OBSTETRICS II

LE 2: DYSTOCIA: POWER AND PASSENGER

Dr. M. De Guzman

EVIDENCE FOR ADEQUATE AND ARRESTED LABOR

DYSTOCIA 1. Arrest of labor
− Difficult labor − Dx should not be made until adequate time has
− Abnormalities that may interfere with the orderly elapsed
progression spontaneous delivery
2. Adequate labor
4 DISTINCT ABNORMALITIES − >6cm dilatation w/ membrane rupture and 4 or more
1. Power of the mother (uterine contractions + abdominal hrs of adequate contractions (200 Montevideo units)
muscle contractions) − 6 hrs or more if contractions are inadequate w/ no
2. Passenger: baby (characteristics of the fetus: size, cervical change
position or presentation)
3. Passage: pelvic bones or cavity 3. Second stage labor
4. Soft tissue abnormalities: impede normal flow of − No progress for >4hrs in nulliparous women w/ an
delivery epidural
− >3hrs in nulliparous women w/o an epidural

I. DYSTOCIA DUE TO ABNORMALITIES OF *No CS before these time limits

POWERS

COMMON CLINICAL FINDINGS IN WOMEN WITH TYPES OF UTERINE DYSFUNCTION

INEFFECTIVE LABOR 1. Hypotonic uterine dysfunction
1. Inadequate cervical dilatation or fetal descent − No basal hypertonous
a) Protracted labor – slow progress − Uterine contractions have a normal gradient pattern
b) Arrested labor – no progress − Pressure during contractions is insufficient to dilate
c) Inadequate expulsive effort – ineffective pushing the cervix

2. Fetopelvic disproportion 2. Hypertonic uterine dysfunction

a) Excessive fetal size − Incoordinate uterine dysfunction
b) Inadequate pelvic capacity − Basal tone is elevated appreciably or pressure
c) Malpresentation or position of the fetus gradient is distorted
• More forceful contraction of the uterine
3. Ruptured membranes without labor midsegment than the fundus
NOTE!!!! ALWAYS INDICATION of CEPHALOPELVIC • Complete asynchrony of the impulses originating
DISPROPORTION (CPD) in each cornu

3. Combination of both
FACTORS INFLUENCING THE PROGRESS OF THE 1st
STAGE OF LABOR
1. Uterine contractions: synchronous manner ACTIVE PHASE DISORDERS
(cornua→fundus→body of uterus→ LUS) Active Phase: Cervical Dilatation at least 4cms
FUNDUS: strongest contraction
1. Protraction disorder
2. Cervical resistance: collagen fibers and fibrils failed to
− Slower-than-normal progress
dilate.
Most common cause: CPD − <1 cm/hr cervical dilatation for a minimum of 4hrs

2. Arrest disorder
3. Forward pressure exerted by the leading fetal part
Fetus not in cephalic presentation: no help in dilation of − Complete cessation of progress
cervix − No dilatation for 2 hrs or more
− Inadequate uterine contractions (<180Montevideo
units)
DIAGRAMS OF BIRTH CANAL
1st STAGE LABOR ARREST
− Latent phase has been completed
− Cervix is dilated 4 cms or more
− Uterine contraction pattern of 200 Montevideo units or
more in a 10 minute period has been present for 2 hrs
w/o cervical change (“2 hr rule”)
o ACOG 2013
o Rousse & associates (1999)
▪ At least 4 hrs is necessary before concluding
A) At the end of pregnancy that the active phase of labor has failed
B) During the second stage of labor, showing formation of
the birth canal
2nd STAGE DISORDERS
1. Arrest of descent
2. Failure of descent
− Fetal descent largely follows complete dilatation

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 OBSTETRICS II
LE 2: DYSTOCIA: POWER AND PASSENGER
Dr. M. De Guzman

− 2nd stage incorporates many of the cardinal − Multiparas: 1 hr, extended to 2 hrs with regional
movements of labor analgesia
− Disproportion of the fetus and pelvis→apparent − After 3 hrs in the 2nd stage, delivery by CS or other
− Nulliparas: limited to 2 hrs and extended to 3 hrs with operative method increases progressively
regional analgesia − By 5 hrs in the 2nd stage – only 10-15% chance of
spontaneous delivery
MEMORIZE THIS TABLE!

