DYSTOCIA DUE TO ABNORMALITIES TO  Dystocia is the most common contemporary indication for

POWERS primary cesarian section.

 The recommendations of the American College of

Obstetricians and Gynecologists that the cervix be dilated
Uterine Dysfunction to 4 cm or more before a diagnosis is made. The diagnosis of
dystocia is often made before the active phase of labor and thus,
Hypotonic Uterine Dysfunction
before an adequate trial of labor. Cesarian sections done for
Hypertonic Uterine Dysfunction dystocia in the latent phase of labor are inappropriate.

Complications and Management  Factors which have been implicated in the increased use of
cesarian delivery for dystocia include incorrect diagnosis of
Active Management of Labor dystocia, epidural analgesia, fear of litigation, and even
clinical convenience. Insufficient oxytocin stimulation of
Abnormal Labor Patterns
labor is also another factor implicated.
Prolonged Latent Phase

Protraction Disorders
UTERINE DYSFUNCTION
Arrest Disorders
 Failure of the cervix to dilate or the presenting part to
Precipitate Labor and Delivery descend is cause for concern. Uterine dysfunction in any
phase of cervical dilatation is characterized by lack of
Inadequate Voluntary Expulsive Force progress.

 The management of uterine dysfunction has changed from

DYSTOCIA
 or difficult labor is characterized by abnormally slow
progress of labor
 The four abnormalities that may exist singly or in
combination and result in dystocia are:
1. Abnormalities of the expulsive forces
a. Uterine dysfunction- uterine forces insufficiently
strong or not appropriately coordinated to efface and dilate
the cervix
b. Inadequate voluntary muscle effort during the
second stage of the fetus
2. Abnormalities of presentation, position or
development of the fetus
3. Abnormalities of the maternal bony pelvis- pelvic
contraction
4. Abnormalities of the birth canal other than those of
the bony pelvis that form an obstacle to fetal descent
the attitude of watchful waiting to a more aggressive
approach brought about by the 1) realization that undue
prolongation of labor may contribute to perinatal morbidity and
mortality, 2) use of dilute solutions of intravenous oxytocin in
certain types of uterine dysfunction, and 3) more frequent use of
cesarian delivery rather than difficult midforceps delivery when
oxytocin fails or is inappropriate.
 Uterine contractions of normal labor are characterized by a
gradient of myometrial activity; being greatest and lasting
longest at the fundus (fundal dominance) and diminishing
towards the cervix.
 In addition to a gradient of activity, there was a time
differential in the onset of the contractions in the fundus,
midzone and lower uterine segments when small balloons
were inserted into the myometrium at various levels and
attached to strain-gauge transducers.
 The stimulus starts in one cornu and then several
milliseconds later in the other, the excitation waves then
joining and sweeping over the fundus and down the uterus.
 The lower limit of contraction pressure required to dilate the
cervix is 15 mmHg. The normal spontaneous contractions often
exert pressures of about 60 mmHg.

