OB3B DYSTOCIA DUE TO ABNORMALITIES IN

POWER AND PASSAGE

Dra. Ahyong-Reyes

DYSTOCIA
 difficult labor characterized by abnormally slow
progress of labor

FOUR DISTINCT ABNORMALITIES

1. Abnormalities of the expulsive forces (POWER; uterine
contactions)
2. Abnormalities of presentation, position, or development
of the fetus (PASSENGER)
3. Abnormalities of the maternal bony pelvis (PASSAGE)
4. Abnormalities of soft tissues of the reproductive tract Diagrams of the birth canal:
(e.g. myoma) (A) at the end of pregnancy and
B) during the second stage of labor, showing formation of the
birth canal.
Categories according to the American College of Obstetricians (C.R. = contraction ring; o.i. = internal cervical os; o.e. = external
and Gynecologists cervical os.) (From Williams, 1903.)
1. Abnormalities of the powers—uterine contractility and
maternal expulsive effort. Pathologic Ring of Bandl
2. Abnormalities involving the passenger—the fetus.  sign of impemding uterine rupture
3. Abnormalities of the passage—the pelvis.
REVISED DYSTOCIA DIAGNOSIS
COMMON CLINICAL FINDINGS IN WOMEN WITH INEFFECTIVE - used to  CS rate; requires longer observation
LABOR
American College of Obstetrician and Gynecologist
(Spong.2012)
DILATATION OR FETAL DESCENT  New Definitions for arrest in labor progress to prevent
Protracted labor-slow progress unnecessary first cesarean deliveries
Arrested labor-no progress  Adequate time for normal latent and active phases of
Inadequate expulsive effort-ineffective pushing labor
FETOPELVIC DISPROPORTION  Second stage should be allowed as long as the
maternal and fetal conditions permit
Excessive fetal size
 Time allowed for each of the stages are longer than the
Inadequate fetal capacity
traditional
Malpresentation or position of the fetus
-
RUPTURED MEMBRANES WITHOUT LABOR
Evidence for Adequate and Arrested Labor

MECHANISMS OF DYSTOCIA
ARREST OF LABOR should not be made until adequate
time has elapsed
At the end of pregnancy:
 Obstacles for the fetal head as it traverse the birth
canal: ADEQUATE LABOR > 6 cm dilatation with membrane
 Thicker lower uterine segment (from isthmus) rupture and
 Undilated cervix
 Less developed and less powerful fundal muscles >4 hours of adequate contractions
(>200 montevideo) or
Factors influencing the progress of the 1ST STAGE OF LABOR
(from regular uterine contractions to full cervical dilation) >6 hours if contractions are
 Uterine contractions inadequate with no cervical change
 Cervical resistance SECOND STAGE OF no progress for >4 hours in nulliparous in
 Forward pressure of the presenting part LABOR women with epidural

SECOND STAGE OF LABOR (Fully Dilated Cervix): > 3 hrs without epidural
 Fetopelvic proportion is observed No cesarean section before this time limits in the presence of
o Relationship of the fetal head size,position reassuring maternal and fetal status.
with pelvic capacity
 Uterine muscle malfunction
o results in uterine overdistension or obstructed
labor or both

THUS INEFFECTIVE LABOR IS A POSSIBLE WARNING SIGN OF

FETOPELVIC DISPROPORTION

BERNABE, Maria Katrina R. 1

Medicine 3i - 2015
 ABNORMALITIES OF THE EXPULSIVE FORCES ACTIVE-PHASE DISORDERS

Active phase  4 cm
1ST STAGE Contractions of the uterus  cervical dilatation,
OF LABOR: propulsion and expulsion of the fetus CLASSIFICATION
2ND STAGE Voluntary or involuntary muscular action of 1. Protraction Disorder (slower than normal)
OF LABOR: abdominal wall --“PUSHING” 2. Arrest Disorder (complete cessation of progress)

