Dystocia

 difficult labor, characterized by abnormally slow

progress of labor
 Cause long parturition:
a. POWER: abnormalities of the expulsive forces
b. PASSANGER: abnormalities of presentation, position,
or development of the fetus.

c. PASSAGE: abnormalities of the maternal bony pelvis,

abnormalities of soft tissues of the reproductive tract
 Mechanisms of Dystocia
At the end of pregnancy:
 Obstacles for the fetal head to traverse the birth

canal:
◦ uterine contractions
◦ cervical resistance
◦ forward pressure exerted by the leading fetal head
 Factors influencing the progress of the 1st stage
of labor
◦ thicker lower uterine segment
◦ undilated cervix
◦ uterine muscle is less developed and presumably
less powerful.
Mechanisms of Dystocia
 After complete cervical dilatation (2nd
Stage): the
mechanical relationship between the
following is clearer:
◦ fetal head size and position } fetopelvic
◦ the pelvic capacity } proportion
◦ uterine musculature is much thicker and
thus more powerful
◦ abnormalities in fetopelvic disproportions
become more apparent
Mechanisms of Dystocia
Uterine muscle malfunction can result from
 uterine overdistention or
 obstructed labor

 Thus ineffective labor is a possible

warning sign of fetopelvic disproportion

 Uterine dysfunction } labor

abnormalities
 Pelvic disproportion } so closely
interlinked
Diagrams of the birth canal (A) at the end of pregnancy and (B) during
the second stage of labor, showing formation of the birth canal. (C.R.
= contraction ring; o.i. = internal cervical os; o.e. = external cervical
os.) (From Williams, 1903.)
ABNORMALITIES OF THE EXPULSIVE FORCES

 1ST STAGE OF LABOR: Contractions of the

uterus cervical dilatation, propulsion
and expulsion of the fetus

 2ND STAGE OF LABOR: Contractions of the

uterus or involuntary muscular action of
abdominal wall --“PUSHING”
2 types of Uterine Dysfunction
 Hypotonic Uterine Dysfunction
◦ More common
◦ No basal hypertonus
◦ Uterine contractions have a normal gradient
pattern (synchronous)
◦ Slight rise in pressure during a contraction is
insufficient to dilate the cervix
◦ Treatment: Oxytocin
 Hypertonic/Incoordinate Uterine Dysfunction
◦ Basal tone is elevated
◦ Pressure gradient is distorted (asynchronism)
◦ Treatment: sedation
 Reported Causes of Uterine Dysfunction

 Various labor factors have been implicated as

causes of uterine dysfunction
 Epidural Analgesia

◦ epidural analgesia can slow labor

◦ epidural analgesia has been associated with
lengthening of both first- and second-stage
labor as well as slowing of the rate of fetal
descent
 Chorioamnionitis

◦ infection itself plays a role in the

development of abnormal uterine activity
Reported Causes of Uterine Dysfunction
 Maternal Position during Labor

◦ recumbency or ambulation during labor

 shorten labor
 decrease rates of oxytocin augmentation
 decrease the need for analgesia
 lower the frequency of operative vaginal delivery
◦ the uterus contracts more frequently but
with less intensity with the mother in the
supine position compared with that of lying
on her side.
◦ contraction frequency and intensity have
been reported to increase with sitting or
standing
 Birthing Position in Second-Stage Labor
SECOND-STAGE DISORDERS

 incorporates many of the cardinal

movements necessary for the fetus to
negotiate the birth canal

 disproportion of the fetus and pelvis

frequently becomes apparent
DURATION OF 2ND STAGE
 nulliparas - 2 hours
 extended to 3 hours with regional analgesia
 multiparas - 1 hour
 extended to 2 hours with regional analgesia

“Bearing down” or “pushing” – repetitive

contraction of the abdominal
musculature with vigor to generate
increased intra-abdominal pressure
throughout the uterine contractions
propulsion of the fetus downward
Factors that prevent spontaneous
vaginal delivery

 compromised magnitude of the force

created by contractions of abdominal
musculature
 heavy sedation or regional analgesia
(lumbar epidural or spinal) that reduces
the reflex urge to push, and impair the
ability to contract the abdominal muscles
sufficiently
 inherent urge to push is overridden by the
intense pain created by bearing down.
FETOPELVIC DISPROPORTION

 arises from diminished pelvic capacity,

excessive fetal size, or more usually, a
combination of both.
EFFECTS OF DYSTOCIA
Maternal Effects
 Intrapartum Infection

