Dystocia

MARIA LOURDES E. PORRAS RM, RN, MAN

Dystocia

● Difficult labor
( placenta cord membranes and
amniotic fluid)

● Refers to any labor which does not

advance normally.
Factors:

● Abnormal uterine contractions or

forces.

● Abnormal position of the passenger

( infant).

● Abnormal passage way ( birth

canal).
I. Abnormal uterine contractions or forces
(DYSFUNCTIONAL LABOR)
● Uterine inertia
• Sluggishness of uterine contractions
during labor

2 types:
According to time it occurs
● Primary uterine inertia
● Secondary uterine inertia
1. Primary uterine inertia

Occurs at onset of labor or prolonged latent

phase of labor

Management:
stimulate without enemas, administer oxytocin
and encourage to walk.
2. Secondary uterine inertia

Occur later part of labor or prolonged active

phase of labor; fetus does not descend; cervix
not dilated.
B. Ineffective or abnormal uterine contractions

3 types:
According to strength

a. Hypertonic uterine contractions

b. Hypotonic uterine contractions
c. Uncoordinated uterine contractions
a. Hypertonic uterine contractions

● Greater than normal tension.

● Increase 15mmHg in resting tone
● Very painful- not relieve by exercise
anoxic uterine muscles
lack of relaxation
Management:

no oxytocin
rest and sedatives
darkened room; decrease noise
stimulation
provide support to client
ask client to breath with contractions
b. Hypotonic uterine contractions

● Tension is defective or inadequate to

cause or accomplish dilatations
● Decrease 10mmHg
● Uterine contractions not increasing
2-3 / 10 mins.
Causes:

1. Too early administration of analgesics

before 3-4 cm
2. Bladder/ bowel distended
3. Overstretch uterus-multiple gestation
4. Large fetus
5. Hydramnios
Management:

1. Administer oxytocin- increase strength tone

and effectiveness
Disadvantage:
● Cause maternal exhaustion and uterine
exhaustion
● Increase post-partal hemorrhage
secondary to ineffective contractions
● Prone to infection- over-dilation of cervix
2. Administer antibiotics
C. Uncoordinated uterine contractions

More than one contractions occur at the same

time due to myometrium -acts independently
from each other.

Management:
• fetal and uterine external monitor applied
q15
• Oxytocin to stimulate labor
Complication:

Mother:
exhaustion and dehydration

Fetus:
injury and death
II. Abnormal in the Passenger (Infant)

A. Congenital Anomalies
B. Abnormal fetal position/ Presentation
C. Cephalopelvic disproportion (CPD)
A. Congenital Anomalies

1. Hydrocephalus

2. Anencephalus

3.) Condition causing abdominal (fetal) distention,

overgrowth of liver (hepatomegaly), ascetic cysts, cystic
gastrointestinal functions), erythroblastosis fetalis (
large immature RBCs compensating for anemia
producing edema in peritoneum, pericardium and
pleural spaces)

Risk:
• Rupture of uterus
• Difficult delivery
4. Excessive fetal size > 71/2 Kg or 3, 400
grams

Cause: large parents, DM, prolonged

gestation, overeating, multiparous

5. Multiple Gestation, cord prolapsed, uterine

dysfunction, premature separation of the
placenta, abnormal fetal presentation, over
distended uterus-prone to hemorrhage
from uterine atony.
B. Abnormal fetal position/ Presentation

● Persistent occiput posterior

● Breech
● Face
● Brow- fetal head is halfway between flexion and
extension between vertex and face
● Transverse- long axis transversely lie across short
axis of uterus
● Compound- more than one fetal parts presenting
e.g. head and hand, head and foot
● Umbilical cord- cord lies in front of presenting part;
‘Vasa Previa’-prolonged cord

Note: do not allow client to ambulate after rupture of

BOW
Management:
A. Maneuvers
● Internal podalic version- Direct manipulation of the
baby inside the uterine activity to the breech
position is called internal podalic version.
● External podalic version- External cephalic Version
(ECV) refers to a procedure by which an
obstetrician or midwife turns the baby from the
breech to the cephalic position by manipulating the
baby through the maternal abdomen.