ADVERSE MATERNAL OUTCOMES WITH FETAL STATION AT ONSET OF LABOR

PROLONGED 2nd STAGE OF LABOR − Engagement: descent of the leading edge of the
✓ Cesarean delivery presenting part to the level of the ischial spines
✓ Instrumented delivery (station 0)
✓ Perineal trauma − Fetal station at the time of arrested labor – risk factor
✓ Postpartum hemorrhage for dystocia
✓ Chorioamnionitis − 5% CS rate for fetal head at or below station 0
− 14% CS rate for those with higher stations (-1 to -5)
RELATIONSHIP BETWEEN 1st AND 2nd STAGE OF
LABOR DURATION
− The length of the 2nd stage significantly REPORTED CAUSES OF UTERINE DYSFUNCTION
increased concomitantly with increasing ✓ Epidural analgesia: impaired sensory
length of the 1st stage lasting >15.6 hrs had ✓ Chorioamnionitis
a 16.3% rate of a 2nd stage labor lasting 3 ✓ Maternal position during labor
hrs • Recumbency ambulation
✓ Birthing in the 2nd stage of labor
• Upright supine or lithotomy
✓ Water immersion: help in labor

PREMATURELY RUPTURED MEMBRANES AT TERM

− Risk for CPD
− Complicates 8% of pregnancies
− Mx: labor stimulation if contractions did not begin after 6-
12 hrs
• Augmentation with Oxytocin

PRECIPITOUS LABOR AND DELIVERY

− Precipitous: Abnormally rapid labor
MATERNAL PUSHING EFFORTS − Rate of cervical dilatation of 5 cm/hr (nullipara) or 10
− The combined force created by contractions of the cm/hr (multipara)
uterus and abdominal musculature propels the fetus − May result from:
downward (“bear down” or “push”)
✓ Abnormally low resistance of the soft parts of the
− Heavy sedation or regional anesthesia may reduce birth canal
the reflex urge to push and may impair the ability to ✓ Abnormally strong uterine and abdominal
contract abdominal muscles sufficiently contractions
− Intense pain created by bearing down may override the ✓ Absence of painful sensations and lack of
inherent urge to push awareness of vigorous labor
− Expulsion of fetus in <3 hrs

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 OBSTETRICS II
LE 2: DYSTOCIA: POWER AND PASSENGER
Dr. M. De Guzman

Serious maternal complications: • Usually undergo spontaneous anterior rotation followed by

✓ Cervix is effaced appreciably and compliant uncomplicated delivery
✓ Vagina has been stretched previously RISK FACTORS
✓ If the perineum is relaxed 1. Epidural analgesic
2. Nulliparity
COMPLICATIONS 3. Greater fetal weight
− Uterine rupture 4. Prior Occiput posterior position delivery
− Extensive lacerations of cervix, vagina, vulva, or MORBIDITY
perineum 1. Prolonged second stage of labor
− Amniotic fluid embolism 2. Increased CS delivery and operative vaginal
− Uterine atony delivery (Forceps or Vacuum)
3. Increased blood loss (vaginal delivery)
FETAL AND NEONATAL EFFECTS 4. Higher order vaginal lacerations (3rd • and 4th
− Prevent appropriate uterine blood flow and fetal degree laceration)
oxygenation
− Intracranial trauma due to resistance of the birth canal
− Duchenne brachial palsy
− Newborn may fall to the floor and be injured

TX
✓ Tocolytic agents (MgSO4) – unproven
✓ General anesthesia (isoflurane) – excessively heroic
✓ Stop any oxytocin agents