 Pelvic contraction is often accompanied by uterine TYPES OF UTERINE DYFUNCTION

dysfunction and the two constitute the most common
cause of dystocia.
 Abnormalities in presentation, position and development
may also be accompanied by uterine dysfunction.
 As a general rule: uterine dysfunction is common whenever
there is disproportion between the presenting part of the
fetus and the birth canal
1. Hypotonic Uterine Dysfunction- is characterized by
absence of basal hypertonus, presence of a normal gradient
pattern with fundal dominance, but the slight rise in
pressure during a contraction is insufficient to dilate the
cervix at a satisfactory rate.
 Contractions become less frequent and the uterus is
easily indentable at the height of a contraction.
  It usually occurs in the active phase of labor after the
cervix has dilated to more than 4 cm. This type of
dysfunction often responds favourably to treatment with
oxytocin.
2. Hypertonic Uterine Dysfunction- or incoordinate
uterine dysfunction is characterized by basal hypertonus
with distorted pressure gradient because of absence of
fundal dominance or by complete asynchronism of the
impulses originating in each cornu, or a combination of
these two.
 The contractions are painful but ineffective.
 The use of oxytocin in this type of dysfunction will
usually result in accentuation of abnormal pattern of
uterine contractions and increase in uterine tone. This
will usually respond to sedation.
COMPLICATIONS OF UTERINE DYSFUNCTION
1. Fetal and neonatal death.
2. Intrauterine infections in prolonged dysfunctional labor
3. Maternal exhaustion
4. Difficult labors and deliveries are likely to leave
psychological scars on the mother which may affect future
childbearing.
TREATMENT OF HYPOTONIC UTERINE
DYSFUNCTION
 Before a treatment plan can be formulated, it must be
ascertained that the woman is in active labor with the
cervix at least 4cm dilated and cephalopelvic disproportion
must be ruled out.
 A contracted pelvis is most unlikely with clinical findings of
1) normal diagonal conjugate, 2) pelvic sidewalls nearly parallel,
3) ischial spines not prominent, 4) sacrum not flat, 5) subpubic
angle not narrow, 6) occiput is the presenting part, and 7) fetal
head is engaged.
 Once the diagnosis of active labor followed by hypotonic
uterine dysfunction has been made, amniotomy is done
to determine the character of the amniotic fluid. The
patient is then closely observed for 30 to 50 minutes to see
whether amniotomy will improve uterine contractions,
after which a decision is made whether to do cesarian
section or to stimulate labor with oxytocin.
OXYTOCIN STIMULATION
 Traditionally: 10 units of oxytocin are incorporated in 1 liter of
dextrose or lactated Ringer’s solution and infused at a rate of 1
milliunit per minute initially and titrated against uterine
contractions, with increments of 1 milliunit every 30 minutes
when necessary.
 The Society of Obstetricians and Gynecologists of Canada
(SOGC) recommends the following protocol: Initial dose of
oxytocin of 1-2 mU/ minute, increase interval of 30 minutes,
and dosage increment of 1-2 mU. The usual dose for good labor
is 6-12 mU/ minute.
 The following precautions are exercised with the use of
oxytocin stimulation:
1. The woman should be in true labor with the cervix at least
4cm dilated.
2. Cephalopelvic disproportion and any abnormalities of the
birth canal must be ruled out.
3. Oxytocin is avoided in the presence of abnormal fetal
presentation and marked uterine overdistention as in
hydramnios and multifetal pregnancy.
4. Women above 35 years, more than para 5 and those with
previous uterine scars are generally not given oxytocin
because of the danger of rupture.
5. The condition of the fetus must be good- no meconium
stained amniotic fluid, normal fetal heart rate
6. Patient must be watched very carefully for sign of
hyperstimulation (more than 5 contractions in 10 minutes),
which will necessitate discontinuation of oxytocin infusion.
7. Continuous electronic monitoring of fetal heart and uterine
contractions.
ACTIVE MANAGEMENT OF LABOR
 Labor is diagnosed when painful contractions are
accompanied by complete cervical effacement, bloody show,
or spontaneous rupture of membranes.
 Onset of labor is considered to begin with admission and
progress of cervical dilatation is noted at 1 hour interval for
the first three hours and every two hours thereafter.
 The slowest acceptable rate is 1cm per hour. Lack of
acceptable progress is treated with oxytocin using the high
dose regimen. Oxytocin is started at a dosage of 6 mU/ min
and advanced in 6 mU/ min increments.
 Duration of labor in the hospital is equated with time spent
in the labor unit, which should not exceed 12 hours. After
this period, cesarian section is performed unless safe vaginal
delivery could be predicted within the hour.
 Active management of labor is not associated with untoward
maternal or neonatal outcomes. It may lead to shortened labor
in nulliparous women but has not consistently led to a reduction
in cesarian deliveries.
TREATMENT OF HYPERTONIC UTERINE
DYSFUNCTION
 Hypertonic uterine dysfunction is characterized by uterine pain
that appears out of proportion to the intensity of the contraction
and their effectiveness in effacing and dilating the cervix.
 Placental abruption must always be considered as a
possible cause of uterine hypertonus. Cesarian delivery
must be employed if fetal distress is suspected.
 If membranes are intact and there is no evidence of
fetopelvic disproportion or fetal distress, the woman may
be sedated with morphine or meperidine to relieve pain
and rest the mother as well as arrest abnormal uterine
activity, after which it is hoped that more effective labor
will be established.
ABNORMAL LABOR PATTERNS
 Friedman defined seven types of dysfunctional labor, each
of which occurs singly or in combination with the other
disorders.
 Prolonged latent phase, protracted active phase
dilatation, protracted descent and prolonged
deceleration phase are qualitatively indistinguishable
from normal labor in that they follow the general shape of
dilatation or descent pattern.
 They differ from normal only in a strict quantitative sense,
falling outside the normal range of some specific phase
duration or shape.
 Secondary arrest of dilatation involves a pattern
change from the expected sigmoid shaped curve of cervical
dilatation. Progressive dilatation in the active phase stops
before full cervical dilatation is attained.
 Arrest of descent also involves a pattern change, with cessation
of progressive linear descent occurring most often in the second
stage of labor when the head is beyond station 0. Usually, 1
hour of arrest of descent is sufficient to make a diagnosis of this
disorder.
 Failure of descent is diagnosed in the deceleration phase or
during the second stage when active descent is expected to
