Abnormal Labour

Perceptor :
dr. Nurul Islamy, M. Kes., Sp. OG

KEPANITERAAN KLINIK ILMU OBSTETRI DAN GINEKOLOGI

RSUD Dr. H. ABDUL MOELOEK
BANDAR LAMPUNG
 Introduction

• Labor is a physiological process during which a

fetus is expelled.

• The mainly labor force is uterine contracion.

• In the labor process, cervical effacement and dilation

and fetal delivery occur.
 Normal labor
• Normal labor is divided into 3 stages by Friedman.

• The first stage, the second stage and the third

stage.

• The first stage is subdivided into the latent phase

and the active phase.
Overview Dystocia
Power
● Abnormalities of the expulsive
forces.
● Uterine contractions may be
insufficiently strong or
inappropriately coordinated to
efface and dilate the cervix—
uterine dysfunction.
● Also, there may be inadequate
voluntary maternal muscle
effort during second-stage
labor.
Passanger
Abnormalities of presentation,
position, or development of
the fetus
Passage
● Abnormalities of the
maternal bony pelvis—
that is, pelvic
contraction.
● Abnormalities of soft
tissues of the
reproductive tract that
form an obstacle to fetal
descent
Dystocia Definitions

prior to the 20th century to describe obstructed labor

Cephalopelvic resulting from disparity between the size of the fetal head
and maternal pelvis.
Disproportion

Failure to progress This term is used to include lack of progressive

cervical dilatation or lack of fetal descent. Most
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 Causes of abnormal labor
• Abnormalities of expulsive forces

• Abnormalities of birth canal

• Abnormalities of presentation & position of fetus

 Abnormalities of birth canal

• The morphology and capacity are primary causes of dystocia.

• Pelvic structure: pubis, sacrum and ischium.

• Pelvic plane: inlet, midpelvic and outlet

• Bony marker: ischial spine

 Ischial spine
• The Ischial spine is halfway of birth canal.

• Station of fetal presentation is described in relationship with

the ischial spine.

• The axis of birth canal above and below the ischial spine is
divided into fifth respectively

• As the presenting part reaches the ischial spine, the

designation is 0 station.
 Classification of abnormalities of pelvis

• Contracted pelvis
contracted inlet plane
contracted midpelvis
contracted outlet plane
• Pelvic malformation
FETOPELVIC DISPROPORTION

● Contracted Inlet

○ The pelvic inlet usually is considered to be contracted if its shortest

anteroposterior diameter is < 10 cm or if the greatest transverse diameter
is < 12 cm.
● Contracted Midpelvis

○ There is reason to suspect midpelvic contraction whenever the

interspinous diameter is < 10 cm. When it measures < 8 cm, the
midpelvis is contracted
● Contracted Outlet

○ This finding usually is defined as an interischial tuberous diameter of 8 cm

or less. The pelvic outlet may be roughly likened to two triangles, with the
interischial tuberous diameter constituting the base of both.
Estimation of Pelvic Capacity

● The examiner attempts to judge the anteroposterior diameter of the inlet,

the diagonal conjugate, the interspinous diameter of the midpelvis, and
the intertuberous distances of the pelvic outlet.
● A narrow pelvic arch of less than 90 degrees can signify a narrow pelvis.
An unengaged fetal head can indicate either excessive fetal head size or
reduced pelvic inlet capacity.
Anteroposterior view of a digital radiograph.
A. Illustrated is the measurement of the transverse diameter of the pelvic inlet using an electronic cursor. The fetal body is
clearly outlined.
B. Lateral view of a digital radiograph. Illustrated are measurements of the anteroposterior diameters of the inlet using the
electronic cursor.
C. An axial computed tomographic section through the midpelvis. The level of the fovea of the femoral heads was ascertained
from the anteroposterior digital radiograph because it corresponds to the level of the ischial spines. The interspinous
diameter is measured using the electronic cursor. The total fetal radiation dose using these three exposures is approximately
250 mra
 Management
• To assess cephalopelvic relationship by a series of
examination.

• Mild cephalopelvic disproportion: trial labor

• Obvious cephalopelvic disproportion: cesarean

section.
 Abnormalities of fetus

• Abnormalities of fetal position

• Macrosomia

• Fetal malformation
 Fetal status
• Fetal lie:The relation of the fetal long axis to that of
the mother is termed fetal lie and is either
longitudinal or transverse

• Fetal presentation: the foremost part in birth canal.

• Cephalic, breech and should presentation.

 Cephalic presentation
• According to degree of fetal head flexy, cephalic
presentation is divided into vertex, brow and face
presentation.

• Brow and face presentation result in dystocia.

 Fetal head diameter
• Bi-parietal dimension: 9.5cm

• Suboccipitobregmatic dimension: 9.5cm

• Occipitofrontal dimension:11.5cm

• Occipitomental dimension: 13cm

 Fetal position

• Refer to relation of fetal presentation to mother’s

pelvis.

