Dystocia Is a broad term referring to prolonged and difficult labor (any labor that lasts more than 24 hours

) Types of Dystocia 1. Uterine dysfunction: abnormalities of the powers a. Hypotonic uterine dysfunction b. Hypertonic uterine dysfunction c. Inadequate secondary forces 2. Abnormalities with passageway a. Pelvic dystocia • Inlet dystocia • Midpelvis dystocia • Outlet dystocia b. Soft tissues dystocia • Placenta previa that partially or complete obstructions the birth canal • Presence of tumors that obstruct the birth canal 3. Fetal dystocia: abnormalities of the passenger a. Malposition – persistent d. Brow occiput posterior position e. Shoulder b. Breech presentation f. Multiple presentation c. Face Abnormal Labor Patterns Is defined as exceeding 20 hours in nulliparas and more than 14 hours in multiparous Diagnosis of abnormal labor i. Imaging studies: Xray pelvimetry and computerized tomography ii. Clinical pelvimetry: Causes: 1. Entering labor with poor cervical condition characterized by unripe, rigid and firm cervix 2. Excessive sedation administered during the course of the latent phase 3. Conduction analgesia Management: 1. Therapeutic rest: using strong sedatives 2. Active intervention: oxytocin stimulation if without CPD and uterine contractions are still inadequate upon awakening Uterine Dysfunction May be caused by any or a combination of the following conditions: pelvic contraction, fetal malposition, over distension, and excessive rigidity of the cervix. 2 common types of uterine dysfunction 1. Hypotonic Uterine contractions: are characterized by weak and inadequate contractions which are insufficient to dilate the cervix. Contractions are not painful because of their poor intensity. Causes: • Over distension of the uterus - multiple pregnancy, hydramnios • Malpresentation and malposition • Pelvic bone contraction • Unripe or rigid cervix • Congenital abnormalities of the uterus • Unknown causes Complications: 1) Maternal and fetal infections because cervix is dilated for a long time 2) Post partum hemorrhage because of prolong labor making the uterus too exhausted to contract effectively 3) Fetal distress and death 4) Maternal exhaustion Management: i. Reevaluate pelvic size

ii. sexual intercourse. dancing and lifting heavy objects for 6-8 weeks Inversion of the Uterus Is a serious complication of the third stage wherein the uterus is partly or completely turned inside out. Signs of maternal shock and fetal distress are observed because of internal bleeding. Watch for danger signals: fetal distress. and then contractions stop altogether. Maintenance of fluid and electrolytes balance by infusion of IV fluids iii. iii. obstructed labor. the procedures being done. Separation of the placenta from the uterus cuts off blood supply to the fetus resulting in fetal hypoxia and death. Evaluation of pelvic size ii. 2) Incomplete Rupture: symptoms are localized tenderness and persistent pain over the abdomen. internal version • Precipitate labor and delivery • Manual removal of the placenta • External trauma – sharp or blunt • Gestational trophoblastic neoplasia Signs and symptoms i. relief is felt as the uterus loses the capacity or if still does. During the peak of contraction. Impending uterine rupture is often manifested by a pathologic retraction ring in obstructed labor ii. e) Post OP care (same as care after hysterectomy) • Explain need to avoid driving for 3-6 weeks • Explain need to avoid jogging. Therapeutic rest: morphine and Phenobarbital iv. Management: a) Blood transfusion and administration of IVF to correct shock b) Administer mask oxygen to the woman at 8L/m c) Expect emergency laparotomy to deliver the baby d) Provide emotional support. malposition and malpresentation • Over distention of the uterus • Injudicious use of oxytocin. Causes: • Rupture of scar from previous CS • Prolong labor. It is characterized by contractions that are too frequent but uncoordinated. Contractions may still continue or stop but no progress in cervical dilatation will be observed. the woman experiences a sudden excruciating pain at the peak of a contraction. do not give false reassurances. the contractions are too weak to cause much discomfort Types of Uterine rupture 1) Complete Rupture: when the uterus ruptures. Causes . Vaginal delivery: • Amniotomy if membranes are not yet ruptured • Augmentation of oxytocin administration If contracted pelvis is present. Inform woman of what is happening. caesarian section is the method of delivery Provide supportive nursing care Hypertonic Uterine contractions: are usually encountered in the latent phase of labor. passage of meconium stained amniotic fluid Uterine rupture: or the tearing of the muscles of the uterus occurs when the uterus can no longer withstand the strain placed upon it. answer questions as realistically as possible. Two swellings will be visible in the abdomen: the uterus and the extra uterine fetus. iv. forceps and vacuum extraction. the uterus does not relax completely in between contractions and tend to be more painful Management i. 2. Vaginal bleeding may or may not be present. Encourage side lying position to maximize blood flow to the placental fetus vi. the woman complains of a sudden sharp tearing pain which. Keep bladder empty to provide more space for the passage of fetus v. Internal hemorrhage soon follows and vaginal bleeding may or may not occur.

