Dystocia

• Abnormally slow labor

• Arises from 4 distinct abnormalities:
1. Abnormal expulsive powers (POWERS)
• UCs are insufficiently strong or inappropriately coordinated (uterine
dysfunction) to cause cervical dilatation and effacement
• Inadequate voluntary maternal effort during the 2nd stage of labor
2. Fetal factors: presentation, position, development
(PASSENGER)
3. Abnormalities of the maternal bony pelvis (contracted
pelvis) (PASSAGES)
4. Soft tissue abnormalities
Most cases of dysfunctional labor result from MALPOSITION OF THE FETAL
HEAD WITHIN THE PELVIS (ASYNCLITISM) or from INEFFECTIVE UTERINE
CONTRACTIONS.
Uterine Dysfunction
• Myometrial contractions are greatest and last
longest at the fundus (fundal dominance)
• The stimulus for uterine contraction starts at
the cornu
• The lower limit of contraction pressure
required to dilate the cervix is 15mmHg
 Types of Uterine Dysfunction
Basal tone Pressure
gradient
Hypotonic* normal normal/
synchronous
Hypertonic or elevated Distorted**
Incoordinate
*pressure during a contraction just isn’t enough to bring out cervical dilatation and
effacement
**gradient distortion may result from more forceful contraction of the uterine
midsegment than the fundus OR from complete asynchrony of the impulses
originating in each cornu or a combination of these two.
 Reported Causes of Uterine Dysfunction

• Epidural anesthesia
 Prolongs the both the 1st and 2nd stages of labor; slows rate of
fetal descent
• Chorioamnionitis
 Unclear whether uterine infection causes dystocia, or uterine
infection is a consequence of prolonged labor
• Maternal position during labor
 No proven benefit nor harm in assuming varied positions during
labor in women with uncomplicated pregnancies
• Birthing position in the 2nd stage of labor
• Water immersion
 Active Phase Disorders
• A woman must be in the active phase of labor with a
cervical dilatation of at least 4cm to be diagnosed with
any of the active phase disorders:
 Protraction Disorder: slower-than-normal progress
 Arrest Disorder: complete cessation of progress
• Criteria to be met before a diagnosis of first stage labor
arrest is made (ACOG):
1. Latent phase has been completed
2. Cervix is dilated 4 cm or more
3. Uterine contraction pattern of 200 Montevideo units or more
has been present for at least 2 hours without cervical change
Prolonged second stage >2 hrs >1 hr (without epidural)
of labor >3 hrs >2hrs (with epidural)
Montevideo units are calculated by subtracting the baseline uterine
pressure from the peak contraction pressure for each contraction in a 10-
minute window and adding the pressures generated by each contraction.
 Second Stage Disorders
• Disproportion of the fetus and pelvis becomes
apparent during the 2nd stage of labor
 the 2nd stage incorporates many of the cardinal
movements necessary for the fetus to negotiate the birth
canal
Prolonged second stage >2 hrs >1 hr (without epidural)
of labor >3 hrs >2hrs (with epidural)
“…the purported safety of the proposed new criteria for second stage
labor management should be viewed with caution until more
published experiences accrue.”
 Maternal pushing efforts
• During the second stage, most women cannot resist
the urge to push or bear down each time the uterus
contracts
• Heavy sedation or regional anesthesia (epidural)
may reduce the reflex urge to push and may impair
the ability to contract abdominal muscles sufficiently
 PROM at Term
• Membrane rupture at term without spontaneous
uterine contractions
– managed by labor induction (IV oxytocin) if contractions do
not begin spontaneously after 6-12 hours
 Precipitous Labor and Delivery
• Extremely rapid labor and delivery
 5 cm/hr or faster: nulliparas
 10 cm/hr: multiparas
• May result from:
 abnormally low resistance of the soft tissues of the birth
canal
 abnormally strong uterine and abdominal contractions
 absence of painful sensations and thus lack of awareness
of vigorous labor
 Precipitous Labor and Delivery
• MATERNAL EFFECTS:
 seldom accompanied by serious maternal complications if
the cervix is effaced appreciably and is compliant, if the
vagina and perineum are relaxed
 vigorous uterine contractions combined with a long, firm
cervix and a non-compliant birth canal may lead to uterine
rupture or extensive lacerations of the cervix, vagina,
vulva, or perineum
 may also lead to amniotic fluid embolism
 uterine atony
 Precipitous Labor and Delivery
• FETAL AND NEONATAL EFFECTS
 tumultous uterine contractions (with negligible intervals of
relaxation) prevent appropriate uterine blood flow and
fetal oxygenation
 during an unattended birth, the newborn may fall to the
floor and get injured
 TREATMENT:
 use of tocolytic agents unproven
 Oxytocin administration should be stopped
immediately
Fetopelvic Disproportion
 Fetopelvic Disproportion
• Arises from diminished:
 pelvic capacity (pelvic inlet, midpelvis, pelvic
outlet),
 excessive fetal size
 or both
 Contracted Inlet