Criteria for the diagnosis of arrest during first-stage labor (ACOG

2 TYPES OF UTERINE DYSFUNCTION
1989)
 The latent phase has been completed, with the cervix
HYPOTONIC HYPERTONIC/INCOORDINATE
dilated 4 cm or more.
More common Basal tone is ELEVATED  A uterine contraction pattern of 200 Montevideo units
NO basal hypertonus or more in a 10-minute period has been present for 2
(weak power) hours without cervical change.
Uterine contractions have a Pressure gradient is distorted
normal gradient pattern (ASYNCHRONISM) CRITERIA FOR DIAGNOSIS OF ABNORMAL LABOR DUE TO ARREST
(SYNCHRONOUS) OR PROTRACTION DISORDERS
Slight rise in pressure during a
contraction is insufficient to LABOR PATTERN NULLIPARA MULTIPARA
dilate the cervix
Protraction disorder
Usually seen in active phase of
labor Dilatation < 1.2 cm/hr < 1.5 cm/hr
Descent < 1.0 cm/hr < 2.0 cm/hr
Treatment: OXYTOCIN Treatment: SEDATION
Arrest disorder
CAUSES OF UTERINE DYSFUNCTION No dilatation > 2 hr > 2 hr
No descent > 1 hr > 1 hr
1. EPIDURAL ANALGESIA
o Can slow labor Note:
o Lengthening of both first- and second-stage DILATATION
labor and slowing of the rate of fetal descent  Happen during the active phase (4cm)
o Add 1 hour for observation
DESCENT
2. CHORIOAMNIONITIS  Happens during the deceleration phase
 Normal:
3. MATERNAL POSITION DURING LABOR Nullipara – 1cm/hr
o conflicting reports on which position is Multipara – 2cm/hr
better(Recumbent or ambulating)
SECOND-STAGE DISORDERS
4. BIRTHING POSITION IN SECOND STAGE (proven)
Upright  incorporates many of the cardinal movements
o shorter delivery interval to delivery(4mins) necessary for the fetus to negotiate the birth canal
o Less pain  disproportion of the fetus and pelvis frequently
o lower non reassuring fetal status and becomes apparent
operative deliveries
Disadvantage of upright position: DURATION OF 2ND STAGE
o Increased blood loss (>500ml)
o Fibular nerve nephropathy(SQUATTING) NULLIPARAS 2 hours
3 hours if with regional analgesia
5. WATER IMMERSION
MULTIPARAS 1 hour
o Less epidural anesthesia
2 hours if with regional analgesia
o decreased BP
o Not associated with uterine infection
o Neonatal complications “Bearing down” or “pushing”
 contraction of the abdominal musculature to
 drowning
 hyponatremia generate increased intra-abdominal pressure together
with uterine contractions  propulsion of the fetus
 waterborne infection
 cord rupture downward
 polycythemia
FACTORS THAT PREVENT SPONTANEOUS VAGINAL DELIVERY
THREE SIGNIFICANT ADVANCES IN THE TREATMENT OF UTERINE
DYSFUNCTION  compromised force created by contractions of
abdominal musculature
1. Prolongation of labor - perinatal morbidity and
mortality.  heavy sedation or regional analgesia (lumbar epidural
2. Dilute intravenous infusion of oxytocin in the treatment or spinal) that reduces the reflex urge to push
of hypotonic uterine dysfunction  urge to push is overridden by the intense pain created
3. Use of cesarean delivery rather than difficult by bearing down
midforceps delivery

BERNABE, Maria Katrina R. 2

Medicine 3i - 2015
ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA, AND METHODS OF TREATMENT

Labor Pattern Diagnostic Criteria Preferred Treatment Exceptional Treatment

Nulliparas Multiparas
Prolongation Disorder
(Prolonged latent phase) > 20 hr > 14 hr Bed rest Oxytocin or cesarean
delivery for urgent
problems
Protraction Disorders
1. Protracted active-phase < 1.2 cm/hr < 1.5 cm/hr Expectant and support Cesarean delivery for CPD
dilatation
2. Protracted descent < 1.0 cm/hr < 2 cm/hr
Arrest Disorders
1. Prolonged deceleration phase > 3 hr > 1 hr Oxytocin without CPD Rest if exhausted
2. Secondary arrest of dilatation
3. Arrest of descent > 2 hr > 2 hr Cesarean delivery with Cesarean delivery
4. Failure of descent > 1 hr, with no descent > 1 hr CPD
in deceleration phase
or second stage

NOTE: ANTERIOR MIDPELVIS POSTERIOR MIDPELVIS

 FALIURE OF DESCENT: never beyond station 0 bounded anteriorly by the bounded dorsally by the
 ARREST OF DESCENT: Beyond station 0 lower border of the symphysis sacrum and laterally by the
 Waiting time: >2 hours pubis and laterally by the sacrospinous ligaments
ischiopubic rami
FETOPELVIC DISPROPORTION
Average Midpelvis Measurements
 arises from:
o Diminished pelvic capacity, Transverse ( interspinous) 10.5 cm(IS)
o Excessive fetal size, Anteroposterior (lower border of the 11.5 cm(APM)
o More commonly- combination of both. symphysis pubis to the junction of S4–S5)
Posterior sagittal (from the midpoint of the 5 cm (PSM)
CONTRACTED PELVIC INLET interspinous line to the same point on the
sacrum)

