DYSTOCIA

1.0107/18/16
NENITA TEH, MD
201 8 OUTLINE FUNCTIONAL DIVISIONS OF LABOR
I. Dystocia
Includes the latent and
A. Causes
B. Normal labor acceleration phase
C. Stages of labor A. Sensitive to sedation and analgesia
D. Functional divisions of labor PREPARATORY Change in the connective tissue
E. Phases of cervical dilatation components of the cervix (cervical
F. WHO partograph softening)
G. Modified WHO partograph
Dilatation occurs at most rapid rate
H. Maternal-Fetal effects of dystocia
II. Abnormal Labor B. Unaffected by sedation
III. Abnormalities in Power DILATATIONAL Corresponds to rapid dilatation of
A. Types of Uterine dysfunction cervix
B. Uterine activity Commences with deceleration
C. Hyperstimulation phase
IV. Abnormalites in the Passenger Cardinal movement of labor occur
A. Face presentation
(EDFIREERE)
B. Brow presentation
C. Transverse lie Engagement
D. Compound presentation Descent
E. Persistent Occiput Posterior C. Flexion
F. Shoulder Dystocia PELVIC Internal Rotation
V. Abnormalites in the Passages Extension
A. Pelvic Inlet External Rotation
B. Pelvic Midplane Expulsion
C. Pelvic Outlet
In actual practice, however, the
onset of pelvic division is seldom
DYSTOCIA clearly identifiable
Means difficult labor or prolonged labor
Characterized by abnormally slow progress of labor
The most common indication for primary CS delivery
Contributing factor in >70% of maternal death

CAUSES
Abnormalities of powers
Abnormalities of passenger (fetus)
Abnormalities of passages
Abnormalities of the birth canal other than those of the
bony pelvis eg. masses

NORMAL LABOR
TRUE LABOR
Fig. 1. Friedman curve
o Uterine contraction that bring about demonstrable
effacement and dilation of the cervix
PHASES OF CERVICAL DILATATION
o It does not need pain for it to become true labor
o Note: normal spontaneous vaginal delivery requires not Preparatory division of labor
only dilatation, head descent must also occue Commence with maternal perception of
regular uterine contraction
LATENT
When does labor start? Accompanied by progressive cervical
PHASE
o When painful contractions become regular dilatation and ends between 3 to 4 cm
o At the time of admission to the labor unit dilatation
Duration of labor = time elapsed from admission to 10% are false labor
delivery Cervical dilatation of 3-5 cm or more, in the
presence of uterine contractions, can reliably
STAGES OF LABOR represent the threshold for active labor
st From regular uterine contraction to full
1 stage 1. Acceleration phase
cervical dilatation (10cm)
Full dilatation of the cervix up to the delivery o Determines the ultimate outcome of labor
of the baby o Faster acceleration, faster dilatation, faster
ACTIVE
delivery
PHASE
Average: 2. Phase of maximum slope
o Good measure of overall efficiency of the
NULLIPARA average 50 minutes
uterus/machine
2-3 hours if w/ regional
3. Deceleration phase
anesthesia o Reflects feto-pelvic relationship
2nd 2 hours if w/o regional o Starts at 7-8 cm dilatation
stage anesthesia
MULTIPARA average 20 minutes
1-2 hours if w/ regional
anesthesia
1 hour if w/o regional
anesthesia
*Nullipara never completed pregnancy beyond
20 weeks gestation
From the delivery of the baby to placental
3rd stage
expulsion

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In the 2nd stage of labor, the 95th percentiles for

nulliparas with and without epidural analgesia were 3.6
hours and 2.8 hours, respectively. The duration of the
Hyperbolic curve 2nd stage was much shorter in multiparas.
(Descent)

Sigmoid curve
(Dilatational)

Fig.2. Dilatational and descent patterns

The dilatational and descent pattern in normal labor

traces a characteristic sigmoid (dilatational) and
hyperbolic curve (descent)
Average rate of descent of fetal head
o Nullipara 1cm/hr (begins at about 7-8cm dilated)
o Multipara 2cm/hr MATERNAL-FETAL EFFECTS OF DYSTOCIA
MATERNAL EFFECTS
WHO PARTOGRAPH (1994) Intrapartum infection
LATENT Should not last > 8 hours o Intrapartum chorioamnionitis and postpartum pelvic
PHASE infection: more common with desultory and prolonged
Starts at 3 cm dilatation labors
ACTIVE Rate should not be slower than 1cm/hr Postpartum hemorrhage from atony increased with
PHASE A minimum of 4 hours is recommended prolonged and augmented labors
before intervention Pathological ring of Bandl
MODIFIED WHO PARTOGRAPH (2006) o Pathological contraction ring
Women in labor (parturients) should be o Associated with stretching and thinning of lower uterine
referred to a hospital when cervical dilatation segment
ALERT
moves to the right of the alert line o May be seen as a uterine indentation; signifies
LINE impending rupture
Management: Artificial rupture of membrane
Uterine rupture
(AROM), close observation
Fistula formation
If labor crosses the action line (4 hours to the
right of alert line) Pelvic floor injury
ACTION It requires active intervention
FETAL EFFECTS
LINE Management: provide analgesia, augment
o Caput succedaneum focal swelling of the scalp
with oxytocin as long as there is no evidence
o Cephalohematoma injury to the periosteum
of fetal distress or obstructed labor
o Molding
No latent phase
Should be started in women with active labor (4cm
cervical dilatation)
It has 2 sets of observation
o 1st set
relate to progress of cervical dilatation, descent of
fetal head and uterine contractions
o 2nd set
Focuses on the fetus
Fetal heart rate, membranes, amniotic fluid and
molding of head Fig. 4. Caput succedaneum Fig. 5. Cephalohematoma