 Uterine Rupture

 Pathological Retraction Ring

Pathological retraction ring of Bandl, an
exaggeration of the normal retraction ring
often the result of obstructed labor
marked stretching and thinning of the lower
uterine segment
may be seen clearly as a uterine indentation
and signifies impending rupture of the lower
uterine segment
EFFECTS OF DYSTOCIA
Maternal Effects
 Fistula Formation
vesicovaginal, vesicocervical, or rectovaginal fistulas
develops from impaired circulation, necrosis becoming
evident several days after delivery
 PelvicFloor Injury
 Postpartum Lower Extremity Nerve Injury
Footdrop - secondary to injury at the level of the lumbosacral
root, lumbosacral plexus, sciatic nerve, or common peroneal
nerve
most common mechanism of injury, however, is external
compression of the peroneal nerves usually caused by
inappropriate leg positioning in stirrups especially during a
prolonged second stage of labor
symptoms resolve within 6 months of delivery in most
women.
EFFECTS OF DYSTOCIA
Fetal Effects
 Caput Succedaneum
 Fetal Head Molding

associated with: nulliparity

oxytocin labor stimulation
delivery with a vacuum extractor
 Skull fractures
Postpartum Infection
Predisposition factors:
prolonged and premature rupture of the
membranes
prolonged (more than 24 hours) labor
frequent or unsanitary vaginal examinations
or unsanitary delivery
hemorrhage
maternal conditions, such as anemia, poor
nutrition during pregnancy.
urinary catheter
Ways of become infected
Patient's hand or helper’s hand that carrying bacteria
Droplets infection
Hospital infection
carried by water, air, tools and objects that the hospital
was often used by patients (towels, blanket, etc)
Coitus in late pregnancy, but not so dangerous, except
when the membranes have ruptured.
Prevention
Avoid the risk factors
Keep the episiotomy site clean
Careful attention to antiseptic procedures during
childbirth is the basic underpinning of preventing
infection. With some procedures, such as cesarean
section, a doctor may administer prophylactic antibiotics
as a preemptive strike against infectious bacteria.
 Post Partum
HEMORRHAGE
 Definition:
Blood loss > 500ml in the first 24 hours after
delivery (with average blood loss at Cesarean
delivery of 1000ml)

Causal of bleeding:
1. Bleeding from the placental implantation
   Consists of:
   a. Hipotoni to uterine atony
   b. The rest of the placenta

2. Bleeding due to laceration
3. Coagulation disorders
Risk Factors - Antepartum
 Pre-eclampsia
 Nulliparity
 Multiple gestation
 Previous PPH
 Previous C/S

B.Moss 7/23/07
Risk Factors - Postpartum

 Augmented labor
 Arrest of descent
 Assisted delivery (forceps/vacuum)
 Third Stage longer than 30 minutes
 Episiotomy, mediolateral or midline
 Laceration (cervical/vaginal/perineal)

B.Moss 7/23/07
Kinds of bleeding:

1. Primary bleeding
 Occured within the first 24 hours.
2. Secondary bleeding
 Occurred after 24 hours
Atone Uteri
This is the weak state of tonus or contractions of the
uterus that causes the uterus is notable to close
the open bleeding from the implantation of the
placenta, after birth the babyand placenta.

Predisposing factors:
1. Excessive uterine stretch

2. Fatigue due to give birth

3. Pregnancy grande multiparous

4. Mother's general condition is poor, anemis, or annual disease

5. Myoma uterine

6. Intrauterine infection

7. Have a history of previous

Laceration of the birth canal

It occurs when themore manipulative and traumatic.
Kinds of tears:
1. Laceration
2. Episiotomy wound
3. Spontaneous perineal tear
4. Ruptured uteri totalis
5. Tear in the wall of the vagina, fornix uteri, cervix, the
area around the clitoris, and urethra.
Inversion of the uterus
It occurs in stage 3
This is the state of the uterine lining (endometrium) down and
out through
the ostium uterieksternum either be complete or incomplete

Predisposing factors:
1. Uterine atony
2. Cervix is still wide open
3. There are forces pulling
the fundus downward, eg placenta accreta, placenta increta,place
nta percreta, or umbilical cord is pulled down to hard)
4. Pressure on the fundus uteri from above (maneuver trede)
5. Intraabdominal pressure is hard and
suddenly, eg: coughing and sneezing
Bleeding due to coagulant

The result:
1. Bleeding occurs every dressmaking

2. Bleeding can be translucent, so the resulting scar and hematoma at

the injectio
3. Leeding from the gums, nasal cavity, etc.