Shortest anteroposterior diameter <10cm

(obstetrical conjugate) CONTRACTED MIDPELVIS
- Symphisis pubis to sacral promontory  More common than inlet contraction
Greatest transverse diamete <12 cm  Causes transverse arrest of the fetal head
Diagonal conjugate <11.5 cm  IS +PSM IS less than 13.5 cms
- Only one that is measurable clinically  Interspinous diameter is < 8cm
 CLINICAL PELVIMETRY:
o spines are prominent
 Fetal biparietal diameter – average-9.5 - 9.8 cm o pelvic sidewalls converge
 Cervical dilatation - facilitated by : o narrow sacrosciatic notch
o hydrostatic action of the unruptured  MIDPLANE – smallest part of pelvis
membranes
o direct application of the presenting part
CONTRACTED PELVIC OUTLET
 CPD INLET-no direct pressure on the cervix and lower
 interischial tuberous diameter of 8 cm or less
uterine segment-
uterine contractions
Pelvic outlet likened to 2 triangles:
 Related to abnormal presentations /asynclitism and
descent does not take place until after labor onset
ANTERIOR TRIANGLE
Base interischial tuberous diameter
 Fetal head floats over pelvic inlet or in one iliac fossa
Sides pubic rami
 face and shoulder presentations are three times more
frequent Apex inferior posterior surface of the symphysis pubis
 cord prolapse - four to six times more frequent
POSTERIOR TRIANGLE
Base interischial tuberous diameter
Obstetrical plane of the midpelvis Sides no bony sides
 Inferior margin of the symphysis pubis through the ischial Apex tip of the last sacral vertebra (not the tip of the
spines and touches the sacrum near the junction of the coccyx).
fourth and fifth vertebrae
A transverse line connecting the ischial spines divides the  Often associated with midplane contraction
midpelvis into anterior and posterior portions.  PURE outlet contraction is RARE
 Related to perineal tears
BERNABE, Maria Katrina R. 3
Medicine 3i - 2015
PELVIC FRACTURES
 Trauma from automobile collisions-most common
cause
 Fracture pattern,minor malalignment,retained
hardware-are NOT absolute indication for Cesarean
section
 Review of previous radiograph and xray pelvimetry
later in pregnancy

ESTIMATION OF PELVIC CAPACITY

 Clinical estimation
 X-Ray Pelvimetry
 Computed Tomographic scanning(250-1500 mrad)
o reduced radiation exposure,greater accuracy
and easier performance as compared to
conventional X ray
 Magnetic Resonance
o lack of radiation, accurate measurements,
complete fetal imaging, evaluate soft tissue
dystocia - Failure of descent

FETAL DIMENSIONS IN FETOPELVIC DISPROPORTION EFFECTS OF DYSTOCIA

Estimation of Fetal Head Size:
MATERNAL EFFECTS
1.Clinical-(Mueller Hillis Maneuver)  Intrapartum Infection
 Fetal brow and suboccipital region are grasped  Uterine Rupture
through the abdominal wall with the fingers and firm  Pathological Retraction Ring of Bandl
pressure is directed downward in the axis of the inlet o an exaggeration of the normal retraction ring
2.Sonogram-fetopelvic index o result of obstructed labor
o marked stretching and thinning of the lower
NO SATISFACTORY METHOD FOR PREDICTION OF FETOPELVIC uterine segment
DISPROPORTION o signifies impending rupture of the lower
uterine segment
CASE:  Fistula Formation
o vesicovaginal, vesicocervical, or rectovaginal
L.M., 26 years old, G1P0, was admitted at FEU-NRMF MC due to fistulas
hypogastric pain radiating to the lumbosacral area  Pelvic Floor Injury
 AOG: 39-40 wks  Postpartum Lower Extremity Nerve Injury
 FH: 32 cm o Footdrop
 FHT: 140s bpm  secondary to injury at the level of the
 IE: cervix 2 cm dilated 1cm long, intact BOW, cephalic, lumbosacral root, lumbosacral
station -1 plexus, sciatic nerve, or common
 Uterine contractions: 2-5 min, 50-60 sec, moderate peroneal nerve
intensity  usually caused by inappropriate leg
positioning in stirrups during a
Labor record: prolonged second stage of labor
2 hours later, IE: 3 cm, 1cm long, intact BOW, station -1 o symptoms resolve within 6 months of delivery
Uterine contractions: 2-5 min, 50-60 sec, moderate; FHT: 140 in most women.

