21/04/2024

DYSTOCIA
HIGH RISK LABOR AND DELIVERY POWER PASSAGE PASSENGER PSY CHE
(PASSAGE) • Ineffective Uterine
Force (Hypotonic,
• Pelvic dystocia
• Cephalopelvic
•
•
Cord prolapse
Malposition
• Inability to Bear
Down Properly
Hypertonic or disproportion • Malpresentation • Fear/Anxiety
uncoordinated (CPD) • Oversized Fetus
contractions) • Shoulder dystocia
• Dysfunctional
labor and
Prepa red by : associated stages
Mercy Li za R. Cru z RM MAN of labor
• Precipitate Labor
Sch ool of Nu rsi n g • Uterine rupture

The Pelvis Cont..

⋄ 2. Sa cr um – w edge shape ⋄ 3. Coccy x-tail-like bony
1 . Hip/innom inate bones bon e formed by the fusion pr ojection. It m oves
 Com posed of three pair of of t h e five vertebrae. Upper ba ckward during labor t o
fu sed bones por t ion is sacral pr ov ide more room for
 Ilium pr om ontory which guide in fet us.
 Isch ium det ermining the pelvic
 Pu bic bone m easurements

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Division of the Pelvis

⋄ 1 . False pelvis – is the
u pper flaring portion, the
ilia. It supports the uterus
du ring the late months of
pr egnancy and aids in
dir ecting the fetus into the
t r ue pelvis for birth.
⋄ 2. T r ue pelvis –
r epresents the bony limits
of t h e birth canal. Forms a
curved canal through which
t h e presenting part of the
ba by m ust pass during
bir th.

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1. The Pelvic Inlet
1 . AP diameters:
⋄ Diagonal Conjugate(12.5 cm). It is the distance
between the midpoint of sacral promontory to the
anterior portion of the symphysis pubis.
- It can be measured manually during a pelvic examination.
- Most useful measurement for estimation of pelvic size
- Subtracting 1 .5 cm from this gives obstetric conjugate.
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TRUE PELVIS
• The true pelvis is divided into 3 parts:
a. Pelv ic inlet or pelvic brim– is the entrance to true pelvis.
b. Pelv ic cavity or pelvic canalis situated between the inlet
and outlet. (also known as midpelvis)
c. Pelvic outlet
Cont..
⋄ Obstetric conjugate(10.5 cm): . It is the distance
between the midpoint of sacral promontory and the
midline of symphysis pubis.
> Most important AP diameter.
> The size of this diameter determines whether the fetus
can move down into the birth canal in order for
engagement to occur.
Cont..
⋄ T rue Conjugate or conjugate vera (11.5cm)
- Cannot be directly measured but it can be estimated
- Measured from the sacral prominence – posterior
portion of the symphysis pubis
- Diagonal conjugate measurement minus 1.5 or 2 cm
(depth of symphysis pubis)
- 1 0.5 – 1 1 cm (actual diameter of pelvic inlet through
which the fetal head must pass)
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1. The Pelvic Inlet

2.Transverse diameter(13.5cm)
Widest distance between iliopectineal lines
Widest diameter of the inlet
Most fetuses engage in transverse or oblique diameter

3. Oblique diameters(12.5cm)
Ex tends from sacroiliac joint of one side to opposite iliopectineal
eminence.

Pelvic inlet
2. Midpelvis/ Pelvic canal
• The pelvic canal curves at its lower half, below the level of the
ischial spines.
• This curvature is designed by nature to control the speed of
descent of the fetal head.
• The comfort of the pelvic cavity compresses the chest of the fetus
as it passes through this area expelling lung fluid and mucus.

3. Pelvic outlet Pelvic outlet

● The most important diameter is its transverse diameter, also
called the bi-ischial diameter as it is which is about 11.5 cm.

● In contrast to the inlet of the pelvis, the greatest diameter of the

outlet is its anteroposterior diameter which increases during birth
as the presenting part pushes the coccyx posteriorly at the mobile
sacrococcygeal joint.

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ABNORMALITIES OF PASSAGEWAY 1. PELVIC DYSTOCIA

1. Pelv ic dystocia • Occurs when there is narrowing in one or more important
• Inlet dystocia diameters of the pelvis: inlet, mid pelvis, outlet.
• Midpelvis dystocia • Gy necoid and Anthropoid – good prognosis for vaginal
• Outlet dystocia delivery
2. Soft tissue dystocia • Android and Platypeloid – poor prognosis for v aginal delivery.
• Placenta previa that partially or completely obstructs the birth • Pelv is is contracted when the diagonal conjugate is <11.5 cm and
canal its bi-ischial diameter is less than 8 cm. CS is the management
• Presence of tumor that obstructs the birth canal for pelvic contraction.
• CPD

SIGNS AND SYMPTOMS CONT..

• INLET CONTRACTURE
• Inlet Dystocia is defined as anteroposterior diameter less than
1 1 cm and greatest transverse diameter that is less than 1 2 cm, or
diagonal conjugate less than 11.5 cm.
• Can be due to several conditions including rickets and flat pelvis.
• Lack of engagement between 36 th and 38th week of pregnancy in
primiparas is an important sign of pelvic contraction.
• Incidence: 1 – 2% in term pregnancies
MIDPELVIS CONTRACTURE
• Most common pelvic dystocia. Occurs when the sum of the
interspinousand posterior sagittal diameters of the mid pelvis is
<1 3.5 cm.
• Fetus is able to engage, but due to the narrowed diameter of the
mid pelvis, the fetal head is prevented from rotating internally
from transverse to AP diameter.