Predisposing factors:
4. Solusio placenta
5. A dead fetus in the womb
6. Eclampsia

7. Amniotic fluid embolism
8. Sepsis
Causes of PPH – THE FOUR T’s
 TONE (70 %)
 TRAUMA (20 %)
 TISSUE (10 %)
 THROMBIN (1 %)

B.Moss 7/23/07
TONE - Treatment
 Atonic Uterus – (70%)

◦ Bimanual Uterine massage

◦ Oxytocic agents

B.Moss 7/23/07
 Bimanual Uterine
Massage
1)Insert one hand into the
vagina and push up
agianst the body of the
uterus
2)Place the other hand
above the uterus and
compress the uterus
against the hand in the
vagina
3)Massage the posterior
aspect of the uterus with
the abdominal hand
and, at the same time,
massage the anterior
aspect with the vaginal
hand

B.Moss 7/23/07
Oxytocic Agents
 Oxytocin (Pitocin)
◦ Stimulates upper uterine segment contraction,
decreasing blood flow through uterus
◦ Physiologic
◦ Once receptors saturated, higher doses only lead
to water intoxication
◦ DOSE: 10-40 units/1000ml IVF (eg Ringers
Lactate), which is approx. 80milliunits/minute if
choose 20 units/1000ml IVF

B.Moss 7/23/07
Oxytocic Agents (#2) – Ergot
Alkaloids
 Methylergonovine (Methergine)
◦ Causes generalized smooth mm contraction in both
upper and lower uterine segments
 placental entrapment more at risk
 Contraindicated in Htn: Increases chance of Htn and
peripheral vasoconstriction
◦ DOSE: .2 mg IM

B.Moss 7/23/07
Oxytocic Agents (#3) -
Prostaglandins
 Carboprost (Hemabate)
◦ 86% of PPH controlled when other means (uterine
massage, oxytocin or ergots) have failed
◦ Use with caution in pts c asthma, htn, active
cardiac, pulmonary, renal or hepatic disease
◦ Side effects of n/v, diarrhea, htn, ha, flushing or
pyrexia
◦ DOSE: .25mg IM or Intramyometrially

B.Moss 7/23/07
Oxytocic Agents for Uterine Atony
Summary

ALSO,
B.Moss 7/23/07 2006, p.6
TRAUMA - Treatment
 UTERINE INVERSION
◦ Appears as bluish grey mass protruding from vagina
◦ Disproportionate Vasovagal shock as clue
◦ BEFORE CERVICAL CONTRACTION RING HAS DEVELOPED: grasp
fundus with one hand, fingers directed toward posterior fornix, lift
uterus out of the pelvis forcefully holding the uterus in the
abdominal cavity above the level of the umbilicus (this hand and
2/3 of forearm may therefore be in vagina). Allow uterine
ligaments to pull the uterus back into position
◦ Promote uterine tone as above
◦ If symptomatic bradycardia/hypotension develops, consider
atropine .5mg IV and fluid bolus

B.Moss 7/23/07
TRAUMA – Treatment (2)
 UTERINE RUPTURE
◦ Signs:
 prolonged fetal bradycardia,
 non-reassuring fetal heart tracing,
 vaginal bleeding,
 abdominal tenderness,
 maternal tachycardia,
 circulatory collapse out of proportion to amount of
external blood loss,
 increasing abdominal girth
◦ TO SURGERY!!!!

B.Moss 7/23/07
TRAUMA – Treatment (3)
 BIRTH TRAUMA
◦ Repair lacerations c hemostasis
◦ Small hematomas can be managed expectantly

B.Moss 7/23/07
TISSUE - Treatment
 Retained Placenta - >30 minutes (3% of
vaginal deliveries)
 For entrapped placenta: apply firm traction

on the umbilical cord with one hand,

suprapubic pressure with the other
 Manual removal

B.Moss 7/23/07
Manual Removal of Placenta
 O2, 2 large bore IV, adequate anesthesia, surgical
assist notified
 Relax uterus (cease massage, administer subq
terbutaline or other agent)
 ID cleavage plane, advance fingertips along plane
 Ensure entire placenta removed, massage uterus
 If no success, surgical removal or hysterectomy