SIGNIFICANT ADVANCES IN THE TX OF UTERINE

DYSFUNCTION
− Undue labor prolongation may contribute to maternal
and perinatal morbidity and mortality rates
− Dilute IV infusion of oxytocin as Tx for certain types of
uterine dysfunction
− CS > difficult midforceps delivery when oxytocin fails or
its use is inappropriate
II. DYSTOCIA DUE TO ABNORMALITIES OF THE
FETUS (PASSENGER)
Fetal Dimensions In Fetopelvic Disproportion
− Asynclitism
− Occiput posterior position
− Face presentation
− Brow presentation
Asynclitism
• Determine the position of the fetal occiput
with respect to the maternal pelvis
• The side to which the occiput is positioned
will indicate the laterality of the asynclitism
a.anterior. R or L
(ROA.LOA.OA)
b.posterior, R or L
(ROP,LOP,OP)
• In anterior asynclitism, the presenting parietal bone will be
opposite to which side it is rotated
• Common complications: arrest of fetal descent
ASYNCLITISM COMMON ETIOLOGIES
o Abnormal/peculiar maternal bony pelvic anatomy
o Tone of the pelvic musculature
o Force and consistency of uterine contractions
o Increased diameter of fetal cranium
o Naegele's obliquity : if the sagittal suture is felt to be
curving anteriorly
o Litzmann's obliquity : if the sagittal suture is felt to be
curving posteriorly
• PERSISTENT Occiput posterior position
• 2-10 % of deliveries; Does not rotate, hence persistent
• Transverse narrowing of the midpelvis is undoubtedly a
contributing factor
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*Occiput posterior presentation in early labor compared
with presentation at delivery.
Ultrasonography was used to determine position of the
fetal head in early labor
POSSIBILITIES OF VAGINAL DELIVERY
ARE:
• Spontaneous delivery
• Forceps delivery with the occiput directly posterior
• Manual rotation to the anterior position followed by
spontaneous or forceps delivery
• Forceps rotation of the occiput to the anterior position
and delivery
Delivery of P.O.P.
• Spontaneous Vaginal Delivery
o Roomy pelvic outlet or relaxed perineum
• Manual rotation to occiput anterior and spontaneous
deliver
o Resistant vaginal outlet or form perineum
• Forceps or Vacuum delivery
o Ineffective expulsive efforts Must meet criteria for
forceps or vacuum delivery
• Cesarean section
Elongation of fetal head (molding/caput
succidaneum) Head not engaged
DELIVERY
• If rotation ceases because of poor expulsive forces and
pelvic contractures are absent, vaginal delivery usuallyncan
be accomplished with oxytocin infusion
• The occiput may be manually rotated anteriorly or posteriorly
and forceps delivery performed from either the anterior or
posterior position
• Application of Kielland forceps to the fetal head to rotate the
occiput to the anterior position, and then deliver the head
either with the same forceps or with
• Simpson or Tucker-McLane forceps
• Difficult rotation is expected on platypelloid and android
(heartshaped) pelvis. Persistent occiput transverse
is seen in patypelloid pelvis
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 OBSTETRICS II
LE 2: DYSTOCIA: POWER AND PASSENGER
Dr. M. De Guzman

FACE PRESENTATION BROW PRESENTATION

Lie: Longitudinal
Presentation: Cephalic
Presenting part: Face
Attitude: Complete extension
Denominator & leading role: Chin (mentum)
Presenting diameter: Submentobregmatic (9.5 cm) Attitude: Partial extension
Presenting part: area between the orbital ridges and the
ETIOLOGY bregma
− Preterm infants Denominator: forehead
− Fetal malformations and hydramnios Presenting dm: verticomental = 13.5 cm
− Anencephalic fetus (longest anteroposterior dm of the fetal
− Inlet contractiions head)
− High parity
ETIOLOGY
DIAGNOSIS
− Vaginal examination and palpation of facial features − Cephalopelvic disproportion
− The clue to diagnosis is a negative finding − Some fetal conditions that prevent flexion
• Tumors of the neck, e.g., thyroid
− Softer and irregular presenting part (in place of the
dome of the skull) • Coils of umbilical cord around the neck
− X-ray: hyperextended head with the facial bones at or • Fetal anomalies
below the pelvic inlet − Increased fetal mobility
• Polyhydramnios
MECHANISM OF LABOR • Small or premature baby
1. Extension − Premature rupture of membranes
2. Descent − Uterine anomalies
3. Internal rotation • Neoplasm of the lower segment
4. Flexion • Bicornuate uterus
5. Restitution
− Abnormal placental implantation: placenta previa
6. External rotation
− Iatrogenic: external version
7. Molding
No engagement! − Idiopathic: nearly 30% are unexplained

MANAGEMENT (ANTERIOR FACE PRESENTATION) MECHANISM OF LABOR

1. Extension
− Disproportion: cesarean section
2. Descent – slow and late
− Normal pelvis: most deliver spontaneously or with the
3. Internal rotation
aid of low forceps
4. Flexion
− FHR monitoring with external devices to avoid damage 5. Extension
to the face and eyes
− DO NOT ATTEMPT: *spontaneous delivery is rare, and can take place only
✓ Manual conversion into a vertex presentation when there is the combination of a large pelvis, strong
✓ Manual or forceps rotation of posterior chin to a uterine contractions, and a small baby
mentum anterior position *molding is extreme
✓ Internal podalic version and extraction *the verticomental dm is compressed
*the occipitofrontal dm is elongated markedly, so that the
MANAGEMENT (POSTERIOR FACE PRESENTATION) forehead bulges greatly
− Disproportion: cesarean section *face is flattened, and the distance from the chin to the top
− Trial of labor: 2/3 of cases rotate anteriorly of the head is long. This is exaggerated by the large caput
− Persistent posterior face: operative interference is succedaneum that forms on the forehead
necessary
− Cesarean section – Tx of choice MANAGEMENT
− Trial of labor – in the hope that flexion to an occiput
presentation or complete extension to a face presentation
will take place
− Persistent brow presentation – cannot deliver
spontaneously
• Cesarean section – tx of choice