ABNORMAL LABOR
I. Protraction (slower-than-normal progress)
Slow rate of cervical dilatation or descent
30% with protraction disorders have cephalo-pelvic
disproportion (CPD)
*Vaginal delivery is still possible
*During protraction, check which of the power or
passenger is defective. If neither is defective, do
amniotomy. Hindi CS agad!
A. Dilatation
B. Descent
Fig. 3. Partograph
II. Arrest disorder (no progress)
45% had CPD
A. Dilatation
Zhangs labor pattern
B. Descent
Threshold for active labor: 6cm
Rate of cervical dilatation: Nullipara: 0.5-0.7cm/hr III. Failure
Multipara: 0.5-1.3cm/hr A. Descent

The 95th percentiles indicate that at 4 cm, it could take IV. Precipitate labor
more than 6 hours to progress to 5 cm, while at 5 cm, it Delivery in <3 hours (faster delivery)
may take more than 3 hours to progress to 6 cm. May result in intracranial hemorrhage, atony
A. Dilatation
Only after 6 cm did multiparas show faster labor than B. Descent
nulliparas, which is consistent with the labor curves.

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ABNORMAL LABOR Slight increase in pressure insufficient to

NULLIPARA MULTIPARA
PATTERNS dilate cervix
Prolonged latent phase Management:
>20hrs >14hrs o Augment with oxytocin
M: observe lang?
Oxytocin is not effective by mouth
Protracted active phase Each mL = 10 USP units
(maximum slope) Half-life = 3mins
<1.2cm/hr <1.5cm/hr
M: active action- Preparation
amniotomy/oxytocin 10 U oxytocin in 1 L D5W
Prolonged deceleration total dose <10u
(cervical dilation arrested >3hrs >1hr infusion rate not > 30-40 mL/min
at 8-9 cm) SIDE EFFECTS of Oxytocin
o Cardiovascular
Secondary arrest of
>2hrs >2hrs IV bolus can cause transient fall in
dilatation BP with abrupt increase in CO
Arrest of descent >1hr >1hr ECG changes in MI
Lack of descent during Increase in mean pulse rate
deceleration phase or 2nd o Water intoxication
Failure of descent
stage of labor Due to anti-diuretic action
(Until Staion 0 only) Increased basal tone
Precipitate active phase Pressure gradient distorted
HYPERTONIC
(maximum slope)
>5cm/hr >10cm/hr Uterine contraction at midsegment >
UTERUS
fundus
Precipitate descent >5cm/hr >10cm/hr
Management: Sedate the patient
*M- Management
UTERINE ACTIVITY
MANAGEMENT Quantified as the number of contractions present in a 10-
1. Prolonged latent phase: rest, analgesia; CS only if with CPD minute window, average over 30 minutes
Normal: 5 or less in 10 minutes
2. Protracted active phase dilatation- amniotomy with early Uterine tachysystole: >5 contractions in 10 minutes,
oxytocin augmentation qualified as to +/- of associated FHR decelerations

3. Arrest disorder- if with CPD, CS; if without, CS until at least HYPERSTIMULATION

4 hrs of uterine activity (>200MVU) but not sufficient Persistent tachysystole WITH fetal distress
Single uterine contraction > 2 min
ABNORMALITIES IN POWER Uterine contraction w/in 1 min of each other
(UTERINE DYSFUNCTION)
NORMAL UTERINE CONTRACTION ABNORMALITIES IN THE PASSENGER
Fundus greatest & longest myometrial activity (ABNORMALITIES IN PRESENTATION/POSITION & LIE)
15 mmHg lower limit of contraction pressure required to A. FACE PRESENTATION
dilate the cervix
60 mmHg normal spontaneous contraction
80-120 Montevideo units (cutoff: 180 MVU) uterine
activity where clinical labor starts

MONTEVIDEO UNITS (MVU)

