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SUBJECT OBSTETRICS

2010 PLMCM
Topic DYSTOCIA
Lecturer DR. THE
Date June 16, 2008
Trans grp bam.joel.toni.hannah

DYSTOCIA__________________________________ Multipara – average 20 min (1 to 2
o
hours)
 Difficult labor  Stage 3 - Fetal delivery to the expulsion of
 Abnormal slow progress of labor placenta
 Common whenever there is disproportion
between the presenting part of the fetus and Three Functional Division of Labor_______________
the birth canal
 Preparatory division – the connective tissue
ABNORMALITIES that may lead to components of the cervix change
DYSTOCIA_______ considerably (sedation and conduction of
analgesia
1. Abnormalities of the POWERS – uterine contractility  Dilatational division – dilatation proceeds at
and maternal expulsive effort. its most rapid rate, unaffected by sedation or
2. Abnormalities involving the PASSENGER – the conduction of analgesia.
fetus.  Pelvic division – deceleration phase or
3. Abnormalities of the PASSAGE – the pelvis. cervical dilatation. Where the cardinal fetal
movements of the cephalic presentation
Clinical Findings in Women with Ineffective (engangement, flexion, descent, internal
Labor___ rotation, extension, and external
rotation) takes place.
 Inadequate cervival dilatation or fetal descent
o Protracted labor – slow progress Two phases of Cervical Dilatation________________
o Arrested labor – no progress
o Inadequate expulsive effort –  LATENT PHASE
ineffective pushing • mother perceives regular contractions
 Fetopelvic disproportion • ends between 3 and 5 cm of
o Excessive fetal size dilatation (3 to 4 accdg to Dr. The)
o Inadequate pelvic capacity • prolonged latent phase – greater than
o Malpresentation or position of fetus 20 hours in nullipara and 14 hours in
 Ruptured membranes without labor multipara
 ACTIVE PHASE
Normal Labor________________________________ • Acceleration phase – determines the
ultimate outcome of labor
 Uterine contraction that bring about • Phase of Maximum slope – good
demonstrable effacement and dilatation
measure of overall efficacy of the
of the cervix
uterus
 Onset of labor as beginning at the time of
• Deceleration phase – 8 to 10 cm,
admission to the labor unit
reflects pelvic relation
 Painful uterine contractions accompanied by
any one of the following: (1) ruptured THE DILATATIONAL AND DESCENT
membranes, (2) bloody “show”, (3) CURVES________
complete cervical effacement

Stages of Labor______________________________

 Stage 1 – regular uterine contraction to full
cervical dilatation (10 cm)
 Stage 2 – Full cervical dilatation to fetal
delivery
o Nullipara – average 50 min (2 to 3
hours)

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OBSTETRICS: DYSTOCIA – Dr. The
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o Caphalhematoma (beneath
10 -3 periosteum)

Abnormal Labor______________________________

• Protraction
o Slow rate of cervical dilatation or
descent 30% w/ protraction disorders
have cephalo-pelvic disproportion
• Arrest Disorders
o Does not descend after 2 hours

0 +3
Criteria for Diagnosis of Abnormal Labor Due to
Arrest or Protraction Disorders

(characteristic sigmoid & hyperbolic curve) Labor Pattern Nullipara Multipara
Protraction disorder
 Average rate of descent of fetal head • Dilatation < 1.2 cm/hr < 1.5 cm/hr
o Nullipara – 1 cm/hr; begins about 7 to • Descent < 1.0 cm/hr < 2.0 cm/hr
8 cm Arrest disorder
o Multipara – 2 cm/hr
• No > 2 hr > 2 hr
dilatation > 1 hr > 1 hr
• No descent