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 OBSTETRICS II
LE 2: DYSTOCIA: POWER AND PASSENGER
Dr. M. De Guzman
o Flexion of the head – may be attempted in multiparas;
carried out when the cervix is fully dilated and soon after
the membranes have ruptured. If success is not
immediate, the procedure must be abandoned in favor
of caesarean section without delay
TRANSVERSE LIE
In desperate situations, a destructive operation can be
performed on the child. Decapitation is carried out, the trunk is
delivered, and then the head is extracted by forceps
− When the long axes of the mother and fetus are right
angles to one another
− Referred to as shoulder presentation
− Denominator: scapula
− The situation of the head determines whether the
position is left or right, and that of the back indicates
whether it is anterior or posterior (LScP-lie is transverse,
the head is on the mother’s left side, and the baby’s back
is posterior)
DIAGNOSIS
− Appearance of the abdomen is assymetrical
− Long axis of the fetus is across the mother’s abdomen
− Uterine fundus is lower than expected for the period
of gestation. It has been described as squat uterus
− Palpation of the upper and lower poles of the uterus
reveals neither the head nor the breech
− The head can be felt in one maternal flank
− The buttocks are on the other side
− Fetal heart – best heard below the umbilicus and has
no significance regarding position
− Neither head nor breech can be felt by the examining
finger on vaginal examination
− Presenting part is high
− UTZ will confirm the diagnosis; can detect abnormalities
in the fetus like hydrocephaly and anencephaly
− Flat plate of the abdomen – if UTZ is not available
MECHANISM OF LABOR
− Persistent transverse lie – cannot
deliver spontaneously
− Spontaneous version – takes place occasionally
− Naglected transverse lie – fetal shoulder is forced into
the pelvis, the uterus molds itself around the baby
→state of impaction→progress is halted
✓ Uterine rupture
✓ Uterine inertia
*in either event, fetal death is certain and maternal
mortality is possible
MANAGEMENT OF NEGLECTED TRANSVERSE LIE
The ff. conditions should be present:
✓ There has been prolonged labor
✓ The membranes have been ruptured for a long time
✓ The lower uterine segment is stretched and thin
✓ Intrauterine infection is present
✓ Fetal impaction has taken place
✓ The cord, arm, or both have prolapsed
✓ The baby is dead
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Management under these circumstances is difficult:
− CS and intensive therapy with antibiotics are carried
out even if the baby is dead
− If infection is severe and widespread, hysterectomy
may be necessary following the CS
− Internal podalic version and extraction may be
considered if cesarean is not feasible. This procedure is
attended by a grave risk of uterine rupture
MANAGEMENT
− Cesarean section
− Internal podalic version and extraction – dangerous
procedure for fetus and mother.
− The use of podalic version and extraction:
o Turning the baby to a footling breech and delivering it
as such
o Is considered only for the ff:
▪ When the baby is premature, to the degree of
nonviability, and the risk to the mother of CS is not
justified
▪ Delivery of a second twin
▪ When the px is admitted to hospital with the
membranes intact, cervix fully dilated, and CS
cannot be performed immediately
Conclusion: Transverse lies at term, after failure of external
version, are treated best by cesarean section. They must
never be neglected or left to nature.
COMPOUND PRESENTATION
− An extremity prolapses alongside the presenting part,
and both present simultaneously in the pelvis
− Hand or arm alongside the head
− Lower extremities alongside the breech
CAUSES
− Conditions that prevent complete occlusion of the pelvic
inlet by the fetal head (preterm labor)
MANAGEMENT AND PROGNOSIS
− Prolapsed part should be left alone
− Arm alongside the head→ observe closely to ascertain
whether it will retract out of the way with descent of the
presenting part
o Failure to retract à push arm gently upward and the
head simultaneously downward by fundal pressure
(morbidity: ischemic necrosis of the presenting
forearm)
o Increased mortality and morbidity from:
▪ Preterm delivery
▪ Prolapsed cord
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 OBSTETRICS II
LE 2: DYSTOCIA: POWER AND PASSENGER
Dr. M. De Guzman
▪ Traumatic obstetrical procedures • Reduction in the interval of time from delivery of the
head to delivery of the body is great importance to
SUMMARY: survive=al
✓ Take note the number of hours (time) of labor in • An initial gentle attempt at traction assisted by
nullipara and multipara. (Refer to the table) maternal expulsive efforts, is recommended
✓ Review stages of Labor and Phases of cervical Techniques to free the anterior shoulder from its impacted
dilatation (Refer to OB GOLD) position beneath the symphysis pubis
✓ FIRST STAGE: Arrest disorders Moderate suprapubic pressure
✓ SECOND STAGE: Descent disorder; Failure of • Can be applied by an assistant while downward
Descent if there is full cervical dilatation traction is applied to the fetal head
✓ Management: No CPD→ Augment labor • Pressure is applied with the head of the hand on the
anterior shoulder
Read OB Williams 24th or 25th edition for more info :) MCROBERT’S MANEUVER
Shoulder Dystocia
o 0.6-1.49% incidence (ACOG 2012)
o Head to body delivery time
• Normal birth- 24 seconds
• Shoulder dystocia ->60 seconds
o Fetal shoulder become wedged behind symphysis
pubis and fail to deliver with downward traction and pushing
o EMERGENCY – because the umbilical cord is compressed
within the birth canal
o Neonates experiencing shoulder dystocia had significantly
greater shoulder-to- head and chest-to- head
o disproportions compared with those of equally macrosomic
newborns delivered without dystocia