B.Moss 7/23/07
Manual Removal of Placenta

 from Williams, 20B.Moss

th
Ed. p.7/23/07
264
 ALSO, 2006 ed.
B.Moss 7/23/07
Postpartum Depression
Perinatal Psychological Disorders
 The Blues

 Postpartum Depression

 Postpartum Psychosis
Perinatal Depression: Prevalence

Pregnancy Postpartum
Kumar & Robeson 13.4% 14.9%
1984
Watson & Elliott 1984 9.4% 12.0%

O’Hara et al., 1984 9.0% 12.0%

Cooper et al. 1988 6.0% 8.7%

O’Hara et al., 1990 7.7% 10.4%

Evans et al., 2001 13.6% 9.2%

Postpartum Blues
 Most common, 50-80%
 Relatively brief

◦ Few hours to several days

 Onset usually in first week to 10
days PP
 Typically remit spontaneously

◦ May represent the initial stages of

PPD/PPP
 Typical Blues Symptoms

 Low Mood  Anxiety

 Mood Lability  Crying
 Irritability
 Insomnia
 Postpartum Psychosis
 Rare: 1/1000 postpartum women

 Hallucinations and/or Delusions

 Risk Factors:
 History Bipolar Affective
Disorder/Psychosis
 Family history of psychosis
 Having first child

 Aggressive intervention absolutely

necessary
Postpartum Psychosis

 Usually Begins Within 90 Days Postpartum

 Length is Quite Variable
 Prevalence: 1/500 to 1/1000
 Family history of bipolar disorder 33/1000
 Family history of postpartum psychosis 22/1000
 Personal history bipolar disorder: 1/2
 Sequelae: Future Postpartum Psychosis
 Postpartum Depression

 Not as mild or transient as the blues

 Not as severely disorienting as

psychosis
 Range of severity
 Often undetected
Symptoms of
Major Depression
 Depressed  Loss of Interest or Pleasure
Mood  Psychomotor agitation or

 Decreased or retardation
 Feelings of worthlessness
increased
appetite with or or guilt
 Concentration or problems
without weight
changes making decisions
 Suicidal thoughts
 Insomnia or

Hypersomnia
 Low
Postpartum Depression: Risk Factors
 Lower SES/unemployment
 Past depression or anxiety disorder
 Past history of alcohol abuse
 Stressful life-events
 Poor marital relationship
 Inadequate social support
 Child-care related stressors
 African American ethnicity
Effects of Perinatal Depression:
An Overview

Depression negatively effects:

 Mother’s ability to mother

 Mother—infant relationship
 Emotional and cognitive development of

the child
 Postpartum Depression:
Maternal Attitudes

◦ Infants perceived to be more bothersome

◦ Make harsh judgments of their infants

◦ Feelings of guilt, resentment, and ambivalence

toward child

◦ Loss of affection toward child

Postpartum Depression:
Maternal Behaviors

 Gaze less at their infants

 Take longer to respond to infant’s utterances

 Show fewer positive facial expressions

 Lack awareness of their infants

 Increased risk for abusing children

Postpartum Depression:
Maternal Interactions

Flat affect, low activity level, and lack of

contingent responding

OR

Alternating disengagement and intrusiveness

Effects of Maternal Depression

 Infants- lowered Brazelton scores, frequent

looking away, fussiness

 Toddlers- poorer cognitive development,

insecure attachment

 Children- cognitive development of low ses

boys

 Adolescents-higher cortisol levels

Treatment
 Psychotherapy

 Medication

 Nurse care (based on model of care from

the U.K- a “thinking out-of-the box”
solution
PERINEAL RUPTURE
Predisposition Factor :
 Parity : primiparity have high risk than

multiparity
 Jarak Lahir ? : < 2 years
 Weight of Baby : > 3500 gram
CLASSIFICATIONS :
 First-degree lacerations involve the fourchette,
perineal skin, and vaginal mucous.
 Second-degree lacerations involve, in addition to
skin and mucous membrane, the fascia and muscles
of the perineal body tears usually extend upward on
one or both sides of the vagina, forming an irregular
triangular injury.
 Third-degree lacerations extend through the skin,
mucous membrane, and perineal body, and involve
the anal sphincter.
 A fourth-degree laceration extends through the
rectal mucosa to expose the lumen of the rectum.
Tears in the region of the urethra that may bleed
profusely may also accompany this type of
REPAIR
•First Degree :
Doesn’t need
repair
•Second and
Third
Degree :
Repair like
episiotomy’s
repair
•Fourth
Degree : Refer Layered repair of a fourth-degree perineal
laceration