DYSTOCIA DUE TO EXPULSIVE FORCES, FETOPELVIC DISPROPORTION AND MATERNAL FETAL ANOMALIES

DYSTOCIA - ABNORMAL LABOR difficult labor characterized by abnormally slow progress of labor Four distinct abnormalities Abnormalities of the expulsive forces Abnormalities of presentation, position, or development of the fetus. Abnormalities of the maternal bony pelvis Abnormalities of soft tissues of the reproductive tract Categories according to the American College of Obstetricians and Gynecologists Abnormalities of the powersuterine contractility and maternal expulsive effort. Abnormalities involving the passengerthe fetus. Abnormalities of the passagethe pelvis. Mechanisms of Dystocia At the end of pregnancy: Obstacles for the fetal head to traverse the birth canal: uterine contractions cervical resistance forward pressure exerted by the leading fetal head st Factors influencing the progress of the 1 stage of labor thicker lower uterine segment undilated cervix uterine muscle is less developed and presumably less powerful. nd After complete cervical dilatation (2 Stage): the mechanical relationship between the following is clearer: fetal head size and position } fetopelvic the pelvic capacity } proportion uterine musculature is much thicker and thus more powerful abnormalities in fetopelvic disproportions become more apparent Uterine muscle malfunction can result from uterine overdistention or obstructed labor Thus ineffective labor is a possible warning sign of fetopelvic disproportion Uterine dysfunction } labor abnormalities Pelvic disproportion } so closely interlinked

Diagrams of the birth canal (A) at the end of pregnancy and (B) during the second stage of labor, showing formation of the birth canal. (C.R. = contraction ring; o.i. = internal cervical os; o.e. = external cervical os.) (From Williams, 1903.) ABNORMALITIES OF THE EXPULSIVE FORCES ST 1 STAGE OF LABOR: Contractions of the uterus cervical dilatation, propulsion and expulsion of the fetus ND 2 STAGE OF LABOR: Contractions of the uterus or involuntary muscular action of abdominal wall --PUSHING Uterine dysfunction characterized by lack of progress of labor 2 Types of Uterine Dysfunction Hypotonic Uterine Dysfunction More common No basal hypertonus Uterine contractions have a normal gradient pattern (synchronous) Slight rise in pressure during a contraction is insufficient to dilate the cervix Treatment: Oxytocin Hypertonic/Incoordinate Uterine Dysfunction Basal tone is elevated Pressure gradient is distorted (asynchronism) Treatment: sedation

Reported Causes of Uterine Dysfunction Various labor factors have been implicated as causes of uterine dysfunction Epidural Analgesia epidural analgesia can slow labor epidural analgesia has been associated with lengthening of both first- and second-stage labor as well as slowing of the rate of fetal descent Chorioamnionitis infection itself plays a role in the development of abnormal uterine activity Maternal Position during Labor recumbency or ambulation during labor shorten labor decrease rates of oxytocin augmentation decrease the need for analgesia lower the frequency of operative vaginal delivery the uterus contracts more frequently but with less intensity with the mother in the supine position compared with that of lying on her side. contraction frequency and intensity have been reported to increase with sitting or standing Birthing Position in Second-Stage Labor Immersion in Water Three significant advances in the treatment of uterine dysfunction Realization that undue prolongation of labor may contribute to perinatal morbidity and mortality. Use of dilute intravenous infusion of oxytocin in the treatment of certain types of uterine dysfunction. More frequent use of cesarean delivery rather than difficult midforceps delivery when oxytocin fails or its use is inappropriate. ACTIVE-PHASE DISORDERS Classification Protraction Disorder (slower than normal) Arrest Disorder (complete cessation of progress) Criteria for Diagnosis of Abnormal Labor Due to Arrest or Protraction Disorders