CONSEQUENCES
Maternal
• Postpartum hemorrhage- usually from uterine atony,
vaginal and cervical lacerations
Fetal
o Fetal morbidity and mortality (Neuromusc uloskeletal
injuries)
o Brachial Plexus Injury
o Clavicular fracture/Hu meral fracture/Rib Fracture
DELIVERY OF POSTERIOR SHOULDER
o Hypoxia

PREDICTORS
1. Increasing fetal weight risk
factors:
a) Obesity
b) Multiparity
c) Diabetes Mellitus and
Gestational Diabetes
Mellitus
d) Post term pregnancy
e) 75% shoulder dystocia
cases -> Birthweight >4000
grams 2.

2. Intrapartum Factors: SHOULDER DYSTOCIA IMPACTED ANTERIOR

o Prolonged second stage SHOULDER OF THE FETUS
o Operative vaginal delivery or prior shoulder dystocia

ACOG 2012 CONCUSION ON STUDIES ABOUT SHOUDER

DYSTOCIA
• Most cases of shoulder dystocia cannot be accurately
predicted or prevented
• Elective induction of labor or elective CS for all women
suspected of having macrosomic fetus is not appropriate
• Planned CS maybe considered for non-diabetics with
fetus whose estimated weight is> 5000 grams or for
diabetics > 4500 grams
Management:
• Large episiotomy
• Adequate analgesia

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 OBSTETRICS II
LE 2: DYSTOCIA: POWER AND PASSENGER
Dr. M. De Guzman
WOODS CORKSCREW MANEUVER 7) Rubin’s maneuver
*If it fails….
8) Cleidotomy -with a dead fetus
9) Symphysiotomy-risk for UT/ST surgery
10) Zavanelli-cephalic replacement into the pelvis and
then CS delivery
Complications with dystocia
Maternal
• Uterine rupture
• Pathological retraction ring
• Fistula formation
• Pelvic formation
• Pelvic floor injury
• Infection
THE SECOND RUBIN’S MANEUVER • Post-partum hemorrhage
Perinatal
• Fetal sepsis
• Caput succedaneum
• Molding
• Nerve injury/fractures
• Cephalohematoma

HIBARD MANEUVER
• Pressure is applied to the fetal jaw and neck in the
direction of maternal rectum, with strong fundal pressure
applied by an assistant as the anterior shoulder is freed
CLEIDOTOMY
• Cutting the clavicle with scissors or other sharp
instruments
• Usually used for a dead fetus
SYMPHYSIOTOMY
• Surgical procedure in which the cartilage of the pubic
symphysis is divided to widen the pelvis allowing childbirth
ZAVANELLI MANEUVER
• Cephalic replacement into the pelvis and then cesarean
delivery
Gaskin maneuver
Is to advise or place the patient with all force to widen dm of
pelvis to deliver the baby on her knees

SHOULDER DISTOCIA DRILL

-when there is a mechanical problem
1) Call for help
• Mobilize assistants, an anesthesiologist and a
pediatrician
• initially, a gentle attempt at traction is made
• Drain the bladder if it is distended
2) A generous episiotomy (mediolateral or episiotomy)
may afford room posteriorly
3) Suprapubic pressure is used initiallty by the most
practitioners because it has the advantage of
simplicity. Only one assistant is needed to provide
suprapubic pressure while normal downward traction
is applied to the fetal head
4) The McRoberts maneuver requests two assistants
*If above fails,
5) Delivery of arm and shoulder
6) Wood Corkscrew
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