Symphysis pubis

Sacral promontory

Diagonal conjugate < 11.cm

Clinical pelvimetry: sacral promontory not accessible
 Contracted Inlet
• predisposes to early membrane rupture
• predisposes to less effective contractions
• plays an important role in the production of
abnormal presentations
 head floats freely over the pelvic inlet or rests
more laterally in one of the iliac fossae
 face and shoulder presentations are encountered
3x more frequently, and the cord prolapses 4-6x
more often
 Contracted Midpelvis
• Interspinous diameter measures <8 cm
• Clinical pelvimetry findings:
 Prominent ischial spines
 Pelvic sidewalls convergent
 Sacrosciatic notch is narrow
• More common than inlet contraction
• Frequently causes transverse arrest of the fetal head
 Contracted Outlet
• Interischial tuberous diameter < 8 cm
• Outlet contraction without concomitant
midpelvic contraction is rare
• May play a role in perineal tears
• Clinical pelvimetry: narrow pubic arch
 Estimation of Pelvic Capacity
• Clinical pelvimetry
• Imaging:
 xray
 CT
 MRI
 Fetal Dimensions in FPD
• Fetal size
 Fetal size threshold to predict FPD is still elusive
 2/3rd of neonates who required CS delivery weighed
<3.7kg
• Position of the head
 Asynclitism
 Posterior position
• Fetal presentation
 Face
 Brow
 Face Presentation
• Occiput is in contact with the
fetal back; the chin is
presenting
• Precludes flexion of the fetal
head necessary to negotiate
the birth canal
• Mentum posterior (in relation
to the symphysis pubis) is
undeliverable by vaginal route
• Mentum anterior may be
delivered vaginally
 Face Presentation
• Etiology: (conditions that favor extension or prevent head flexion)
 Preterm infants
 Marked enlargement of the neck or coils of cors
around the neck (may cause extension)
 Fetal malformations
 Hydramnios
 Anencephaly
 Pelvic contraction
 Large fetus
 High parity (pendulous abdomen)
 Face Presentation
• Diagnosis:
 By vaginal examination and palpation of facial
features
• Commonly mistaken for a breech presentation
 The anus may be mistaken for the mouth and the ischial
tuberosities for the malar eminences
 The finger encounters muscular resistance with the anus, and
upon removal, may be stained with meconium
 The mouth and the malar eminences form a triangular shape,
whereas the ischial tuberosities and anus lie in a straight line
 Radiographic demonstration of the hyperextended
head
 Face Presentation
• Management:
 Vaginal delivery is possible in mentum anterior
positions (in the absence of pelvic contraction,
and with effective labor)
 Mentum posterior: CS
 Attempts to convert a face presentation manually
into a vertex presentation are dangerous and
should NOT be attempted
 Brow Presentation
• Fetal head occupies a position
midway between full flexion
(occiput) and extension (face)
• Unstable and often converts to
face or occiput presentation
• Etiology: same as that of face
presentation
 Brow Presentation
• Diagnosis:
 Both the occiput and chin can be easily palpated
abdominally
 On vaginal examination:
 Frontal sutures, large anterior fontanel, orbital ridges, eyes,
and root of nose are felt
 The mouth nor the chin is palpable
 Management:
 Vaginal delivery possible only if the fetus is very small
and pelvis is large; otherwise, CS is warranted
 Transverse Lie
• Long axis of the fetus is perpendicular to that
of the mother
• Creates a shoulder presentation
 right or left acromial, depending on which side of
the mother the acromion rests
 dorsoanterior or dorsoposterior: whether the
fetal back is directed anteriorly or posteriorly
 Transverse Lie
• Etiology:
 High parity (abdominal wall laxity) - >4
 Preterm fetus
 Placenta previa
 Abnormal uterine anatomy
 Hydramnios
 Contracted pelvis
 Transverse Lie
• Diagnosis:
 PE:
 Abdomen is unusually wide
 Uterine fundus extends to only slightly above the
umbilicus
 No fetal pole is detected in the fundus
 Ballotable head and breech are found in the iliac fossae
 Dorsoanterior: hard resistance plane extends across the
front of the abdomen
 Dorsoposterior: irregular nodulations (fetal parts) are
felt through the abdominal wall
 Transverse Lie
• Diagnosis:
 PE:
 On vaginal examination, a “gridiron” feel of the ribs
may be felt if the side of the thorax can be reached
Neglected
Transverse Lie
• Shoulder is impacted firmly
in the upper part of the
pelvis
• Pathologic retraction ring
develops
• Uterus may eventually
rupture
 Conduplicato Corpore

