Dystocia

• Dystocia of labor is defined as difficult labor or

abnormally slow progress of labor. Other
terms that are often used interchangeably
with dystocia are dysfunctional labor, failure
to progress (lack of progressive cervical
dilatation or lack of descent), and
cephalopelvic disproportion (CPD).
 Abnormal patterns of labor

• “Latent phase arrest”—means labor never began

• “prolonged latent phase”—greater than 20h in nullip
---greater than 14h in multip
• Prolongation of latent phase is variable; doesn’t mean the fetus will have
a bad outcome or that the patient needs a c/s. Can be managed
expectantly (presuming mom and baby other wise look good)
Can administer analgesics (eg morphine 15-20 mg for
therapeutic rest)
Augmentation (Pitocin)
Defer amniotomy!
 Abnormal patterns of labor

• Abnormalities of second stage

“Failure to Progress” “Arrest of dilatation”
generally patient is falling off Friedman’s curve, or no
cervical change in 2 hours

Consider augmentation, placement of IUPC

 Abnormal patterns of labor

“Protraction of descent”
Descent of < 1 cm/h in nullips
Descent of < 2 cm/h in multips

Deliveries complicated by prolonged second stage put the fetus at risk of

acidosis, thus, ACOG recommends intervention after 2 h without epidural,
3 h with epidural.

In reality, can consider expectant management if mother and fetus are

otherwise reassuring, descent is progressive, and delivery is imminent.
 Abnormal patterns of labor

• “Arrest of Descent”
This requires an assessment of contractions, maternal
fetal well being, and CPD

Re-evaluate clinical pelvimetry, fetal station, caput.

The decision to proceed with assisted vaginal delivery or C/S
should be individualized
 Reasons instrumental deliveries fail

CPD
Bad technique (eg pulling without contractions, upward
pull before crowning: deflexed, paramedian application
Large Caput
Shoulder dystocia
• www.shoulderdystociaattorney.com
 If the anterior and posterior shoulders descend together instead of sequentially, the anterior
shoulder can become impacted behind the symphysis pubis (or the posterior shoulders on the
sacral promontory)
• If descent of the fetal head continues while
the shoulders remain impacted, stretching of
the nerves of the brachial plexus can occur.

• Most brachial plexus injuries resolve on their

own, but permanent injury is a often a
medicolegal issue.
Risks for shoulder dystocia
maternal obesity, diabetes, post dates,
macrosomic infant, operative delivery

Other risks associated with shoulder dystocia:

fetal hypoxia and neurologic injury; fractured
clavical or humerus, fetal death.
 Management of Shoulder dystocia
• Call for help!
• Suprapubic pressure
• McRoberts Maneuver
• Episiotomy
• Woods screw/ Ruben’s manuevers
• Deliver posterior arm
• Fracture clavicles
• Zavenelli maneuver
• Mom should not push during maneuvers!!
 Henry Lerner, MD
Graphics Susan Seif, medical graphics
 After difficult delivery…

Careful documentation

Explain to patient the events, explanation of

problem, steps taken to correct the problem,
and what the anticipated sequelae are