SECOND-STAGE DISORDERS incorporates many of the cardinal movements necessary for the fetus to negotiate the birth canal disproportion of the fetus and pelvis frequently becomes apparent Duration of 2 Stage nulliparas - 2 hours extended to 3 hours with regional analgesia multiparas - 1 hour extended to 2 hours with regional analgesia Bearing down or pushing repetitive contraction of the abdominal musculature with vigor to generate increased intra-abdominal pressure throughout the uterine contractions propulsion of the fetus downward Factors that prevent spontaneous vaginal delivery compromised magnitude of the force created by contractions of abdominal musculature heavy sedation or regional analgesia (lumbar epidural or spinal) that reduces the reflex urge to push, and impair the ability to contract the abdominal muscles sufficiently inherent urge to push is overridden by the intense pain created by bearing down. FETOPELVIC DISPROPORTION arises from diminished pelvic capacity, excessive fetal size, or more usually, a combination of both. Contracted Pelvic Inlet shortest anteroposterior diameter is less than 10 cm or greatest transverse diameter is less than 12 cm or diagonal conjugate of less than 11.5 cm Prior to labor, the fetal biparietal diameter averages from 9.5 to as much as 9.8 cm. Cervical dilatation - facilitated by hydrostatic action of the unruptured membranes or, after their rupture, by direct application of the presenting part against the cervix Membrane rupture absence of pressure by the head against the cervix and lower uterine segment less effective contractions further dilatation proceeds very slowly or not at all A contracted inlet plays an important part in the production of abnormal presentations In normal nulliparas, the presenting part at term commonly descends into the pelvic cavity before the onset of labor. In contracted inlet, descent usually does not take place until after the onset of labor, if at all.
ND

In women with contracted pelves, face and shoulder presentations are encountered three times more frequently, and cord prolapse occurs four to six times more frequently. Contracted Midpelvis more common than inlet contraction causes transverse arrest of the fetal head interischial spinous diameter is < 8cm spines are prominent pelvic sidewalls converge narrow sacrosciatic notch Obstetrical plane of the midpelvis extends from the inferior margin of the symphysis pubis through the ischial spines and touches the sacrum near the junction of the fourth and fifth vertebrae A transverse line theoretically connecting the ischial spines divides the midpelvis into anterior and posterior portions. Anterior midpelvis - bounded anteriorly by the lower border of the symphysis pubis and laterally by the ischiopubic rami Posterior midpelvis - bounded dorsally by the sacrum and laterally by the sacrospinous ligaments forms the lower limits of the sacrosciatic notch. Average midpelvis measurements transverse or interspinous = 10.5 cm anteroposterior (from the lower border of the symphysis pubis to the junction of S4S5) = 11.5 cm posterior sagittal (from the midpoint of the interspinous line to the same point on the sacrum) = 5 cm Contracted Pelvic Outlet interischial tuberous diameter of 8 cm or less Pelvic outlet likened to 2 triangles: Anterior triangle base - interischial tuberous diameter sides - pubic rami apex - inferior posterior surface of the symphysis pubis Posterior triangle base - interischial tuberous diameter no bony sides apex - tip of the last sacral vertebra (not the tip of the coccyx).

Estimation of Pelvic Outlet X-Ray Pelvimetry Computed Tomographic scanning Magnetic Resonance A contracted outlet may cause dystocia through the often-associated midpelvic contraction INEFFECTIVE LABOR Common Clinical Findings in Women with Ineffective Labor Inadequate cervical dilatation or fetal descent Protracted laborslow progress Arrested laborno progress Inadequate expulsive effortineffective "pushing" Fetopelvic disproportion Excessive fetal size Inadequate pelvic capacity Malpresentation or position of fetus Ruptured membranes without labor Abnormal Labor Patterns, Diagnostic Criteria, and Methods of Treatment

Criteria for the diagnosis of arrest during first-stage labor (ACOG 1989) The latent phase has been completed, with the cervix dilated 4 cm or more. A uterine contraction pattern of 200 Montevideo units or more in a 10minute period has been present for 2 hours without cervical change. CASE: L.M., 26 years old, G1P0, was admitted at FEU-NRMF MC due to hypogastric pain radiating to the lumbosacral area AOG: 39-40 wks FH: 32 cm FHT: 140s bpm IE: cervix 2 cm dilated 1cm long, intact BOW, cephalic, station -1 Uterine contractions: 2-5 min, 50-60 sec, moderate intensity CASE: Labor record: 2 hours later, IE: 3 cm, 1cm long, intact BOW, station -1 Uterine contractions: 2-5 min, 50-60 sec, moderate; FHT: 140 4 hours later, IE: 4 cm, 0.5 cm long, intact BOW, station -1 Uterine contractions: 2-5 min, 50-60 sec, moderate; FHT: 140 Amniotomy was done and revealed clear amniotic fluid Oxytocin was started 6 hours later, IE: 6 cm, 0.5 cm long, station 0 2-3 mins strong contractions; FHT: 140 8 hours later, IE: 6 cm, 0.5 cm long, station 0 2-3 mins. Strong contractions, FHT: 130 10 hours later, IE: 6 cm, 0.5 cm long, station 0 2-3 mins. Strong contractions, FHT: 130 AP decided to do a Cesarean section Below is the patients labor curve

