ring is very prominent
Prolonged membrane rupture & intrauterine infection Caput succedaneum The caput may reach almost to the pelvic floor while the head is not engaged. Fetal head molding Tentorial tears, laceration of fetal blood vessels and fetal intracranial hemorrhage
Labor is diagnosed : painful uterine contractions + complete cervical dilatation, bloody show, or ruptured membranes Pelvic examination : Performed each hour for the next 3 hours -> at 2 hour intervals When dilatation has not increased by at least 1 cm ->amniotomy Progress is again assessed at 2 hours, If not significant progress (i.e., 1 cm/hr) -> high-dose oxytocin infusion
Cesarean rates in nulliparous and parous women were 8.7 and 1.5 %, respectively These labor interventions and the relatively infrequent use of cesarean delivery did not jeopardize the fetus-newborn infant
Amniotomy
2 hours
3 hours
Oxytocin
Delivery
Definition Expulsion of the fetus in less than 3 hours Causes An abnormally low resistance of the soft parts of the birth canal Abnormally strong uterine and abdominal contractions The absence of painful sensations
Maternal effects
Uterine rupture Extensive lacerations of the cervix, vagina, vulva, or perineum Amnionic fluid embolism Postpartum hemorrhage from uterine atony
Increased perinatal mortality and morbidity Intracranial trauma Erb-Duchenne palsy The infant may fall to the floor and be injured. Resuscitation is not immediately available.
Treatment
The use of tocolytic agents such as magnesium sulfate is unproven in these circumstances. Use of general anesthesia with agents that impair uterine contractibility is often excessively heroic. Certainly, any oxytocin agents being administered should be stopped immediately.