B. Trendelenburg position
● Relieve pressure of presenting part to cord

C. Bed rest after rupture of BOW

C. Cephalopelvic disproportion

● either Mother (contracted pelvis)

● fetus abnormally (large vertex)
III. Abnormal Passageway (Birth Canal)

1. Dysfunction of preparatory phase of labor

2. Dysfunction of dilatation phase of labor
3. Dysfunction in the pelvic phase (delivery) of the
labor
a. Preparatory phase

● Prolonged latent phase due to unequal,

irregular contraction
• Primi-20 hours
• Multi-14 hours
● Uterus in hypertonic state- Very painful and
frightening
● Fetal anoxia
● Monitor contractions and FHT
● Administration IV to prevent dehydration
● Administer morphine to relieve hypertonicity
b. Dilatation phase
1. Prolonged active labor= 4-8cm
Causes:
● fetal malposition and CPD
● Multi- 1.5 cm increase/ hour
● Nulli- 1.2 cm increase/ hour
2. Protracted descent
● Multi- descent rate 2cm/hr
● Nulli- descent rate 1 cm/hr
• Starts with good contractions then diminish gradually
and become infrequent and poor in quality

Assessment: anxiety, fear and apprehension or

discouragement
Management:

Amnionotomy (rupture of BOW)

Oxytocin drip
Keep client and kin informed of
situation
Management:

● No oxytocin
● Place in LLRP
● Oxygen inhalation
● Prompt assisted delivery large forceps
C. Delivery phase
Causes:

● CPD
● Prolonged deceleration

Characteristics:

● Extend beyond 3 hours (nulli), 1 hour (multi)

● Secondary arrest of dilatation- no progress in
dilatation of cervix >2 hours
● Arrest of descent- no descent occurred in one hour
● Failure of descent- does not begin
Management for Dystocia:
A. Preventive

1. Maintain serum glucose level (e.g. juices, candies,

IV-prevent glucose used up)
2. Prevent F/E loss- prevent dehydration; prevent DVT in
postpartum phase
3. Reduces stress
4. Give supportive measures; reduce pain; give praises,
back rubs, change soiled sheets
5. LLRP-give oxygen
6. Keep bladder empty
B. Curative Management Care
1. antibiotics
2.Sedative- stop abnormal contractions
3. Short acting barbiturates- to promote relax/
rest
4. Monitor FHB
5. NPO-prepare for surgery- CS
6. Assist in delivery, vaginal or CS
7. Trial Labor- in borderline or adequate pelvis
Conditions Complicating Dystocia

A. Precipitate delivery- uterine contractions are so

strong that the woman gives birth with only a
few rapidly occurring contractions
B. Pathologic Retraction Ring or Bandl’s ring
● Junction of upper and lower uterine
segment
● Sign that severe dysfunctional labor occurs
Assessment:

1. Horizontal indentation across abdomen

2. Uncoordinated contractions early in labor
3. Dilation phase- caused by obstetrical
manipulation and administration of oxytocin
Pathophysiology:

● Fetus is grasped by the ring and can’t

advance or descent
● If fetus is delivered, placenta can be
held after delivery
Management:
1. Observe abdominal report immediately
2. Administer IV morphine sulfate and amyl nitrate
3. C/S –or menstrual extraction of placenta if not
attended leads to Mother (Uterine rupture and
postpartum hemorrhage); fetus (death)
C. Rupture of Uterus

Factors:
● Strained uterus
● Its capacity
● Previous CS, repair on hysterectomy
Contributory:

● Prolonged labor
● Faulty presentation
● Multiple gestation
● Unwise use of oxytocin
● Obstruction labor
● Traumatic maneuvers using forceps
Assessment
1. Impending rupture suggested by pathologic resting
strong uterine contractions with cervical dilatation

Management:
● Immediate CS

2. When uterus ruptures

● S/S: sudden severe pain during strong labor,

hemorrhage- uterus, vagina, intra-abdominal,
Cullen’s sign
D. Uterine Inversion

● Fundus is formed thru the cervix, turned

inside out
Causes:
● Attachment of placenta at fundus-sudden
delivery of fetus without support-fundus is
pulled down
● Strong fundal push
● attempts to deliver placenta before
separation
Management:

● Hysterectomy-due to severe
hemorrhage
E. amniotic Fluid Embolism (Lung)

● Amniotic fluid is forced into circulation

thru open maternal sinuses

● S/S as any embolism- fatal

Management:

1. Supportive- prognosis depends on

the size of the embolism and the
skills and the emergency aid
available
2. Oxygen administration
3. CPR
4. ICU care