ABNORMAL

LABOR
GROUP 2
 DYSTOCIA
-difficult labor
-abnormally slow progress
-Three abnormalities:
● Powers
-uterine contractions may be insufficiently strong or inappropriately coordinated to efface
and dilate the cervix
● Passenger
-fetal abnormalities of presentation, position or anatomy may slow progress
● Passage
-structural changes can contract the maternal bony pelvis
-soft tissue abnormalities of the reproductive tract may block fetal descent
Ineffective labors
● Cephalopelvic disproportion (CPD)
-obstructed labor resulting from disparity between the fetal head size and maternal pelvis
● Failure to progress
-reflects lack of progessive cervical dilation or halted fetal descent
 ABNORMALITIES OF UTERINE
EXPLOSIVE FORCES
TYPES OF UTERIN DYSFUNCTION
-Two physiological types:
● Hypotonic uterine dysfunction
-basal tone is normal and uterine contracts have a normal gradient pattern (synchronous)
-pressure during contraction is insufficient to dilate the cervix
● Hypertonic Uterine/ Incoordinate Uterine Dysfunction
-either basal tone is elevated appreciably or the pressure gradient is distorted
RISK FACTORS FOR UTERINE DYSFUNCTION
-Neuraxial analgesia can slow labor has been associated with longer first and second stages
-Chorioamnionitis is associated with prolonged labor
-Affected gravidas are monitored for labor progress, and augmentation of protracted labor is
prudent
-Dystocia rate rises proportionally with maternal age even after adjusting for maternal and fetal
weight parity
-Maternal obesity lengthens the first stages of labor by 30 to 60 minutes in nulliparas, even after
adjusting for associated diabetes, fetal weight, and parity
LABOR DISORDERS
Latent-phase prolongation
-may be prolonged, which is defined as >20 hours in the nullipara and >14 hours in
the multipara
-often treated with amniotomy and oxytocin stimulation
-Women who are not yet in active labor often are erroneously treated for perceived
uterine dysfunction
Active-phase disorders
● Protraction disorder
-slow progress
● Arrest disorder
-halted progress
Second-stage Descent Disorders
-incorporates many of cardinal movements necessary for the fetus to negotiate birth
canal
-disproportion of the fetus and pelvis frequently becomes apparent during second-stage
labor
-Second stage in nulliparas: limited to 2 hours and extended to 3 hours when regional
analgesia is used
-Multiparas: 1 hour has been the limit, extend to 2 hours with regional analgesia
-Higher rates of chorloamnionitis, anal sphincter injury, operative vagainal birth, and
postpartum hemorrage accrue as the second stage lengthens
-The goal to lower cesarean delivery rates is best balance with one to ensure neonatal
safety
-Recommended: Nullipara push for at least 3 hours and a multipara push for at least 2
hours before second-stage labor arrest is diagnosed
-The second stage significantly lengthened concomitantly with increasing first stage
duration
-The 95th percentile was 15.6 and 2.9 hours for the first and second stages
-Women with first stages stages lasting longer than 15.6 hours (>95th percentile) had a
16-percent rate of second stage labor lasting 3 hours (95th percentile)
Maternal Pushing Efforts
-The combined force created by contractions of the uterus and abdominal
musculature propels the fetus downward
-Force created by abdominal musculature is compromised sufficiently to
slow or even prevent spontaneous vaginal delivery
-Heavy sedation or regional analgesia may reduce the reflux urge to push
and may impair the ability to contract abdominal muscles sufficiently
-The urge to push is overridden by the intense pain created by bearing
down
-Options include emotional support and encouragement, parenteral
analgesia, pudendal blockade or neuraxial analgesia
 PREMATURELY RUPTURED
MEMBRANES AT TERM
-Membrane rupture at term without spontaneous uterine contractions complicates
approximately 8% of pregnancies
-Labor stimulation was initiated if contractions did not begin after 6 to 12 hours
-Labor induction with intravenous oxytocin was preferred management
-Significantly fewer intrapartum and postpartum infections in women whose labor
was induced
-Reported lower rates of chorioamnionitis, metritis, and neonatal intensive care unit
admissions for women with term ruptured membrane whose labors was induced
compared with those managed expectantly
-Hypotonic contractions or with advanced cervical dilation: oxytocin is selected to
lower potential hyperstimulation risk
-Unfavorable cervix: no or few contraction, and no significant fetal heart rate
decelerations, prostaglandins E1 (Misoprostol) is chosen to promote cervical
ripening and contractions
-Membranes ruptured longer than 18 hours, antibiotics are instituted for group B
streptococcal infection prophylaxis
 PRECIPITOUS LABOR AND DELIVERY
Precipitous Labor and Delivery is extremely rapid labor and
delivery
● It may result from:
○ Abnormally low resistance of the soft parts of the birth
canal
○ Abnormally strong uterine and abdominal contractions
○ Lack of pain with contractions to cue advanced labor
(rarely)