be in full progress but has not occurred. The station of the
head remains high and does not go beyond station 0.
PROLONGED LATENT PHASE
 A prolonged latent phase is one longer than 20 hours in
nulliparous or 14 hours in multiparous women.
 Etiologic factors: excessive sedation or conduction
analgesia, unfavourable cervix (e.g. thick, rigid, uneffaced,
undilated). false labor and uterine dysfunction
 Most women with prolonged latent phase are already
thoroughly exhausted and may suffer from fluid and
electrolyte imbalance.
 If there is no contraindication for a 6-10 hour delay of delivery, a
therapeutic rest is recommended using strong sedatives.
PROTRACTION DISORDERS
 Protracted active phase dilatation means that the maximum
slope of dilatation is less than 1.2 cm per hour in nulliparous or
1.5 cm per hour in multiparous women.
 Protracted descent means descent of the fetal head is
less than 1 cm per hour in nulliparous or 2 cm per hour in
multiparous women.
 Possible etiologic factors: malposition, excessive sedation,
conduction analgesia and cephalopelvic disproportion
 28% of these women have CPD and require cesarian
section. If CPD has been ruled out, the therapy
recommended is physical and emotional support, and a
prolonged labor can be anticipated.
 One should guard against the temptation to effect
instrumental delivery. Continuous fetal monitoring is
essential.
ARREST DISORDERS
 Before the arrest disorder can be diagnosed in the first
stage of labor, the ACOG (1995) suggested that the
following criteria should be met: 1) the latent phase is
completed (i.e., cervical dilatation is a minimum of 4 cm), and 2)
the uterine contraction pattern exceeds 200 Montevideo units
for two hours without cervical change.
 In assessing the optimal contraction pattern, the effect of
anesthesia should be considered.
 Secondary arrest of dilatation occurs when cervical
dilatation stops in the active phase (maximum slope) for 2
hours or more.
 Prolonged deceleration phase occurs when it lasts longer
than 3 hours in nulliparas or 1 hour in multiparas.
 Arrest of descent is cessation of descent progression in the
pelvic division of labor for 1 hour or more.
 Failure of descent is lack of expected descent during the
pelvic division with the head at station 0 or above.
 Most patients (52%) with arrest disorders have CPD and
require cesarian delivery. Other etiologic factors include
hypotonic uterine dysfunction, malposition, excessive
sedation and anesthesia.
 Prolonged second stage is diagnosed in nulliparous women
who experience lack of continuing progress for 2 hours
without or 3 hours with regional anesthesia. It is diagnosed
in parous women who experience lack of progress for 1
hour without or 2 hours with regional anesthesia.
PRECIPITATE LABOR AND DELIVERY
 Precipitate labor terminates in expulsion of the fetus in less
than 3 hours. Precipitate dilatation is diagnosed when the
 maximum slope of dilatation is more than 5cm per hour in
nulliparas or 10 cm per hour in multiparas.
 This may result from an abnormally low resistance of the
soft parts of the birth canal, from abnormally strong uterine
abdominal contractions, or very rarely, from absence of
painful sensations and thus, a lack of awareness of vigorous
labor.
 Short labors were associated with abruption (20%),
meconium, postpartum hemorrhage, cocaine abuse, and
low Apgar scores.
MATERNAL EFFECTS
 Precipitate labor and delivery are seldom accompanied by
serious maternal complications if the cervix is effaced
appreciably and easily dilated, the vagina has been stretched
previously, and the perineum is relaxed.
 Conversely, vigorous uterine contractions combined with a
long, firm cervix and a vagina, vulva or perineum that resists
stretch may lead to rupture of the uterus or extensive
lacerations of the cervix, vagina, vulva or perineum.
 It is in these latter conditions that amniotic fluid embolism
is most likely to occur. The uterus that contracts vigorously
before delivery is likely to be hypotonic after delivery
resulting in hemorrhage from the placental implantation
site.
EFFECTS ON FETUS AND NEONATES
 Perinatal mortality and morbidity from precipitate labor
may be increased considerably for the following reasons:
1. The tumultuous uterine contractions prevent appropriate
uterine blood flow and oxygenation of the fetal blood
2. The resistance of the birth canal to expulsion of the fetal
head may cause intracranial trauma.
3. During an unattended birth the infant may fall to the floor
and be injured or may need resuscitation that is not
immediately available.
TREATMENT
 Unusually forceful spontaneous uterine contractions are
not likely to be modified significantly by administration of
analgesia. Any oxytoxic agents being administered should
be stopped immediately.
 The use of tocolytic agents such as ritodrine and parenteral
magnesium sulphate is unproven. Use of general anesthesia
with agents that impair uterine contractility such as
halothane and isoflurane is often excessively heroic.
INADEQUATE VOLUNTARY EXPULSIVE FORCE
 When the woman in labor reaches full cervical dilatation
with descent of the head, she starts to bear down every
time the uterus contracts. The combined force created by
the contractions of the uterus and the abdominal
musculature propels the fetus down the vagina and through
the vaginal outlet.
 The magnitude of the force created by contractions of the
abdominal musculature may be compromised and prevent
spontaneous vaginal delivery when the patient has been
given conduction analgesia (lumbar, epidural, caudal, or
intrathecal), general anesthesia, or heavy sedation.
MANAGEMENT
 Careful selection of the kind of analgesia and the timing of
its administration are important to avoid compromise of
voluntary expulsive efforts.
 With rare exceptions, intrathecal analgesia or general
anesthesia should not be administered until all conditions
for a safe outlet forceps delivery have been met.
 With continuous epidural analgesia, it may be necessary to
allow the paralytic effects to wear off so that the woman
can generate intraabdominal pressure sufficient to move
the fetal head into position appropriate to outlet forceps
delivery.
 The urge to bear down is overridden by the intensification
of pain or bearing down. Long standing paralysis of the
abdominal musculature as in poliomyelitis or transection of
the spinal cord may also give rise to insufficient expulsive
efforts.
 For the woman who cannot bear down appropriately
because of pain, analgesia is likely to be of considerable
benefit.
 The safest choice for both fetus and mother is nitrous
oxide mixed with equal volume of oxygen and provided
during the time of each contraction. At the same time,
appropriate encouragement and instruction are most likely
to be of benefit.
 2. Large for the pelvic opening (macrosomia)