Fetal distress Management 1. Platypelloid Although X-ray pelvimetry provides accurate measurements of the pelvic diameters. cover it with a saline moistened sterile compress 4. Remove after the uterus is replaced and contracting  The placenta is delivered when uterus is already replaced and contracting 4. Cord protrudes from the vagina and palpation of cord in the vaginal canal/cervix during IE 2. or place a folded towel under the hips  Put on sterile gloves and insert two fingers into the vagina.Polyhydramnios . Deliver baby as soon as possible  Vaginal delivery if cervix is fully dilated without fetal distress  Cesarean section if cervix is not yet completely dilated and if fetal distress is present. If cord is exposed to air. Reduced pressure on the cord by:  Place in Knee Chest or trendelenburg position. If the placenta is still attached:  Woman is placed under anesthesia to cause muscular relaxation and facilitate reinsertion of the uterus into the pelvic cavity. Administered mask oxygen until delivery is completed 6. Anthropoid 4.Placenta previa Signs and Symptoms 1. Inlet Contracture . Monitor vital signs Prolapsed Umbilical Cord Occurs when the cord passes out of the uterus ahead of the presenting part Causes . If the placenta has already separated: the uterus is replaced in the uterine cavity then oxytocin is administered 3. Prevention  Never apply pressure on an uncontracted uterus  Never pull the cord to hasten placental delivery 2. its use to evaluate pelvic size during pregnancy is seldom employed because of the potential radiation exposure hazards to the fetus.Long cord . The lower uterine segment is inserted first and fundus last. then push presenting part upward 3. Never replaced the cord back into the vagina as this will result in cord kinking 5. sneezing or straining Signs and symptoms  Fundus is no longer palpable  Sudden gush of blood from the vagina  Uterus appear in the vulva Management 1. Then oxytocin is administered  Do not attempt to remove the placenta if it still attached to the uterus as this will only enlarge the bleeding area. Blood transfusion and administration of IVF to combat shock 5.Malposition and malpresentation (shouloder and foot presentation) . Prevention placed the woman in bed rest after membranes have ruptured 2. Gynecoid 3. Pelvic Dystocia Occurs when there is a narrowing in one or more of the important diameters of the pelvis 4 Types of Pelvis 1.• Pulling of umbilical cord or applying pressure on uncontracted uterus • Uterine relaxation due to the effects of anesthesia or analgesia • Sudden increase in intrabdominal pressure such as when coughing. Android 2.Prematurity .

Outlet Contracture Outlet dystocia occurs when the biischial diameter (distance between ischial tuberosities) is less than 8cm Occiput Posterior Position One of the most common causes of prolonged labor. the physician may perform manual rotation or use forceps to rotate presenting part to anterior position.Is defined as anteroposterior diameter less than 10 cm and greatest transverse diameter that is less than 12cm or diagonal conjugate less than 11. Concavity of sacrum is shallow 4. Inlet contracture is due to several conditions including rickets and flat pelvis. a malposition of vertex presentation. for some unknown reasons.5 cm. Kielland forceps is the type of forceps for this purpose. 4 types of Breech Presentation 1. Prominence of the ischial spines 2. Frank breech 2. Single footling Causes • Uterine relaxation due to multiparity • Fetal abnormalities – hydrocephalus • Hydramnios and oligohydramnios • Congenital abnormalities of the uterus • Contracted pelvis • Previous breech delivery • Space occupying mass in the uterus that prevents the head from fitting into the lower portion such as placenta previa and fibroids • Prematurity • Multiple pregnancy Complication 1. the fetus rotates spontaneously to anterior position followed by uncomplicated vaginal delivery 3) If fetus does not rotate. However. The labor is prolonged because the fetus must rotate a longer distance to reach the symphisis pubis with the mother experiencing much back pain due to the pressure exerted by the fetal head as it moves against the sacrum Management: 1) Provide comfort measures as labor tends to be longer and involves more back pains:  Advice the mother to change position frequently to relieve pain  Give back rub  Apply sacral pressure during contractions 2) In most instances. On internal examination the following findings will be noted: 1. Complete breech 3. about 3 to 4% of fetuses maintain breech presentation until delivery. Even dead fetuses have been known to turn from breech to vertex presentation. Pelvic sidewalls are convergent 3. Bi-ischial diameter of outlet is less than 8cm. As a result the head is jammed in the midpelvis causing transverse arrest. Early in pregnancy most fetuses are in breech presentation. Lack of engagement between 36th and 38th week of pregnancy in primiparas is an important sign of pelvic contraction Mid pelvis Contraction The fetus is able to engage but due to the narrowed diameter of the midpelvis the fetal head is prevented from rotating internally. By thirty eight weeks gestation. Breech Presentation is the most common cause of fetal malpresentation. Double 4. most have already assumed vertex presentation. Prolapsed of the cord .

