Abnormal Labor

JI Salas, Shania Myca A

Dystocia
● “Difficult labor”
● Abnormally slow progress
● Abnormalities of:
○ Power
○ Passenger
○ Passage

a. Cephalopelvic Disproportion
- Disparity between fetal head size and
maternal pelvis
B. Failure to progress
- Lack of progressive cervical dilation or
halted fetal descent
 A. Abnormalities of the Expulsive Forces

Types of Uterine Dysfunction

● Normal Spontaneous
○ 60mmHg
● Hypotonic Uterine Dysfunction
○ Basal tone is normal and uterine contractions have a normal gradient pattern
○ Pressure during a contraction is insufficient to dilate the cervix
● Hypertonic Uterine Dysfunction/ Incoordinate Uterine Dysfunction
○ Either basal tone is elevated appreciably or the pressure gradient is distorted
 A. Abnormalities of the Expulsive Forces

Risk Factors:
● Neuraxial Analgesia
○ Longer 1st and 2nd stages of labor
● Chorioamnionitis
● Higher station at the onset of labor
● Advanced maternal age
● Maternal Obesity
○ Lengthens 1st stage by 30-60 minutes
A. Abnormalities of the Expulsive Forces
 A. Abnormalities of the Expulsive Forces

● Maternal Pushing efforts

○ Heavy sedation of regional analgesia may reduce the reflex urge to
push and may impair the ability to contract abdominal muscles
sufficiently
○ Depending on fetal station and anticipated second stage, options
include emotional support and encouragement, parenteral analgesia,
pudendal blockade, or neuraxial analgesia
 A. Abnormalities of the Expulsive Forces

● Maternal Pushing efforts

○ Heavy sedation of regional analgesia may reduce the reflex urge to
push and may impair the ability to contract abdominal muscles
sufficiently
○ Depending on fetal station and anticipated second stage, options
include emotional support and encouragement, parenteral analgesia,
pudendal blockade, or neuraxial analgesia
 B. Prematurely Ruptured Membranes at Term
● Membrane rupture at term without spontaneous uterine contractions complicates
approximately 8 percent of pregnancies.
● Labor stimulation was initiated if contractions did not begin after 6 to 12 hours.
○ Oxytocin was preferred management
● Hypotonic contractions / advanced cervical dilation
○ Oxytocin is selected to lower potential hyperstimulation risk.
● Unfavorable cervix, no or few contraction, and no significant fetal heart rate
decelerations,
○ Prostaglandin E1 (misoprostol) is chosen to promote cervical ripening and
contractions
● Membranes ruptured >18 hrs
○ Group B streptococcal infection prophylaxis
 C. Precipitous Labor and Delivery
● Extremely rapid labor and delivery
● Causes:
○ Abnormally low resistance of the soft parts of the birth canal
○ Abnormally strong uterine and abdominal contractions, or
○ Rarely from a lack of pain with contractions to cue advanced labor
● Terminates in expulsion of the fetus in <3 hours.
● Vigorous uterine contractions combined with a long, firm cervix and a noncompliant
birth canal → uterine rupture or extensive lacerations of the cervix, vagina, vulva, or
perineum
● Amniotic fluid embolism most likely develops
 C. Precipitous Labor and Delivery
● Frequently followed by uterine atony.
● Linked to cocaine abuse and associated with placental abruption, meconium, postpartum
hemorrhage, and low Apgar scores.

● Effects on the neonate:

○ Prevent appropriate uterine blood flow and fetal oxygenation
○ Intracranial Injuries
○ Needed resuscitation may not be immediately available
● Treatment
○ Analgesia is unlikely to modify contractions significantly
○ Magnesium sulfate or terbutaline is unproven
○ A single, intramuscular 250-ug terbutaline dose may be reasonable in an attempt to
resolve a nonreassuring fetal heart rate pattern.
○ Oxytocin administration should be stopped.
 D. Fetopelvic Disproportion
A. Pelvic Capacity
a. Contracted Inlet
● Diagonal Conjugate <11.5cm
● Contributes in the production of abnormal presentations.

a. Contracted Midpelvis
● More common than contracted inlet
● Causes transverse arrest of the fetal head
● Obstetrical plane of the midpelvis extends from the inferior margin of the symphysis
pubis through the ischial spines and touches the sacrum near the junction of the fourth
and fifth vertebrae.
 D. Fetopelvic Disproportion
c. Contracted Outlet
● Interischial tuberous diameter 8 cm or less.
● Outlet contraction without concomitant midplane contraction is rare.
d. Pelvic Fractures
● Fracture pattern, minor malalignment, and retained hardware are not absolute
indications for cesarean delivery.
● Fracture healing requires 8 to 12 weeks and thus recent fracture merits cesarean
delivery
 D. Fetopelvic Disproportion
● Midpelvis measurements are as follows:
● transverse, or interischial spinous: 10.5 cm;
● anteroposterior, from the lower border o the symphysis pubis to the junction o S4
and S5, 11.5 cm;
● posterior sagittal, from the midpoint of the interspinous line to the same point on the
sacrum, 5 cm.