● Precipitous labor terminates in expulsion of the fetus in <3

hours
 PRECIPITOUS LABOR AND DELIVERY
Complication may happen when vigorous uterine contractions combined with
a long, firm cervix and a noncompliant birth canal may lead to uterine rupture or
extensive lacerations of the cervix vagina, vulva, or perineum
❏ Amnionic fluid embolism most likely develops

Maternal complications is avoided:

❏ If the cervix is effaced appreciably and compliant
❏ If the vagina has been stretched previously
❏ If the perineum is relaxed

● Precipitous labor is frequently followed by uterine atony

● Precipitous labors have been linked to cocaine abuse and associated with
placental abruption, meconium, postpartum hemorrhage and low APGAR
scores
 PRECIPITOUS LABOR AND DELIVERY
Reasons for adverse perinatal outcomes:
● Uterine contractions
○ Often with negligible intervals of relaxation it prevents
appropriate uterine blood flow and fetal oxygenation
● Related to trauma
○ Resistance of the birth canal rarely may cause intracranial
injury
● During unattended birth
○ Newborn may fall to the floor and be injured
● Needed resuscitation not immediately available due to delivery
speed
 PRECIPITOUS LABOR AND DELIVERY
Treatment/Management
● Single, intramuscular 250 ug terbutaline
○ in attempting to resolve a nonreassuring fetal heart rate
pattern
● Oxytocin administration should be stopped