the examining fingers feel the mouth. presentation. tell parents that their babies’ unsightly appearance will disappear in a few days. cesarean delivery is employed. • Additional nursing and medical personnel skilled in breech delivery and an obstetrical attendant to watch over the patient continuously and the physician should be available anytime • The decision regarding the method of delivery should be made as soon as possible after admission to avoid complications 3. the physician may attempt to rotate the fetus from breech to cephalic presentation by external version 2. Brow presentation is commonly unstable.LMP) vaginal delivery may be impossible and dangerous if attempted because it can lead to transverse arrest. uterine contractions are strong. rupture of abdominal organs 3. 2) If the chin is in posterior position (RMP. it usually converts to face or vertex presentation. station. Whenever a breech presentation is diagnosed late in pregnancy. • Assessment of fetal condition: ultrasound to determine anomalies such as hydrocephalus. Babies born vaginally from brow presentation experience extreme facial edema. . Brow Presentation Is the most uncommon of all presentations. nose. microcephaly and anencephaly • Continuous monitoring of fetal condition. The different maneuvers: d. Prolonged labor because the soft buttocks do not aid in cervical dilatation 4. Fetal death Management: 1. dilatation. vaginal delivery is possible but longer than usual. Three general techniques of vaginal breech delivery: • Spontaneous breech delivery • Partial breech extraction: the infant is delivered spontaneously up to the umbilicus. effacement. humerus. Face Presentation Occurs when the head is hyper extended and the chin (mentum) is the presenting part. The causes are the same as those of face presentation. molar bones and orbital ridges. Cesarean is the delivery of choice when the chin is posterior. Causes  Large fetus  Contracted pelvis  Multiple pregnancy  lax uterus due to multiparity  Occipitoposterior position because of the tendency of the fetus of extending the head instead of flexing it Management 1) If the chin is in anterior position (LMA or RMA). clavicle. intracranial hemorrhage. Management of the vaginal delivery: • Continuous assessment of the progress of labor: contractions. On internal examination. Vaginal delivery may be attempted if: • There is no pelvic contraction • The fetus is not too large – not more than 3600grams • There are personal skilled in the delivery of breech • Spontaneous labor occurs with progressive cervical dilatation and effacement (add piper forcep to the delivery set up) b. fracture of the skull. Vaginal delivery a. the rest of the body is extracted • Total breech extraction: the entire body of the infant is extracted by the obstetrician c. If it is not possible to deliver the fetus vaginally and to ensure safer route of delivery.2. Intracranial anoxia 5. Birth trauma. the head is small shoulder have already entered the pelvis and there is no pelvic contraction.