WHO partograph
• Failure in Descent
• Latent o Precipitate Labor – delivery in <3
hours
- Modified: 4 cm dilatation  active labor;
2 sets of observation: 1st set – relate to
the progress of cervical dilatation, 2nd set
– fetus
• Alert line (health facility line)
Nullipara Multipara
- Alert line drawn from 3 cm dilatation
Prolonged latent > 20 hours > 14 hours
represents the rate of dilatation of 1
phase
cm/hr
Protracted <1.2 cm/hr <1.5 cm/hr
- Moving to the right means referral to
active phase
hospital
Prolonged > 3 hours > 1 hour
• Action line
deceleration
- Labour crosses the active line, 4 hours to
Secondary > 2 hours > 2 hours
the right of the alert line and parallel to it
arrest of
- This is the critical line at which specific
dilatation
management decisions must be made at
Arrest of > 1 hour > 1 hour
the hospital
descent
- Active intervention – Oxytocin
Failure of - -
augmentation
descent
- Artificaial rupture of membrane after 6 (decelerates)
hours (4 cm)  oxytocin  observe Precipitated > 5 cm/hr > 10 cm/hr
active phase
Maternal Effects of (max. slope)
Dystocia________________________ Precipitate > 5 cm/hr > 10 cm/hr
descent
• Intrapartum infection
• Pathological ring of Bandl
• Uterine rupture Abnormalities of the Expulsive Forces
• Fistula formation (POWER)_____
• Pelvic floor injury
• Fetal effects • Contraction of the uterus  Cervical
o Caput Succedaneum dilatation & propulsion and expulsion of the
o Molding fetus (reinforced during the second stage by
OBSTETRICS: DYSTOCIA – Dr. The
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voluntary or involuntary muscular action of
the abdominal wall. Abnormalities in Passenger_____________________
(Abnormal fetal presentation)
1. Uterine Contraction
 Fundus – increase force ASYNCLITISM – deflection of sagittal suture
 LL of contraction – 15 mmHg to dilate anteriorly or posteriorly
cervix a) Anterior Asynclitism – Naegel’s obliquity
 Normal spontaneous contraction – 60 b) Posterior Asynclitism – Litzman Obliquity
mmHg
 Clinical Labor starts when uterine A. Face Presentation
activity = 80 to 120 MVU • Head is hyperextended
• Occiput is in contact with the fetal back
 Montevideo Units (MVU) – increase
uterine pressure above baseline (not • Chin or mentum is the presenting part
less than <180 MVU) • Submentobregmatic diameter is 9.5 cm
 Montevideo units (MVUs) refer to the • Mentum anterior – can be delivered vaginally
strength of contractions in mm of • Problem: mentum posterior because the brow
mercury multiplied by the frequency is compressed against the maternal
per 10 minutes as measured by symphysis pubis preventing the flexion of the
intrauterine pressure transducer. head
o The uterine contraction • Incidence: 1:600 or 0.17%
pattern must repeat every 2-3 • Diagnosis:
minutes. - Vaginal Exam – fetal mouth, malar
o The uterine contractile force bones, orbital ridges
produced must exceed 200 - X-ray – hyperextended hands
MVUs/10 min for active labor • Etiology
to be considered adequate. - marked enlargement of the head or
For example, 3 contractions coils of cords
in 10 minutes that each reach - contracted pelvis
a peak of 60 mm Hg are 60 X - anencephalic features
3 = 180 MVUs. - very large uterus
o An arrest disorder cannot be - pendulous abdomen
diagnosed until the patient is - high parity
in the active phase and the
contraction pattern exceeds • Mechanism of labor: engagement 
200 MVUs for 2 hours with no descent  internal rotation  flexion 
cervical change. accessory movement of extension and
external rotation  expulsion
• Management
- no contracted pelvis + effective labor
Two types of Uterine Dysfunction = vaginal delivery
- CS delivery is frequently indicated
1. Hypotonic uterus except for mentum anterior which
o No basal hypertonus may be delivered vaginally
o Uterine contractions have a normal
gradient pattern (synchronous) B. Brow Presentation
o Slight rise in pressure during • Fetal head occupies a position midway
contraction is insufficient to dilate between full flexion and extension
cervix • Rarest presentation; unstable
o Management: Augment labor w/ • Portion of the head is between the orbital
Oxytocin ridge and anterior fontanel present at the
pelvic inlet
2. Hypertonic uterus • Verticomental diameter = 13.5 cm
o Incoordinate uterine dysfunction • Fully dilated cervical diameter = 10.5 cm
o Basal tone is elevated appreciably • Engagement of the head and the subsequent
o The pressure gradient is distorted delivery cannot take place
o Gradient distortion may result from
• Diagnosis:
contraction of the mid-segment of the
- abdominal examination – both the chin
uterus with more force than the
and occiput can be palpated on
fundus or from complete
engagement
asynchronism of the impulse
- vaginal exam – frontal sutures, large
originating in each cornu (or a
anterior fontanel, orbital ridges, eyes
combination of these two)
OBSTETRICS: DYSTOCIA – Dr. The
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• Etiology • Spontaneous rotation