EFFECTS OF DYSTOCIA Maternal Effects Intrapartum Infection Uterine Rupture Pathological Retraction Ring Pathological retraction ring of Bandl, an exaggeration of the normal retraction ring often the result of obstructed labor marked stretching and thinning of the lower uterine segment may be seen clearly as a uterine indentation and signifies impending rupture of the lower uterine segment Fistula Formation vesicovaginal, vesicocervical, or rectovaginal fistulas develops from impaired circulation, necrosis becoming evident several days after delivery Pelvic Floor Injury Postpartum Lower Extremity Nerve Injury Footdrop - secondary to injury at the level of the lumbosacral root, lumbosacral plexus, sciatic nerve, or common peroneal nerve most common mechanism of injury, however, is external compression of the peroneal nerves usually caused by inappropriate leg positioning in stirrups especially during a prolonged second stage of labor symptoms resolve within 6 months of delivery in most women. Fetal Effects Caput Succedaneum Fetal Head Molding associated with: nulliparity oxytocin labor stimulation delivery with a vacuum extractor Skull fractures Ruptured Membranes Without Labor Management: stimulation of contractions when labor did not begin after 6 to 12 hours PRECIPITOUS LABOR AND DELIVERY Definition: expulsion of the fetus in less than 3 hours May result from: abnormally low resistance of the soft parts of the birth canal abnormally strong uterine and abdominal contractions, or rarely, absence of painful sensations and thus a lack of awareness of vigorous labor

Short labors rate of cervical dilatation 5 cm/hr for nulliparas 10 cm/hr for multiparas associated with: abruption (20 percent) meconium postpartum hemorrhage cocaine abuse low Apgar scores multiparity Maternal Effects uterine rupture extensive lacerations of the cervix, vagina, vulva, or perineum amnionic fluid embolism postpartum hemorrhage from uterine atony (hemorrhage from the placental implantation site ) Seldom are accompanied by serious maternal complications if: the cervix is effaced appreciably and compliant the vagina has been stretched previously the perineum is relaxed Fetal/Neonatal Effects Perinatal mortality and morbidity Inappropriate uterine blood flow and fetal oxygenation. Intracranial trauma(rare) Erb or Duchenne brachial palsy Injury from fall Treatment: any oxytocin agents being administered should be stopped

The occiput is the longer end of the head lever. The chin is directly posterior. Vaginal delivery is impossible unless the chin rotates anteriorly Diagnosis Vaginal examination palpation of the distinctive facial features of the mouth and nose, the malar bones, and particularly the orbital ridges Radiographic examination demonstration of the hyperextended head with the facial bones at or below the pelvic inlet Etiology Marked enlargement of the neck or coils of cord about the neck may cause extension Anencephalic fetuses Contracted pelvis Very large fetus Multiparous women Mechanism of Labor Face presentations rarely are observed above the pelvic inlet The brow generally presents, converted into a face presentation after further extension of the head during descent Mechanism of labor consists of the following cardinal movements: Descent - brought about by the same factors as in cephalic presentations internal rotation - the objective is to bring the chin under the symphysis pubis o results from the same factors as in vertex presentations flexion accessory movements of extension and external rotation - results from the relation of the fetal body to the deflected head

ABNORMAL PRESENTATION, POSITION AND DEVELOPMENT FACE PRESENTATION the head is hyperextended , occiput is in contact with the fetal back and the chin (mentum) is presenting fetal face may present with the chin (mentum) anteriorly or posteriorly, relative to the maternal symphysis pubis

Diagnosis Abdominal palpation - when both the occiput and chin can be palpated easily Vaginal examination palpation of the frontal sutures, large anterior fontanel, orbital ridges, eyes, and root of the nose Mechanism of Labor very small fetus and a large pelvis - labor is generally easy with a larger fetus - usually difficult, because engagement is impossible until there is marked molding that shortens the occipitomental diameter or, more commonly, until there is either flexion to an occiput presentation or extension to a face presentation TRANSVERSE LIE the long axis of the fetus is approximately perpendicular to that of the mother referred to as shoulder or acromnion presentation the shoulder is usually on the pelvic inlet, with the head lying on one iliac fossa and the breech in another Diagnosis Abdominal examination abdomen is unusually wide, whereas the uterine fundus extends to only slightly above the umbilicus. no fetal pole is detected in the fundus, ballottable head is found in one iliac fossa and the breech in the other back up (anterior) - a hard resistance plane extends across the front of the abdomen back down (posterior)- irregular nodulations representing the small parts are felt through the abdominal wall. Vaginal examination early stages of labor: the side of the thorax or the "gridiron" feel of the ribs Advanced labor: the scapula and clavicle are palpated Etiology Abdominal wall relaxation from high parity. Preterm fetus. Placenta previa. Abnormal uterine anatomy. Excessive amnionic fluid. Contracted pelvis.