4 hours later, IE: 4 cm, 0.5 cm long, intact BOW, station -1 FETAL EFFECTS
Uterine contractions: 2-5 min, 50-60 sec, moderate; FHT: 140  Caput Succedaneum
Amniotomy was done and revealed clear amniotic fluid  Fetal Head Molding
Oxytocin was started o associated with: nulliparity
oxytocin
6 hours later, IE: 6 cm, 0.5 cm long, station 0 vacuum extraction
2-3 mins strong contractions; FHT: 140  Skull fractures

8 hours later, IE: 6 cm, 0.5 cm long, station 0 RUPTURED MEMBRANES

2-3 mins. Strong contractions, FHT: 130
WITHOUT LABOR AT TERM
10 hours later, IE: 6 cm, 0.5 cm long, station 0
2-3 mins. Strong contractions, FHT: 130  (Calkins,1952)-Management: stimulation of
contractions when labor did not begin after 6 to 12
AP decided to do a Cesarean section hours
Below is the patient’s labor curve  (Hanna and Associates,2000)-Concluded that
induction with oxytocin immediately is better than
expectant due to lower incidence of intrapartum and
postpartum infections
 Parkland Hosp-induction is done after admission

BERNABE, Maria Katrina R. 4

Medicine 3i - 2015
 PRECIPITOUS LABOR AND DELIVERY
Case 2 Continuation: Amniotomy was done revealing clear
DEFINITION amniotic fluid.Oxytocin augmentation was given.After 1 hr
 extreme rapid labor and delivery (< 3 hours) ,cervix dilated to 7 cms,0.5 cms long,cephalic station 0.Uterine
contractions at 250 montevideo units.After 3hrs cervix remained
CAUSES: at 7 cms cervical dilatation cephalic, station 0 with caput and
o abnormally low resistance of the soft parts of molding.
the birth canal What is the diagnosis?
o abnormally strong uterine and abdominal How will you manage the patient?
contractions,
 rarely, absence of painful sensations and thus a lack of Case 3:
awareness of vigorous labor G1P0 PU 40 weeks admitted on the 11th hr of labor.Cervix 8 cms
dilated,fully effaced ,ruptured membranes cephalic station -
SHORT LABORS 2.Contractions were good at 200 montevideo units.After 2 hrs
 rate of cervical dilatation repeat IE revealed a 9 cms cervix,fully effaced,cephalic station -
nulliparas 5 cm/hr 2.Further observation done after 2 hrs and revealed same
multiparas 10 cm/hr findings.
What is the diagnosis?
 associated with: How will you manage this patient?
o abruption (20 percent)
o meconium Case 4:
o postpartum hemorrhage G1P0 PU 40 weeks admitted on the 10th hr of labor with
o cocaine abuse adequate uterine contractions.cervix 6 cms dilated,0.5 cms long
o low Apgar scores cephalic station-1.Amniotomy done which showed clear
o multiparity AF.Patient was sedated due to pain.
12th hr- 8cms dilated cephalic station 0
MATERNAL EFFECTS: 13th hr-fully dilated,cephalic station+1
 uterine rupture 15th hr-fully dilated ,cephalic,occiput posterior,station +1
 extensive lacerations of the cervix, vagina, vulva, or What is the diagnosis?How will you manage?
perineum
 amnionic fluid embolism Kindly recheck the answers and make the necessary
 postpartum hemorrhage from uterine atony corrections. 
(hemorrhage from the placental implantation site )

Serious maternal complications is RARE if:

 the cervix is effaced and compliant
 the vagina has been stretched previously
 the perineum is relaxed

FETAL/NEONATAL EFFECTS
 Perinatal mortality and morbidity due to decreased
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

CASE 1:
Diagnosis: Prolonged Latent Phase
SAMPLE CASES:
Management: Bed Rest, Sedation
Case 1
CASE 2:
G1P0 PU 39 weeks admitted on the 8th hour of
Diagnosis: Protracted Active Phase
labor.Contractions occurred every 3-4 minutes moderate
Management: Oxytocin
intensity. Cervix 1 cm dilated 1.5 cms long intact bag of waters
cephalic station -2.Repeat IE done after 5 hrs,cervix 2 cms
CASE 2 (cont):
dilated ,1cm long,cepahalic station -2.After 5 hrs repeat IE done
Diagnosis: Arrest of Cervical Dilatation
revealed same findings. Contractions were occurring 2-3 min.
Management: Cesarean Section
moderate to strong.Repeat IE done after 3hrs and revealed
3cms cervical dilatation,0.5 cms long,cephalic station -1.PLOT
CASE 3:
the findings and what is the diagnosis?
Diagnosis: Prolonged Deceleration Phase
Management: Oxytocin
Case 2:
G1P0 38 weeks admitted on the 10th hr of labor.Cervix4 cms
Diagnosis: Failure of Descent
dilated,0.5 cms long,BOW intact,cephalic station -1.Uterine
Management: Cesarean Section
contractions at 150 montevideo units.After 2 hours,cervix 5 cms
dilated,0.5 cms long.
CASE 4:
What is the diagnosis at this time?
Diagnosis: Arrest of Descent
How will you manage this patient?
Management: Cesarean Delivery
BERNABE, Maria Katrina R. 5
Medicine 3i - 2015