Lax uterine and abdominal muscles due to multiparity is most common cause . hydrocephalus . Causes . Sometimes vaginal delivery is possible if the pelvic canal is large.Shoulder Presentation Occurs when the fetus assumes a transverse or oblique lie. the fetal head occupies one side of the uterus and the buttocks. Risk Factors for shoulder Dystocia 1. It happens when the baby is too large or the pelvis is too small. This is the most common problems and is done during delivery of the shoulders. Monitor fetal heart tone and maternal vital signs closely 3. v. trial labor with oxytocin and amniotomy may be conducted first and if it fails or abnormal fetal heart rate patterns occur during the induction. typically weight more than 4000grams or 10 pounds. Provide short and direct answers to the parents’ questions. Cerebral hemorrhage (intracranial).Multiple pregnancy Management i. • In cases of maternal DM and obesity. Fracture of the clavicle. Feto-pelvic size is determined to find out the best method of delivery is possible. This is due to repeated pounding on the pelvis. Management 1. ii. Shoulder Dystocia Shoulder dystocia is said to occur when the fetal bisacromial diameter cannot negotiate the pelvic brim (the obstetric conjugate). vi.Contracted pelvis . 4. Dislocation of the cervical vertebrae as a result of traction to get the infant out. Causes  Common in male infants  Maternal diabetes  Hereditary  Post term pregnancy Complication i. an ultrasound is often ordered to estimate fetal weight before vaginal delivery is allowed. 2. Shoulder dystocia: the fetus head may deliver. It can also be observed that the shaped of the uterus is more horizontal than vertical. Overall. from impaction of the posterior shoulder on the sacral promontory. ultrasound predictions of fetal weight fall within 20% of actual fetal weight in the third trimester. It may occur when after when the delivery of the head the anterior shoulder is trapped and arrested behind the symphysis pubis and less commonly. Maternal • Abnormal pelvic anatomy .Placenta previa . CS is performed. Fetal Macrosomia Refers to oversized infant. Brachial plexus injury due to damage to the brachial plexus (nerve injury) iv. External version before labor begins can be performed to rotate fetus in a delivery position ii. If version fails.Preterm fetus. the other side. • If feto-pelvic disproportion exists (estimated size is deemed too large to pass through the mother’s pelvis) . Provide comfort measures to the mother as labor is prolonged and maternal exhaustion may occur. In multiparas with adequate pelvic size. Keep them informed of the progress of labor and explain treatment and tests as they are conducted.CS is the method of delivery. often the physician will proceed with CS without trial labor. Trauma to the birth canal such as lacerations of the vagina or of the perineum iii. The infant is also called large for gestational age (LGA). • In primigravidas with macrosomic infants.Fibroid and congenital abnormality of the uterus . but the shoulder are too large for the pelvic inlet. the preferred method of delivery is caesarian section. Shoulder presentation is suspected when upon palpation.

Maternal  Post partum hemorrhage  Rectovaginal fistula  Sympheseal separation or diathesis. This action can make the shoulder adduct and slip under the symphisis. H: call for HELP – the physician calls for additional personnel and equipments to aid in the delivery E: episiotomy – is performed not to enlarge the birth canal but to provide additional room for the physician’s hands when internal rotation maneuvers are required. L: Legs – (Mc Roberts Maneuver) it is done by flexing the legs of the parturient sharply over the abdomen. C. This action raises symphisis pubis and causes in a flattening of the sacral promontory. B. Monitor for nucchal cord. with or without transient femoral neuropathy  3rd or 4th degree episiotomy or tear  Uterine rupture II. Suction the infant’s oropharynx after delivery of the head E. with or without permanent neurologic damage  Fracture of the humerus Management 1) Turtle Sign: shoulder dystocia becomes obvious when the fetal head emerges and then retracts against the perineum 2) When dystocia is diagnosed. D. Provide reassurance by informing the mother of what is being done to facilitate delivery of the infants in short simple sentence. As a result the posterior shoulder of the fetus is pushed over the sacral promontory allowing it to fall into the hollow of the sacrum. Monitor FHT and maternal vital signs .• Gestational diabetes • Post-dates pregnancy • Previous shoulder dystocia short stature 2. Asses for cord prolapsed: the initial danger when the shoulder is stuck under the symphisis is cord compression that can result to hypoxia and acidosis. Fetal: suspected macrosomia Complications of shoulders dystocia I. cut and clamp two ends if present. E: enter Maneuver – (internal rotation) R:Remove the posterior arm R:Roll the patient Nursing care A. and the impacted anterior shoulder slips from the entrapment S:Suprapubic pressure – the assistant’s hand places her/his hand suprapubically over the anterior shoulder and then applies pressure in a compression/relaxation cycle similar to the action when performing CPR. Fetal  Brachial plexus palsy  Clavicle fracture  Fetal death  Fetal hypoxia. avoid the following actions which can only cause injury to the mother and the infant: • Applying excessive pressure to the fetal head or neck • Applying fundal pressure 3) The HELPERR mnemonic – provides a step by step guide for preliminary management of dytocia before more drastic measures are implemented. Shoulder Dystocia can be very frightening to the mother.