Problem with the passage
The third reason dystocia can occur is a contraction or
narrowing of the passageway or birth canal. This can happen
at the inlet, at the midpelvis, or at the outlet. The narrowing
causes CPD, or a disproportion between the size of the fetal
head and the pelvic diameters, which then results in failure to
progress in labor.
Inlet contraction
Inlet contraction is narrowing of the anteroposterior diameter of
the pelvis to less than 11 cm, or of the transverse diameter to
12 cm or less.
 It usually is caused by rickets in early life or by an
inherited small pelvis.
Rickets is caused by a lack of calcium and is therefore rare in
developed countries but can occur among immigrants who
were raised where milk supplies were not plentiful
 In primigravidas, the fetal head normally engages
between weeks 36 and 38 of pregnancy
If this occurs any time before labor begins, it is proof the pelvic
inlet is adequate as lightening, by definition, means the fetal
head has sunk below the inlet.
Following the general rule that “what goes in, comes out,” a
head that engages or proves it fits into the pelvic brim will
probably also be able to pass through the midpelvis and
through the outlet.
If engagement does not occur in a primigravida, then either a
fetal abnormality (larger than usual head) or a pelvic
abnormality (smaller than usual pelvis) should be suspected.
 As a rule, engagement does not occur in
multigravidas until labor begins. For these women,
previous vaginal birth of a full-term infant without
problems is proof their birth canal is adequate.
Every primigravida should have pelvic measurements taken
and recorded before week 24 of pregnancy so, based on these
measurements and the assumption the fetus will be of average
size, a birth decision can be made.
 If CPD exists, because the fetus may not engage but
instead remains “floating,” the possibility of cord
prolapse can lead to a secondary concern.
Outlet contraction
Outlet contraction is a narrowing of the transverse diameter,
the distance between the ischial tuberosities at the outlet, to
less than 11 cm.
Trial labor
If a woman has a borderline (just adequate) inlet measurement
and the fetal lie and position are good, her primary care
provider may allow her a “trial” labor to determine whether
labor will progress normally.
 The trial labor continues as long as descent of the
presenting part and dilatation of the cervix continue to
occur. With a trial labor, monitor fetal heart sounds
and uterine contractions frequently.
 Urge the woman to void every 2 hours so her urinary
bladder is as empty as possible, allowing the fetal
head to use all the space available.
 If, after a definite period (6 to 12 hours), adequate
progress in labor cannot be documented, or if at any
time fetal distress occurs, the trial labor will be
discontinued and the woman will be scheduled for a
cesarean birth.
It may be difficult for women to undertake labor they know they
may not be able to complete because the effort subjects them
needlessly to pain.
 Emphasize, but do not overstress, that it is best for
their baby to be born vaginally.
 If the trial labor fails and cesarean birth is scheduled,
provide an explanation as to why cesarean birth is
necessary and why it has become the best route for
the birth of their baby.
Some women undergoing a trial labor feel as if they
themselves are on trial. When dilatation does not occur, they
begin to feel discouraged and inadequate, as if they are at
fault.
The support person may be as frightened and feel as helpless
as she does and so momentarily stops being a support person.
 You can assure a woman and her support person
that a cesarean birth is just an alternative, not an
inferior, method of birth for them. Because labor
is not progressing, it is the method of choice to
allow them to achieve their goal of a healthy
mother and healthy child.
External cephalic version
External cephalic version is the turning of a fetus from a
breech to a cephalic position before birth.
 It may be done as early as 34 to 35 weeks,
although the usual time is by 37 to 38 weeks of
pregnancy
For the procedure, FHR and possibly ultrasound are recorded
continuously.
 A tocolytic agent may be administered to help
relax the uterus.
 The breech and vertex of the fetus are located
and grasped transabdominally by the examiner’s
hands on the woman’s abdomen
 Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic lie.
Although not always successful, the use of external version
can decrease the number of cesarean births necessary from:
 breech presentations
 Contraindications to the procedure include multiple
gestation,
 severe oligohydramnios,
 small pelvic diameters,
 a cord that wraps around the fetal neck,
 Unexplained thirdtrimester bleeding, which might be
a placenta previa.
External version can be uncomfortable for a woman because
of the feeling of pressure. Women who are Rh negative should
receive Rh immunoglobulin after the procedure in case
minimal bleeding occurs.
Forceps birth
Obstetrical forceps are steel instruments constructed of two
blades that slide together at their shaft to form a handle.
 One blade is slipped into the woman’s vagina next to
the fetal head, and the other is slipped into place on
the other side of the head.
 Next, the shafts of the instrument are brought
together in the midline to form the handle.
 The primary care provider then applies pressure on
the handle to manually extract the fetus from the birth
canal.
In years past, babies were routinely born with forceps. Today,
the technique is rarely used (in only about 4% to 8% of births)
because it can lead to rectal sphincter tears in the woman,
which can lead to dyspareunia, anal incontinence, or
increased urinary stress incontinence
Although no longer used routinely, forceps may be necessary
with any of the following conditions:
 A woman is unable to push with contractions in the
pelvic division of labor such as might happen with a
woman who received regional anesthesia or who has
a spinal cord injury.
 Cessation of descent in the second stage of labor
occurs.
 A fetus is in an abnormal position.
 A fetus is in distress from a complication such as a
prolapsed cord.
Although forceps appear as if they would put forceful pressure
on the fetal head, the pressure registers on the steel blades
rather than the head so they can actually reduce pressure,
thus avoiding a complication such as subdural hemorrhage.
Before forceps are applied:
 Membranes must be ruptured.
 CPD must not be present.
 The cervix must be fully dilated.
 The woman’s bladder must be empty.
 Record the FHR before forceps application because
there is a danger that the cord could be compressed
between the forceps blade and the fetal head,
 assess FHR again immediately after application.
The woman’s cervix needs to be carefully assessed after
forceps birth to be certain no lacerations have occurred
 To rule out bladder injury, record the time and amount
of the first voiding.
 Assess the newborn to be certain no facial palsy
exists from pressure.
 A forceps birth may leave a transient erythematous
mark on the newborn’s cheek. This mark will fade in 1
to 2 days with no long-term effects.
Vacuum extraction

A fetus, if positioned far enough down the birth canal, may be

born by vacuum extraction

 With the fetal head at the perineum, a soft, disk-

shaped cup is pressed against the fetal scalp and
over the posterior fontanelle.
 When vacuum pressure is applied, air beneath the
cup is suctioned out and the cup then adheres so
tightly to the fetal scalp that traction on the vacuum
cord leading to the cup extracts the fetus

Vacuum extraction has advantages over forceps birth in that

little anesthesia is necessary, thus leaving the fetus with less
respiratory depression at birth.

 One disadvantage over natural birth is that more

perineal lacerations may occur.
 Its major disadvantage is that it causes a marked
caput on the newborn head that may be noticeable as
long as 7 days after birth.
 Tentorial tears from extreme pressure also have
occurred.

A woman may need reassurance that the caput swelling is

harmless for her infant and will decrease rapidly.

Vacuum extraction should not be used as a method of birth if

fetal scalp blood sampling was used because the suction
pressure can cause severe bleeding at the sampling site.

Moreover, vacuum extraction is not advantageous for preterm

infants because of the softness of the preterm skull.