3. Abnormal shape (fetal tumors, acardiac co-twin)

4. Impaction of the anterior shoulder (shoulder dystocia)

ABNORMALITIES IN FETAL PRESENTATION

 The fetus enters the pelvic cavity in vertex (occiput

presentation) in most cases. Any presentation other than
occiput is called ‘malpresentation’ which increases the
probability of prolonged or obstructed labor (dystocia) and
may need cesarian delivery.
DYSTOCIA DUE TO ABNORMALITIES OF
 Abnormal fetal presentations that can result to dystocia
THE FETUS
include breech, shoulder, compound, and face or brow
presentation. Among these, the most common is the
breech presentation.
Abnormalities in Fetal Presentation

Breech, Shoulder, Brow, Face and Compound

BREECH PRESENTATION
Abnormalities in Fetal Position
 It occurs in 3-4 % of all deliveries. It is the most common
Persistent Occiput Posterior type of malpresentation comprising 75% of malpresented
fetuses.
Persistent Occiput Transverse
 A term fetus in breech presentation may even revert
Asynclitism spontaneously to cephalic presentation just prior to onset
Abnormalities in Fetal Size and Shape of labor.

Fetal Macrosomia  Predisposing factors: prematurity, uterine malformations or

fibroids, polyhydramnios, very short umbilical cord,
Fetal Tumors placenta previa, fetal abnormalities (e.g. hydrocephalus,
anencephaly, neck masses, aneuploidy) and multiple
Shoulder Dystocia
gestation
Definition, Incidence, Risk Factors

Diagnosis: The “Turtle” Sign

DIAGNOSIS
Mechanism of Shoulder Dystocia
 Breech presentation occurs when the buttocks and/or the
Complications: Fetal and Maternal Injuries feet are the presenting parts. On abdominal examination
(Leopold’s maneuver), the head is felt in the upper
Reduction Maneuvers abdomen and the breech in the pelvic brim.
The ‘HELPERR’ Mnemonic  Auscultation locates the fetal heart higher than expected
with a vertex presentation. On vaginal examination during
The ‘ALARMER’ Mnemonic
labor, the buttocks and/or feet are felt. Thick, dark
meconium is normal.