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CONT.. TRIAL LABOR

OUT LET CONTRACTURE
• Outlet dystocia occurs when the bi-ischial diameter (distance • Women with abnormal size of pelvis can still undergo NSD
between ischial tuberosities) is < 11 cm . provided that:
- Measurements are borderline
- Fetal lie and position are good
• Probably due to:
- Long, narrow pubic arch - Descent and cervical dilation progress
- A ndroid pelvis

PASSAGEWAY: CEPHALOPELVIC
TRIAL LABOR DISPROPORTION
• Nursing interventions: • Presenting part of the fetus is
- Monitor FHT and uterine contractions too large to pass through the
woman’s pelvis
- Urge woman to void every 2 hours
• Infant’s head is too big to fit
• - if no progress, with fetal distress = discontinued
through mother’s pelvis (ex:
hy drocephalus)
• Biparietal diameter is closer to
1 0 cm

CAUSE/RISK FACTORS DIAGNOSTIC PROCEDURES

• Large fetal head • Pelvimetry

- Macrosomic babies (DM) • Ultrasound
- More than 4000 grams
• Multiparity
• Genetics – one or both parents of large body built
• Small pelvis; abnormally shaped pelvis (android, platypelloid)
• A bnormal fetal positions
• A dolescents

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SIGNS AND SYMPTOMS PASSAGEWAY: SHOULDER DYSTOCIA

• Prolonged 1 st stage of labor
• Lack of engagement at the beginning of the labor
• Poor fetal descent (even with strong uterine contractions)
• A fter delivery of head, the anterior shoulder is trapped and
arrested behind the symphysis pubis.
• Usually happens when baby is too large and pelvis is too small.
• Occurs with equal frequency in primi and multigravida.
• Diagnosed only during delivery

RISK FACTORS SIGNS AND SYMPTOMS

MATERNAL
• Gestational Diabetes
• Post-dates pregnancy
• Multiparity
• A bnormal pelvic anatomy
• Prev ious pelvic dystocia
• Short stature
FETAL
• Assisted vaginal delivery
(forceps or vacuum)
• Protracted active phase of first
stage of labor
• Protracted second stage labor
1 . Turtle sign
2. Red puffy face in the fetus
(facial flushing)
3. Prolonged 2nd stage of labor
4. Arrest of descent

MANAGEMENT The H-E-L-P-E-R-R mnemonic

1 . When dy stocia is diagnosed, AVOID the following actions which
can only cause injury to the mother and the infant:
• A pplying excessive pressure to the fetal head or neck
• A pplying fundal pressure
2. The H-E-L-P-E-R-R mnemonic provides a step by step guide for
preliminary management for dystocia before more drastic measures
are implemented.
It is designed to achieve one of these three objectives that will help
to free the shoulder from its impaction under the symphysis:
• Increase functional size of the bony pelvis
• Decrease bisacromial diameter (breadth of the shoulders) of the
fetus
• Change relationship of the bisacromial diameter within the bony
pelv is through internal rotation maneuvers

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MANAGEMENT Mc Robert’s maneuver

• H – Call for HELP – additional personnel and equipment to aid

in deliv ery.
• E – EPISIOTOMY – provide additional room for physician’s
hand when internal maneuver is required.
• L – LEGS (Mc Roberts maneuver) – done by flexing the legs
of the parturient sharply over the abdomen.

CONT.. Cont..
• E – ENT ER Maneuvers (Internal Rotation) – Rotates the
• P – Suprapubic PRESSURE anterior shoulder into an oblique plane under the maternal
– place hand suprapubically sy mphysis to dislodge it from impaction.
ov er the anterior shoulder. • R – REMOVE the posterior arm – when the rotation maneuvers
• A pply pressure in a are successful, the next step is to remove the infant’s posterior
compression / relaxation cycle arm to give more space in the pelvis.
(same with CPR). This action • R – ROLL the patient (Gaskin maneuver) – roll patient onto
can make the shoulder adduct her hand and knees or the “ALL FOURS” position to increase
and slip under symphysis pelv ic diameter (v ia X ray)

Gaskin maneuver or the “ALL FOURS Cont..

3. If HELPERR maneuvers are unsuccessful:
• Deliberate clavicle fracture – reduce shoulder-to-shoulder
distance.
• Zav anelli maneuver – cephalic replacement followed by CS
• General anesthesia – effect general musculoskeletal or uterine
relaxation that reduce tissue resistance in the birth canal, enlarge
space, and dislodge impacted shoulder.
• Sy mphysiotomy – sy mphysis pubis is surgically cut under
local anesthesia.

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COMPLICATIONS
MATERNAL FETAL
• Postpartum hemorrhage • Brachial plexus palsy
• Recto-vaginal fistula • Clav icle fracture
• Sy mphyseal separation or • Fetal death
diathesis • Fetal hypoxia
• 3 r d or 4 th degree episiotomy / • Fracture of the humerus
tear
• Uterine rupture

NURSING CARE

• Ex plain the procedure • https://www.youtube.com/watch?v=PSnhK5JmhCw

• A ssess for cord prolapse
• Monitor for nucchal cord, cut and clamp two ends if present
• Suction infant’s oropharynx after delivery of the head.
• Monitor FHT and maternal V S.

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