• If the fetus is small (<800g), and the pelvis is

large, spontaneous delivery is possible
despite persistence of the abnormal lie

• The fetus which is doubled upon itself is

expelled
 Transverse Lie
• Management:
 CS is usually done in a woman who is in active
labor
 Before labor or early in labor, external cephalic
version may be done in the absence of other
complications
 Uterine incision:
 Classic (vertical) for dorsoanterior positions
 Low transverse for dorsoposterior
 Compound Presentation
• An extremity prolapses alongside the presenting part, and
both present simultaneously in the pelvis
• Caused by conditions that prevent complete occlusion of
the pelvic inlet by the fetal head, including preterm labor
 Compound Presentation
• Management:
 The prolapsed part is left alone in most cases
because it usually doesn’t interfere with labor
 If it fails to retract, the prolapsed arm should be
pushed gently upward and the head
simultaneously downward by fundal pressure
 Complications with Dystocia
• MATERNAL:
 Chorioamnionitis and postpartum pelvic infection are
common in prolonged labor
 Postpartum hemorrhage from uterine atony also increases
with prolonged labor
 Higher incidence of uterine tears with hysterectomy if the
fetal head is impacted in the pelvis
 Uterine rupture in prolonged obstructed labor
 Pathologic ring of Bandl – associated with marked stretching and
thinning of the lower uterine segment; seen as a uterine
indentation and signified impending uterine rupture
 Complications with Dystocia
• MATERNAL:
 Fistula formation
 Excessive pressure on the tissues of the birth canal  impaired circulation
necrosis  fistula formatiob (vesicovaginal, vesicocervical, rectovaginal)
 Pressure necrosis most often follows a very prolonged second stage
 Pelvic floor injury
 Due to direct compression of the fetal head and downward pressure from
maternal expulsive efforts  functional and anatomical alterations in the
muscles, nerves and connective tissues  INCONTINENCE and PWLVIC
ORGAN PROLAPSE
 Postpartum lower extremity nerve injury
 Due to external compression of the common fibular (formerly common
peroneal) nerve
 Caused by inappropriate leg positioning in stirrups
 Symptoms usually resolve within 6 months of delivery
 Complications with Dystocia
• PERINATAL:
 Peripartum fetal sepsis is increased with prolonged labor
 Caput succedaneum and molding
 Mechanical trauma
 nerve injury
 fractures
 cephalhematoma