 The fetus, referred to as ‘the passenger’ plays a significant

role in the outcome of labor and delivery.
TYPES OF BREECH PRESENTATION
 “Fetal dystocia” or difficult labor due to abnormalities
1. Frank (Extended) Breech: occurs when both legs are
pertaining to the fetus usually occurs in the second stage of
flexed at the hips and extended at the knees
labor characterized by prolonged duration or arrested
descent 2. Complete (Flexed) Breech: occurs when both legs are
flexed at the hips and knees
 Fetal dystocia may occur when the fetus has one of the
following abnormalities: 3. Footling Breech: occurs when a leg is extended at the hip
and the knee
1. Abnormally positioned in the birth canal (malpresentation,
malposition)- collectively constitute the most common causes
of fetal dystocia occurring approximately in 5% of all labors.
MECHANISM OF LABOR
 In breech presentation, the baby’s bottom (rather than the  Breech presentation increases the risk of brachial plexus
feet and knees) is commonly the first to descend through injury, spinal cord birth trauma and perinatal death if
the maternal pelvis and emerge from the vagina. delivery is done by an unskilled birth attendant.

 At the beginning of labor, the baby is in oblique position. As
the baby’s bottom is the same size as the head in a term
fetus, descent occurs without difficulty.
 A delay in descent is a cardinal sign of possible problem with the
delivery of the head.
 In order to begin birth, internal rotation has to occur. This
happens when the mother’s pelvic floor muscles cause the
baby to turn so that it can be born with one hip directly in
front of the other.
 At this point, the bitrochanteric diameter of the fetus
occupies the anteroposterior diameter of the pelvis and the
baby is facing one of the mother’s inner thighs.
 After the delivery of the body, external rotation occurs as
the shoulders emerge and the baby’s head enters the
maternal pelvis.
 Nuchal arms, wherein one or both arms are wrapped
around the back of the neck complicates 0-5% of vaginal
breech deliveries. This may result in neonatal trauma
including brachial plexus injury.
 Cervical spine injury can happen wen the fetus presents
with a hyperextended neck prior to delivery.
 Hyperextended neck in breech (‘stargazing’ breech)
is present when the angle of extension of the cervical
vertebra is more than 90°. This can be diagnosed by
ultrasound or radiologic examination.
 Cord prolapse is common in breech presentation
particularly in footling type of breech. It may not always
result in severe fetal heart rate decelerations unlike when
cord prolapse complicates a vertex presentation.

 The combination of maternal muscle tone, uterine
contractions and operator’s maneuvers cause the baby’s
head to flex, chin to chest. Then the face emerges, and
finally the back of the baby’s head.
COMPLICATIONS
 Fetal complications of breech delivery include the following:
1. Head entrapment
2. Birth trauma (broken neck, brachial plexus injury)
3. Cord prolapse
4. Birth asphyxia (neurologic damage)
5. Damage to abdominal organs
TRANSVERSE LIE AND SHOULDER
PRESENTATION
 Transverse lie and shoulder presentation occur when the long
axis of the fetus is perpendicular to that of the mother such that
the shoulder is over the pelvic inlet and becomes the presenting
part, the head in one iliac fossa and the breech in the other.
 When the fetal long axis forms an acute angle with the
maternal axis, an oblique lie results but this is only
transitory and is referred to as an unstable lie because
when labor begins, it is converted to either longitudinal or a
transverse lie.
 The common causes of transverse lie: multiparity,
pendulous abdomen, preterm gestation, placenta previa,
uterine anomaly, polyhydramnios and contracted pelvis.

DIAGNOSIS
 Breech presentation is a potential problem primarily
 Transverse lie can be suspected by inspection alone. The
because the presenting part is a poor dilating wedge which
abdomen is unusually wide and the fundus is only slightly
can cause the head to be trapped during delivery, often
above the umbilicus.
compressing the umbilical cord.

 Fetal head entrapment may result from an incompletely

dilated cervix or from lack of time for the head to mold and
negotiate the maternal pelvis.

 In a full term fetus, the bitrochanteric diameter is about the

same size as the biparietal diameter and the buttocks dilate
the cervix as effectively as the head does in vertex
presentation. However, if the baby is premature, the head
size is relatively larger than the body, so that it is possible
for the baby’s body to emerge while the cervix is not yet
fully dilated resulting to head entrapment.

 Oxygen deprivation may occur and if prolonged, it may

cause permanent neurological damage.