o marked enlargement of the head or • Occiput rotate to the symphysis pubis
coils of cords through 1350 instead of 900 to 400
o contracted pelvis • Generous episiotomy is usually indicated (cut
o anencephalic features until the perineal body)
o very large fetus
o pendulous abdomen F. Shoulder Dystocia
o high parity
• Mechanism of labor: engagement is possible, • Incidence occur due to bigger babies (babies
but caput is over the forehead
of diabetic mothers: high glucose  stimulate
C. Transverse Lie  increased fetal insulin secretion 
• Long axis of the fetus is approximately increased glycogen stores  increased size
perpendicular to that of the mother • Maternal - Fetal consequence
• Shoulder over the pelvic inlet o Postpartum hemorrhage
o Transient brachial plexus palsies
• Back may be directed anteriorly or posteriorly
o Clavicular fractures (most common)
(dorsoanterior or dorsoposterior)
o Humeral fractures
• Incidence: 0.3%
• Risk factors
• Etiology:
o Obesity
o Unusual relaxation of the abdominal
o Multiparity
wall
o Preterm fetus has bigger head o Diabetes
o Placenta previa
ACOG (1997-2000)_________________________________
o Abdominal uterus
o Polyhydramnios
1. Most cases of SD cannot be predicted or
o Contracted pelvis prevented because there are no accurate
• Diagnosis: methods to identify which fetus will develop
o Abdomen usually wide this complication
o No fetal pole detected at the fundus 2. UTZ measurement to eliminate macrosomia
o Ballotable head found in iliac fossa have limited accuracy
• Course of labor 3. Planned CS delivery based on suspected
o Spontaneous delivery of fully macrosomia is not reasonable
developed infant is impossible 4. Planned CS delivery may be reasonable for
o Neglected transverse lie nondiabetic patients with EFW>5kg or
o CONDUPLICATO CORPORE – fetus diabetic with fetus EFX>4.5 kg
doubles upon itself (the dead fetus
assumes an almost folded posture) Management:
• Management:
Initial attempt of traction assisted by
o With onset of labor, CS is indicated
maternal expulsive effort is recommended and large
o External version (only after weeks episiotomy and large anesthesia.
AOG) – doctor inserts hand into the
uterus, pulls one foot, the other Maneuver:
follows and delivers the baby)
• Moderate suprapubic pressure
• Mc Roberts
• Wood Corkscrew
D. Compound Presentation • Delivery of the posterior shoulder
• Rubin
• An extremity prolapses alongside the • Hibbard
presenting part • Zavanelli
• Incidence: 1:700-1,000 deliveries • Deliberate fracture of the clavicle
• Etiology • Cleidotomy
o preterm at birth • Symphysiotomy
• If persistent, CS is indicated
• Macrosomia – increased abdominal Shoulder Dystocia Drill
circumference
1. Call for help
E. Persistent Occiput Posterior 2. Generous episiotomy
3. Suprapubic pressure
OBSTETRICS: DYSTOCIA – Dr. The
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4. McRoberts maneuver Fetal HT – 140 bpm
5. Delivery of the posterior arm
6. Other techniques Prenatal Care
5x with regular intake of vitamins and iron
Abnormality in Passages_______________________
Family History
A. Contracted Pelvic Inlet
Mother – Diabetes
• Obstetric Conjugate Paternal Grandfather – HPN
o Shortest AP diameter <10 cm or diagonal
conjugate <11.5cm Course in the Wards
• True/Anatomic Conjugate
o Distance from upper symphysis pubis to Time Dilatation Effacement C. Station
sacral promontory (hour) (cm) (%)
o Diagonal conjugate + 2 cm On 2 80 -2 (+ BOW)
• Obstetric Conjugate admission
o Distance from the midpoint of pubis to 2 AD 3 80 -2
sacral promontory 4 AD 4 80 -2
o Shortest diameter 6 5 80 -2
o AP diameter ≤ 10 cm 8 6 80 -2
o Diagonal conjugate – 1.5 to 2 cm 10 7 100 (FE) -1
11 8 100 (FE) -1
B. Contracted Midpelvis 13 8 100 (FE) -1
14 9 100 (FE) 0
• If < 10 cm, contracted pelvis average of 15 9 100 (FE) 0
10 cm 16 9 0
• Shortest diameter (midplane)
• Bispinous/Interspinous diameter , 8 cm
• Interspinous diameter + posterior sagittal
1. Compute for the AGE OF GESTATION, Estimate fetal
diameter ≤ 13.5 cm
weight
• Normal 2. Plot curve
o Average transverse 3. What abnormal labor patterns is/are described on
interspinous diameter = 0.5 this case? What are the possible causes?
cm 4. Probable outcome?
o AP diameter = 11.5 cm
o Posterior sagittal = 5 cm
o Interspinous + posterior Classmates  if ever po may corrections paki sabi na
sagittal = 15.5 cm lang po lalu na sa case para masabi po sa class.
• Suggest
Thank you very much! God bless 
o Spines are prominent
o Pelvic walls are converged
o Sacral sciatic notch is narrow

C. Contracted Pelvic Outlet (Intertuberous
Diameter)

•Interischial tuberous diameter , 8 cm
•Outlet contraction without concomitant
contraction is rare
o Spines are palpable
o Pelvic walls are converged
o Sacral sciatic notch is narrow
- END -
OBSTETRICS CASE

18 years old, G1P0, admitted for labor pain
LMP – Sept. 21, 2007
EDC – June 28, 2008

Vital Signs – Normal
Fundic Height – 35 cm
OBSTETRICS: DYSTOCIA – Dr. The
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