Mechanism of labor for right mentoposterior position with subsequent rotation of the mentum anteriorly and delivery Management In the absence of a contracted pelvis, and with effective labor, successful vaginal delivery usually will follow Cesarean delivery Because face presentations among term-size fetuses are more common when there is some degree of pelvic inlet contraction, cesarean delivery frequently is indicated. BROW PRESENTATION Rarest presentation because it is unstable and often converts to a face or occiput presentation The portion of the fetal head between the orbital ridge and anterior fontanel presents at the pelvic inlet The fetal head thus occupies a position midway between full flexion (occiput) and extension (mentum or face) Only transient prognosis depends on the ultimate presenting part Causes and etiology are the same as of the face presentation Management is the same as those for a face presentation Brow Posterior Presentation

Mechanism of Labor Spontaneous delivery of a fully developed newborn is impossible with a persistent transverse lie rupture of the membranes the fetal shoulder is forced into the pelvis corresponding arm frequently prolapses shoulder is arrested by the margins of the pelvic inlet ( head in one iliac fossa and the breech in the other) impacted shoulder neglected transverse lie uterine rupture If the fetus is smallusually less than 800 gand the pelvis is large, spontaneous delivery is possible despite persistence of the abnormal lie Management In general, the onset of active labor in a woman with a transverse lie is an indication for cesarean delivery Because neither the feet nor the head of the fetus occupies the lower uterine segment, a low transverse incision into the uterus may lead to difficulty in extraction of a fetus entrapped in the body of the uterus above the level of incision. Therefore, a vertical incision is likely to be indicated OBLIQUE LIE called an unstable lie when the long axis forms an acute angle usually only transitory, because either a longitudinal or transverse lie commonly results when labor supervenes COMPOUND PRESENTATION an extremity prolapses alongside the presenting part, with both presenting in the pelvis simultaneously The left hand is lying in front of the vertex. With further labor, the hand and arm may retract from the birth canal and the head may then descend normally.

Palpation in transverse lie, right acromidorsoanterior position. A. First maneuver. B. Second maneuver. C. Third maneuver. D. Fourth maneuver.

Neglected shoulder presentation. A thick muscular band forming a pathological retraction ring has developed just above the thin lower uterine segment. The force generated during a uterine contraction is directed centripetally at and above the level of the pathological retraction ring. This serves to stretch further and possibly to rupture the thin lower segment below the retraction ring. (P.R.R. = pathological retraction ring.)

Causes conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm birth Prognosis and Management Perinatal loss is increased as a result of concomitant preterm delivery, prolapsed cord, and traumatic obstetrical procedures In most cases, the prolapsed part should be left alone, because most often it will not interfere with labor Prolapsed arm alongside the head close observation to ascertain whether the arm retracts out of the way with descent of the presenting part, if it fails to retract and if it appears to prevent descent of the head, the prolapsed arm should be pushed gently upward and the head simultaneously downward by fundal pressure vaginal delivery PERSISTENT OCCIPUT POSTERIOR POSITION Transverse narrowing of the midpelvis is undoubtedly a contributing factor Usually undergo spontaneous anterior rotation followed by uncomplicated delivery Delivery

The possibilities for vaginal delivery are: Spontaneous delivery Forceps delivery with the occiput directly posterior Manual rotation to the anterior position followed by spontaneous or forceps delivery Forceps rotation of the occiput to the anterior position and delivery PERSISTENT OCCIPUT TRANSVERSE POSITION Most likely a transitory one because the occiput tends toward the anterior position in the absence of a pelvic architecture abnormality Spontaneous anterior rotation usually is completed rapidly, thus allowing the choice of spontaneous delivery or delivery with outlet forceps. Delivery If rotation ceases because of poor expulsive forces and pelvic contractures are absent, vaginal delivery usually can be accomplished The occiput may be manually rotated anteriorly or posteriorly and forceps delivery performed from either the anterior or posterior position