❏ Tocolytic agents (magnesium sulfate or terbutaline) effect is

unproven in treatment
❏ Analgesia is unlikely to modify forceful contractions significantly
 FETOPELVIC DISPROPORTION
● Fetopelvic disproportion arises from diminished
pelvic capacity or from abnormal fetal size, structure,
presentation, or position
● The pelvic inlet, midpelvis, or pelvic outlet may be
contracted solely or in combination
● Any contraction of the pelvic diameters that
diminishes pelvic capacity can create dystocia
 FETOPELVIC DISPROPORTION
Contracted Inlet
● An anteroposterior diameter of <10 cm inlet or a transverse diameter of <12
cm demonstrates difficulty in delivery
○ When both diameters are shortened, dystocia rates are much greater
than when only one is diminished
● Normally, cervical dilation is aided by hydrostatic action of the unruptured
membranes or by direct application of the presenting part against the cervix
after membrane rupture. But in contracted pelves, because the head is
arrested in the pelvic inlet, the entire force exerted by contractions acts
directly on the portion of membranes that contract the dilating cervix.
Therefore, early spontaneous rupture of the membranes is more likely
● After membrane rupture, absent pressure by the head against the cervix and
lower uterine segment predisposes to less effective contractions. Hence,
further dilation may proceed very slowly or not at all
 FETOPELVIC DISPROPORTION
● A contracted inlet plays an important part in the
production of abnormal presentations
○ Descent usually does not take place until after labor
onset, if at all
○ Cephalic presentations predominate
○ In women with contracted pelves, face and shoulder
presentations are encountered more frequently, and
the cord prolapses more often
 FETOPELVIC DISPROPORTION
Contracted Midpelvis
● This finding is more common than inlet contraction
● Frequently causes transverse arrest of the fetal head, which can lead to a difficult
midforceps operation or to cesarean delivery
● Midpelvis is likely contracted when the sum of the interspinous and posterior
sagittal diameters of the midpelvis falls to 13.5cm or less (Normally, 10.5 plus 5 cm
or 15.5 cm)
● Midpelvic contraction is suspected when the interspinous diameter is <10 cm,
when it measures <8 cm the midpelvis is contracted
● If spines are prominent, pelvic sidewalls converge, or the sacrosciatic notch is
narrow it suggests contraction
● A normal intertuberous diameter does not always exclude a narrow interspinous
diameter
 FETOPELVIC DISPROPORTION
Contracted Outlet
● This finding usually is defined as an interischial tuberous diameter of 8 cm or less
● Diminution of the intertuberous diameter with consequent narrowing of the anterior
triangle must inevitably force the fetal head posteriorly
● Not so much causes dystocia by itself but by an often associated midpelvic
contraction
○ Outlet contraction without concomitant midplane contraction is rare
● May play an important role in perineal tears
○ Increased narrowing of pubic arch > occiput cannot emerge directly beneath
the symphysis pubis > forced father down upon the ischiopubic rami >
perineum becomes increasingly distended > thus exposed to risk of laceration
 FETOPELVIC DISPROPORTION
Pelvic Fractures
● Trauma from automobile collisions was the most common cause
● Fracture pattern, minor malalignment, and retained hardware are not absolute
indications for cesarean delivery
● In determining vaginal delivery candidates, fracture healing requires 8-12 weeks and
thus recent fracture merits cesarean delivery
● With healed fractures, care includes review of pelvic radiographs and possible
pelvimetry later in pregnancy
 FACE PRESENTATION
Etiology and Diagnosis
● In face presentation, the neck is hyperextended so that the occiput is in contact
with the fetal back, and the mentum is presenting
● Causes:
○ Conditions that favor neck extension or prevent flexion
○ Preterm fetuses
○ Multifetal gestations
○ High parity
● Extended neck positions develop more frequently when the pelvis is contracted or
the fetus is very large
● Face presentation is diagnosed by vaginal examination and palpation of facial
features
● Breech may be mistaken for a face presentation
● Sonography can aid unclear cases
● Radiographs demonstrate a hyperextended head with the facial bones at or below
the pelvic inlet
 FACE PRESENTATION
Mechanism of Labor
● Fetal face may present with the mentum anteriorly, transversely, or posteriorly
relative to the maternal symphysis pubis
● Most convert spontaneously to an anterior position, even as late as second stage
labor
● With the mentum anterior, internal rotation of the face brings the chin under the
symphysis pubis
○ This way the neck can then transverse the posterior surface of the symphysis
pubis
● After anterior rotation and descent, the chin and mouth appear at the vulva, and the
undersurface of the chin presses against the symphysis. Once the chin clears the
symphysis, the neck can flex
● The nose, eyes, brow, and occiput then appear in succession over the anterior
margin of the perineum
● After birth of the head, the occiput sags backward toward the anus
● The chin rotates externally to the side toward which it was originally directed, and
the shoulders are born as in cephalic presentations
 FACE PRESENTATION
Management
● Fetal heart rate monitoring during labor
● Cesarean delivery / Low or outlet forceps delivery
● Vacuum extraction and Conversion methods and are dangerous and
are not recommended
 BROW PRESENTATION
In brow presentation, the fetal head is midway between full flexion (vertex) and hyperextension ( face) along
a longitudinal axis. The presenting portion of the fetal head i between the orbital ridge and the anterior fontanel. The face and
chin are not included.

Epidemiology:

Brow presentation is the least common of all fetal presentations and the incidence varies from 1 in 500 deliveries to 1
in 1400 deliveries.

Position:

● The frontal bones are the point of designation and can present ( as with the occiput during a vertex delivery) in any
position relative to the maternal pelvis.
● When the sagittal suture is transverse to the pelvic axis and the the anterior fontanel is on the right maternal side, the
fetus would be in the right fronto-transverse position.
● Most frequent positions are : right fronto - posterior position and left fronto - anterior position.
 ● Vaginal examination in labor:

The orbital ridge, eyes, nose, forehead and anterior fontanel are palpated. The mouth and chin are
not palpated, thus excluding face presentation.

● Fetal ultrasound evaluation again notes a hyperextended neck.