• The occipital bone is the determining point of vertex

presentation.

• vertex presentation has a variety of positions.

• Definition of Persistent Occiput transverse position :
engagement and descent of fetal head in Occiput
transverse position.

• Definition of Persistent Occiput posterior position :

engagement and descent of fetal head in Occiput
posterior position.
 Cephalic dystocia
• In cephalic presentation, when delivery cannot be
accomplished with occiput anterior position, it is
called cephalic dystocia.

• Clinical findings: disorders of labor process

 Management
• To assess cephalopelvic relationship by a series of
examination.

• Mild cephalic dystocia: trial labor

• Obvious cephalic dystocia: cesarean section.

 Transverse lie
• The longitudinal axis of the fetus is perpendicular to
that of the mother.

• The presenting part is the shoulder.

• Management: cesarean section.

Transverse Lie
● In this position, the long axis of the fetus is approximately perpendicular to that of the
mother
● Some of the more common causes of transverse lie include:

○ Abdominal wall relaxation from high parity,

○ Preterm fetus,

○ Placenta previa

○ Abnormal uterine anatomy

○ Hydramnios, and

○ Contracted pelvis.
Diagnosis transverse lie

○ A transverse lie is recognized by abdomen is

unusually wide, whereas the uterine fundus extends
to only slightly above the umbilicus. No fetal pole is
detected in the fundus, and the ballottable head is
found in one iliac fossa and the breech in the other.
The position of the back is readily identifiable.

○ On vaginal examination, in the early stages of labor,

if the side of the thorax can be reached, it may be
recognized by the “gridiron” feel of the ribs. With
further dilatation, the scapula and the clavicle are
distinguished on opposite sides of the thorax
Mechanism of Labor transverse lie
● Spontaneous delivery of a fully developed
newborn is impossible with a persistent
transverse lie.
● After rupture of the membranes, if labor
continues, the fetal shoulder is forced into the
pelvis, and the corresponding arm frequently
prolapses it called neglected transverse lie
● If the fetus is small—usually < 800 g—and the
pelvis is large, spontaneous delivery is possible
despite persistence of the abnormal lie.
Compound Presentation
● In a compound presentation, an extremity prolapses
alongside the presenting part, and both present
simultaneously in the pelvis.
 Breech presentation
• Incidence: 3-5%

• Classification: frank, complete and incomplete

• Basis: hip and knee flexed or extended

• Management
 Abnormal uterine contractions

• The uterine contraction is the most important

expulsive force.

• Bring about dilation of cervix and expulsion of fetus

and placenta.

• Common causes of dystocia

 Classification

Type of uterine dysfunction

● Hypotonic uterine dysfunction, there is no basal hypertonus and uterine contractions have
a normal gradient pattern (synchronous), but pressure during a contraction is insufficient to
dilate the cervix.
● Hypertonic uterine dysfunction or incoordinate uterine dysfunction, either basal tone is
elevated appreciably or the pressure gradient is distorted. Gradient distortion may result
from more forceful contraction of the uterine midsegment than the fundus or from
complete asynchrony of the impulses originating in each cornu or a combination of these
two.
 Clinical presentation
• Abdominal palpation: uterine contraction is weak,
and intervals is prolonged.

• Abnormal labor course: the most important clinical

presentation.
The diagnostic criteria of abnormal labour
 Management
• Vaginal examination: rule out cephalopelvic
disproportion

• Supportive management

• Augmentation
 The Vaginal Examination
• To determine fetal presentation, position and station.

• To assess the cephalopelvic relation.

• To consider the route of delivery.

 The Supportive Management
• Sufficient rest

• To relieve anxiety and fear.

• Fluid and food intake.

 Augmentation
• Increase the frequency and force of the existing
uterine contractions.

• Methods: amniotomy
oxytocin administration
 Amniotomy
• If the fetal head is engaged, amniotomy is a choice
to facilitate the uterine activity.

• After amnitomy the fetal head descends , pressing

directly on cervix to enforce uterine contraction.
Accelerating labor.
 Oxytocin
• Capable of inducing uterine contracion in the third
trimester.

• Contraindiction: cephalopelvic disproportion and

severe fetal malposition.
COMPLICATIONS WITH DYSTOCIA

● Maternal Complications • Perinatal

○ Uterine Ruptur Complications
• Similar to the mother, the
○ Pathological Retraction Ring
incidence of peripartum fetal
○ Fistula Formation sepsis is increased with longer
labors.
○ Pelvic Floor Injury • Caput succedaneum and
molding
○ Postpartum Lower Extremity Nerve Injury • Mechanical trauma such as
nerve injury, fractures, and
cephalohematoma
REFERENCES

Cunningham, F. Gary,, et al. Williams Obstetrics. 24th edition. New York:

McGraw-Hill Education, 2014.
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