Application of Kielland forceps to the fetal head to rotate the occiput to the anterior position, and then deliver the head either with the same forceps or with Simpson or TuckerMcLane forceps Oxytocin may be infused and closely monitored With the platypelloid (anteroposteriorly flattened) and the android (heart-shaped) pelves, there may not be adequate room for rotation of the occiput to either the anterior or the posterior position. SHOULDER DYSTOCIA neonates experiencing shoulder dystocia had significantly greater shoulder-to-head and chest-to-head disproportions compared with those of equally macrosomic newborns delivered without dystocia Most cases of shoulder dystocia cannot be accurately predicted or prevented. Elective induction of labor or elective cesarean delivery for all women suspected of carrying a macrosomic fetus is not appropriate. Planned cesarean delivery may be considered for the nondiabetic woman carrying a fetus with an estimated fetal weight exceeding 5000 g or the diabetic woman whose fetus is estimated to weigh more than 4500 g.

Occiput posterior presentation in early labor compared with presentation at delivery. Ultrasonography was used to determine position of the fetal head in early labor.

Maternal Consequences Postpartum hemorrhage - usually from uterine atony, vaginal and cervical lacerations Fetal Consequences Fetal morbidity and mortality Brachial Plexus Injury Clavicular fracture Humeral fracture Maternal Risk factors Obesity Multiparity Diabetes Mellitus Management Reduction in the interval of time from delivery of the head to delivery of the body is of great importance to survival An initial gentle attempt at traction, assisted by maternal expulsive efforts, is recommended Large episiotomy Adequate analgesia is ideal Techniques to free the anterior shoulder from its impacted position beneath the symphysis pubis: Moderate suprapubic pressure can be applied by an assistant while downward traction is applied to the fetal head. McRoberts maneuver consists of removing the legs from the stirrups and sharply flexing them up onto the abdomen caused straightening of the sacrum relative to the lumbar vertebrae, rotation of the symphysis pubis toward the maternal head, and a decrease in the angle of pelvic inclination pelvic rotation cephalad tends to free the impacted anterior shoulder reduced the forces needed to free the fetal shoulder. The McRoberts maneuver. The maneuver consists of removing the legs from the stirrups and sharply flexing the thighs up onto the abdomen, as shown by the horizontal arrow. The assistant is also providing suprapubic pressure simultaneously (vertical arrow).

Woods corkscrew maneuver The hand is placed behind the posterior shoulder of the fetus and progressively rotating the posterior shoulder 180 degrees in a corkscrew fashion so the impacted anterior shoulder could be released Delivery of the posterior shoulder consists of carefully sweeping the posterior arm of the fetus across the chest, followed by delivery of the arm. The shoulder girdle is then rotated into one of the oblique diameters of the pelvis with subsequent delivery of the anterior shoulder

Shoulder dystocia with impacted anterior shoulder of the fetus. A.The operator's hand is introduced into the vagina along the fetal posterior humerus, which is splinted as the arm is swept across the chest, keeping the arm flexed at the elbow. B. The fetal hand is grasped and the arm extended along the side of the face. C. The posterior arm is delivered from the vagina

Rubins maneuver the fetal shoulders are rocked from side to side by applying force to the maternal abdomen. the pelvic hand reaches the most easily accessible fetal shoulder, which is then pushed toward the anterior surface of the chest

The second Rubin maneuver. A. The shoulder-to-shoulder diameter is shown as the distance between the two small arrows. B. The more easily accessible fetal shoulder (the anterior is shown here) is pushed toward the anterior chest wall of the fetus. Most often, this results in abduction of both shoulders, reducing the shoulder-to-shoulder diameter and freeing the impacted anterior shoulder.

Deliberate fracture of the clavicle pressing the anterior clavicle against the ramus of the pubis to free the shoulder impaction Hibbard Maneuver pressure is applied to the fetal jaw and neck in the direction of the maternal rectum, with strong fundal pressure applied by an assistant as the anterior shoulder is freed Zavanelli maneuver cephalic replacement into the pelvis and then cesarean delivery. Cleidotomy cutting the clavicle with scissors or other sharp instruments usually used for a dead fetus Symphysiotomy Shoulder dystocia drill 1. Call for helpmobilize assistants, an anesthesiologist, and a pediatrician. Initially, a gentle attempt at traction is made. Drain the bladder if it is distended. 2. A generous episiotomy (mediolateral or episioproctotomy) may afford room posteriorly. 3. Suprapubic pressure is used initially by most practitioners because it has the advantage of simplicity. Only one assistant is needed to provide suprapubic pressure while normal downward traction is applied to the fetal head. 4. The McRoberts maneuver requires two assistants. Each assistant grasps a leg and sharply flexes the maternal thigh against the abdomen.

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