Mechanism of labor:

Three labor courses are possible when the fetal head engages in a brow presentation:

● The brow may convert to a vertex presentation

● The brow may convert to a face presentation or
● Remain as persistent brow presentation

More than 50% of brow presentation will convert to vertex or face presentation and labor courses are
managed accordingly when spontaneous conversion occurs.
Diameter: The presenting diameter is occipito - mental ( 13.5 cm)

Etiology:

● Maternal factors include cephalopelvic disproportion or pelvic contracture, uterine malformation,iterin

fibroma
● Ovular factors include fetal malformations, short neck, small fetal thyroid enlargement, musculoskeletal
abnormality, placenta praevia, polyhydramnios, premature rupture of the membranes (27%)

Diagnosis:

Diagnosis of brow presentation can occasionally be made with abdominal palpation of leopold maneuvers

● A prominent occipital prominence is encountered along the fetal back and the fetal chin is also palpable
● However, the diagnosis of brow presentation is usually confirmed by examination of a dilated cervix.
 In the brow presentation, the occipitomental diameter which is the largest diameter of the fetal head, is
the presenting portion.

● Descent and internal rotation occur only with an adequate pelvis and if the face can fit under the pubic
arch.

● While the head descend, it becomes wedged into the hollow of the sacrum. Downward pressure from
uterine contractions and maternal expulsive forces may cause the mentum to extend anteriorly and low to
present at the perineum as a mentum anterior face presentation.

● If the mentum is anterior and the forces of labor are directed toward the fetal occiput, flexing the head and
pivoting the face under the ubic arch, there is conversion to a vertex occiput posterior position.

● If the occiput lies against the sacrum and forces of labor are directed against the fetal mentum, the neck
may extend further leading to a face presentation.

● there is no mechanism of successful labor for a term sized persistent brow under most circumstances and
therefore vaginal delivery is impossible. howerver bvaginald elivary can occur if the fetus is quite small otr
if the pelvis is very large.
Management:

● If dilatation and descent are progressing normally, expectant management is best.

● Forceps deliveries are acceptable if the brow converts to MA face or vertex.

● Once progress in labor has ceased, persistent brow presentation requires a cesarean delivery and all
operative vaginal maneuvers are contraindicated.

● Birth evolution prognosis is reversed.

 TRANSVERSE LIE
● When the long axis forms an acute angle, an oblique lie results. The latter is usually only transitory
because either a longitudinal or transverse lie commonly results when labor supervenes.

● The position is determined by the direction of the back which is the denominator.

● In transverse lie, the shoulder is usually positioned over the pelvic inlet. The head occupies one iliac fossa
and the breech the other.

● This creates a shoulder presentation in which the side of the mother on which the acromion restes
determines the designation of the lie as right or left acromial.

Position:

● Dorsoanterior, which is the commonest (60%). The flexor surface of the fetus is better adapted to the
convexity of the maternal spine.
● Dorsoposterior
● Dorso-superior
● Dorsi Inferior
● In dorsoposterior, chance of feta extension is common with increased risk of arm prolapse.According to the
position of the head, the fetal position is termed right or left, the left one being commoner than the right
Etiology:

● Abdominal wall relaxation from high parity,

● Preterm fetus
● Placenta praevia
● Abnormal uterine anatomy
● Hydramnios
● Contracted pelvis

Diagnosis:

Abdominal examination:

● Inception: The uterus looks broader and often asymmetrical, not maitiang the pyriform shape
● Palpation: The fundus height is less than the period of amenorrhea
* Fundal group - Fetal pole ( breech or head) is not palpable
● Lateral grip:

Soft, broad and irregular breech is felt to one side of the midline and smooth, hard and positions of
transverse lie
* Dorsoanterior and
* Dorsoposterior globular head is felt on the other side. The head is usually placed at a lower level
on one iliac fossa.

The back is felt anteriorly across the long axis in dorso anterior or the irregular small parts are felt
anteriorly in dorsoposterior.

● Pelvic grip : The lower pole of the uterus is found empty

● Auscultation: FHS is heard easily much below the umbilicus in dorsoanterior position. FHS is however
located at higher level and often indistinct in dorsoposterior position.