● Likely contracted when the sum of the interspinous and posterior sagittal diameters of the
midpelvis—normally, 10.5 plus 5 cm, or 15.5 cm—falls to </=13.5 cm
 D. Fetopelvic Disproportion
A. Face Presentations
● Neck is hyperextended so that the occiput is in
contact with the fetal back, and the chin
(mentum) is presenting.

a. Risks:
● Preterm fetuses
● Multifetal gestations
● High Parity
● Fetal Malformation
● Hydramnios
● Anencephaly
 D. Fetopelvic Disproportion
b. Mechanisms of labor:
● With the chin anterior, internal rotation of the face brings
the chin under the symphysis pubis
● Ater anterior rotation and descent, the chin and mouth
appear at the vulva, and the undersurface of the chin presses
against the symphysis.
● Once the chin clears the symphysis, the neck can flex.
● The nose, eyes, brow, and occiput then appear in succession
over the anterior margin of the perineum. After birth of the
head, the occiput sags backward toward the anus.
 D. Fetopelvic Disproportion
C. Management:
● Fetal heart rate monitoring is best done with external
devices to help avoid face or eye injury.
● Rotation to a mentum anterior position may occur late in
labor. Conversion methods should not be pursued.
 D. Fetopelvic Disproportion
B. Brow Presentation
● Uncommon and is diagnosed when that
portion of the fetal head between the orbital
ridge and the anterior fontanel presents at
the pelvic inlet
● Fetal head thus occupies a position midway
between full flexion (occiput) and full
extension (face).
 D. Fetopelvic Disproportion
B. Brow Presentation
● Commonly unstable and converts to a face
or an occiput presentation
● Except when the fetal head is small or the
pelvis is unusually large, engagement of the
fetal head and subsequent delivery cannot
take place as long as the brow presentation
persists
 D. Fetopelvic Disproportion
C. Transverse Lie
● Fetus’ long axis lies approximately perpendicular to that of the
mother.
● Shoulder
○ Usually positioned over the pelvic inlet.
● Head
○ Occupies one iliac fossa, and the breech the other.
● Shoulder presentation
○ The side of the mother on which the acromion rests
determines the designation of the position as right or left
acromial.
○ The back may be directed anteriorly or
○ posteriorly and also superiorly or inferiorly
 D. Fetopelvic Disproportion
C. Transverse Lie
● 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 on one side and the breech on the other.
● Back is anterior:
○ Hard resistance plane extends across the front of the
abdomen.
○ Posterior, irregular nodules that represent fetal small parts
are elt through the mother’s abdominal wall.
 D. Fetopelvic Disproportion
C. Transverse Lie
a. Mechanism of Labor
● Spontaneous delivery of a fully developed newborn is impossible
with a persistent transverse lie.
● With a neglected transverse lie, the uterus will eventually rupture.
● Maternal and fetal morbidity rates with transverse lie are
increased because of the frequent association with placenta
previa, umbilical cord prolapse, and fetal manipulations during
cesarean delivery.
 D. Fetopelvic Disproportion
C. Transverse Lie
a. Mechanism of Labor
● If the fetus is small—usually <800 g—and the pelvis is large,
spontaneous delivery is possible.
● Conduplicato corpore
○ The fetus is compressed with the head forced against its
abdomen.
○ A portion of the thoracic wall below the shoulder thus
becomes the most dependent part, appearing at the vulva.
○ Head and thorax then pass through the pelvic cavity at the
same time.
 D. Fetopelvic Disproportion
C. Transverse Lie
b. Management
● Active labor in a woman with a transverse lie typically requires
cesarean delivery.
● Dorsoanterior or back down position
○ Neither the fetal feet nor head occupies the lower uterine
segment.
● A low transverse uterine incision may lead to difficult fetal
extraction.
○ Vertical hysterotomy incision is typically indicated.
● With dorsoposterior or back up position, one or both feet can be
grasped through a low transverse incision and delivered by
breech extraction.
 D. Fetopelvic Disproportion
D. Umbilical Cord Prolapse
● More common with pelvis contraction.
● Most risks stem from an unengaged presenting part and include:
○ Hydramnios
○ Breech presentation
○ Transverse lie
○ Premature or small fetus with weight <2500 g
○ Preterm rupture of membranes,
○ Multifetal gestation

● Funic presentation
○ Umbilical cord is the presenting part.
■ Potent risk factor for prolapse and merits cesarean delivery prior to labor.
 E. Complications with Dystocia
A. Maternal Infection
- Either intrapartum chorioamnionitis or postpartum endomyometritis, is more common with desultory and
prolonged labors.
B. Postpartum Hemorrhage
C. Uterine tears
D. Uterine Rupture
- Abnormal thinning of the lower uterine segment
- the upper segment o the uterus contracts, retracts, and expels the fetus. In response, the softened lower
uterine segment and cervix dilate and thereby form a greatly expanded, thinned-out tube through which the
fetus can pass.
- Pathological Retraction Ring of Bandl
- an abnormal condition that forms when there is an extreme thinning of the lower uterine
segment such as one seen in obstructed labor.
 E. Complications with Dystocia
E. Fistula formation
- Presenting part is firmly wedged into the pelvis.
- Excessive pressure is exerted against tissues lying between the leading part and the pelvic wall.
- Because of impaired circulation, necrosis may result and become evident several days after delivery as
vesicovaginal vesicocervical, or rectovaginal stulas
F. Lower-extremity nerve injury in the mother
- Can follow prolonged second-stage labor.
- Mainly sensory, and most resolve within 6 months of delivery in most women.

G. Caput succedaneum and molding

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