● Ultrasonography and radiography confirms the diagnosis

Vaginal examination:

● Soft parts.
● Shoulder: acromion process, the scapula, the clavicle and axilla.
● Prolapsed arm: transverse lie, compound presentation. .
● Supine: The palm corresponds to ventral aspect. .
Mechanism of Labor:

● Spontaneous delivery is impossible

● After rupture of membranes, if labor continues fetal shoulder i forced into the pelvis - Arm prolapses
● Uterus contracts vigorously in an unsuccessful attempt to overcome the obstacle.
● With time retraction ring rises increasingly higher and becomes more marked

Neglected transverse lie:

● If not promptly managed- uterine rupture

Mechanism of labor:

● Morbidity increased because of

- Frequent association with placenta previa
- Increased likelihood of cord prolapse
- necessary for major operative efforts
 ● Small fetus (less than 800 g) + large pelvis - Spontaneous delivery is possible
● Conduplicato corpore:
Head and thorax pass through the pelvic cavity at the same time and fetus which is doubled upon
itself is expelled.

Management:

● Cesarean delivery is done in a women with transverse lie

● Vertical incision is indicated - Because a low transverse incision into uterus may lead to difficulty in
extraction of a fetus entrapped in the body of the uterus above the level of incision since neither feet nor
hed occupies the lower uterine segment
 COMPOUND PRESENTATION
Incidence and Etiology:

● An extremity prolapses alongside the presenting part, and both present simultaneously in the pelvis .
● Much less common was prolapse of one or both lower extremities alongside a cephalic presentation or a
hand alongside a breech.
● Causes of compound presentations are conditions that prevent complete occlusion of the pelvic inlet by
the fetal head, including preterm labor.

Management and Prognosis

● In most cases, the prolapsed part should be left alone, because most often it will not interfere with labor. If
the arm is prolapsed alongside the head, the condition should be observed closely to ascertain whether
the arm retracts out of the way with descent of the presenting part.

● The infant developed ischemic necrosis of the presenting forearm, which required amputation.
 COMPLICATIONS WITH DYSTOCIA
Maternal Complications:

● Dystocia, especially if labor is prolonged, is associated with an increased incidence of several common
obstetrical and neonatal complications.
● Intrapartum chorioamnionitis and postpartum pelvic infection are more common with desultory and
prolonged labour.
● Postpartum hemorrhage from atony is increased with prolonged and augmented labors. There is also a
higher incidence of uterine tears with hysterotomy if the fetal head is impacted in the pelvis.

Uterine Rupture

● Abnormal thinning of the lower uterine segment creates a serious danger during prolonged labor,
particularly in women of high parity and in those with a prior cesarean delivery .
● When disproportion is so pronounced that there is no engagement or descent, the lower uterine segment
becomes increasingly stretched, and rupture may follow. In such cases, there is usually an exaggeration of
the normal contraction ring.
Pathological Retraction Ring:

● Localized rings or constrictions of the uterus develop in association with prolonged obstructed labors that
are seldom encountered today.
● The pathological retraction ring of Bandl is associated with marked stretching and thinning of the lower
uterine segment.
● Following birth of a first twin, a pathological ring may still develop occasionally as hourglass constrictions
of the uterus.

Fistula Formation

● With dystocia, the presenting part is firmly wedged into the pelvic inlet and does not advance for a
considerable time.
● Tissues of the birth canal lying between the leading part and the pelvic wall may be subjected to excessive
pressure.
● Because of impaired circulation, necrosis may result and become evident several days after delivery as
vesicovaginal, vesico cervical, or rectovaginal fistulas. Most often, pressure necrosis follows a very
prolonged second stage.
Pelvic Floor Injury :

● During childbirth, the pelvic floor is exposed to direct compression from the fetal head and to downward
pressure from maternal expulsive efforts.
● These forces stretch and distend the pelvic floor, resulting in functional and anatomical alterations in the
muscles, nerves, and connective tissues.
● There is accumulating evidence that such effects on the pelvic floor during childbirth lead to urinary
incontinence and to pelvic organ prolapse.

Postpartum Lower Extremity Nerve Injury:

● The most common mechanism is external compression of the common fibular (formerly common peroneal)
nerve. This is usually caused by inappropriate leg positioning in stirrups, especially during prolonged
second-stage labor.

Perinatal Complications:

● Similar to the mother, the incidence of peripartum fetal sepsis is increased with longer labors.Mechanical
trauma such as nerve injury, fractures, and cephalohematoma are also more frequent.
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