Increase in uterine pressure above the baseline tone in a 10- The occiput is the longer end of the
minute period head lever. The chin is directly
180 MVU adequate uterine contraction posterior. Vaginal delivery is
<180 MVU inadequate uterine contraction (diagnosed in impossible unless the chin rotates
80% of active phase arrest) anteriorly
Description Presenting Part: Chin/Mentum
Neck and back come in contact
Head is hyperextended
Occiput in contact with fetal back
Submento-bregmatic diameter = 9.5
cm (presenting diameter)
Problem: If mentum posterior, the
brow is compressed against the
maternal symphysis pubis preventing
the flexion of the head -> CS!
o A mentum posterior presentation is
undeliverable except with a very
preterm fetus
Incidence 1:600 or 0.17%
Vaginal exam
o fetal mouth, malar bones, orbital
Diagnosis ridges
X-ray
o hyperextended head
Marked enlargement of the neck or
coils of cords
*take note of the baseline pressure. For this example, 20mmHg is the
Anencephalic fetus
baseline, and the first reading is at ~95mmHg. 95-20mmHg= 75mmHg
Etiology Contracted pelvis
(1st peak). Then i-add lahat ng readings to get the final MVU.
Very large fetus
Pendulous abdomen
TYPES OF UTERINE DYSFUNCTION High parity
HYPOTONIC No basal hypertonus
UTERUS Synchronous uterine contraction

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Descent internal rotation Flexion Preterm fetus

Mechanism accessory movement of extension Placenta previa
External rotation Abnormal uterus
CS is indicated Polyhydramnos
No contracted pelvis + effective labor = Contracted pelvis
vaginal delivery (only if mentum Spontaneous delivery of a fully
anterior) developed infant is impossible; CS is
Management THOM MANEUVER: convert brow to Course of
indicated
labor
vertex (NOT RECOMMENDED)-inc CONDUPLICATO CORPORE: fetus
perinatal and maternal morbidity doubled upon itself
continuous EFM is mandatory CS delivery is indicated
oxytocinforceps may be used Management
External version

B. BROW PRESENTATION D. COMPOUND PRESENTATION

Rarest; unstable presentation (military Description The left hand is lying infront of the
Description position) vertex
Fetal head occupies a position midway With further labor, the hand and arm
between full flexion and extension may retract from the birth canal, and
Presenting Part: Eyebrow the head may then descend normally
Vertico-mental diameter = 13.5 cm Extremity prolapses alongside the
therefore delivery cant take place presenting part
(fetal head between orbital ridge and Incidence 1:700-1000 deliveries
fontanel) Etiology Preterm
Abdominal exam
o Chin and occiput can be palpated
E. PERSISTENT OCCIPUT POSTERIOR (POP)
Vaginal
Diagnosis
o Front sutures, eyes, orbital ridges,
root of nose, large anterior fontanel
can be felt
Etiology Same as face presentation
Mechanism Engagement is impossible
expectant management
Management
(spontaneous conversion)
VERTEX POSITION
C. TRANSVERSE LIE Description 1st & 2nd stage of labor are prolonged
Chin and thorax in contact
Presenting Part: Occiput/Posterior
Fontanel
Precise reasons for failure of
spontaneous rotation is unknown
Painful labor (severe)
Generous episiotomy is indicated;
occiput has to rotate 135 instead of
45 thru symphysis
F. SHOULDER DYSTOCIA
Neglected transverse lie. A thick
muscular band forming a pathological
retraction ring has developed just
above the thin lower uterine segment.
The force generated during a uterine
contraction is directed centripetally at
Description and above the level of the pathological
retraction ring. This serves to stretch
further and possibly to rupture the thin
Anterior shoulder against symphysis
lower segment below the retraction
pubis
ring
Incidence increased due to bigger
Presenting Part: Shoulder
babies
Fundal Grip: empty fundus upon
Maternal-Fetal Consequences
palpation
o Post-partum hemorrhage
Long axis of fetus perpendicular to the Description
o Transient brachial plexus palsies
mother o Clavicular and humeral fractures
The back may be directed anteriorly or Risk Factors:
posteriorly (dorso-anterior or dorso- o Obesity
posterior) o Diabetes
Side of the mother toward which o Multiparity
acromion is directed determine
designation of the lie as right or left ACOG (1997-2000)
acromial 1. Most cases cant be predicted or
Incidence 0.3% prevented because there are no
Abdomen is unusually wide accurate methods to identify which
Diagnosis no fetal pole detected in the fundus fetus will develop this complication
ballotable head in iliac fossa 2. UTZ measurements to estimate
Unusual relaxation of the abdominal macrosomia have limited accuracy
Etiology
wall -may be d/t multiparity (Teh, 2015)

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3. Planned CS delivery based on 7. Other technique

suspected macrosomia is not
reasonable MANAGEMENT PROTOCOL FOR
4. Planned CS delivery may be SHOULDER DYSTOCIA
reasonable for nondiabetic with EFW ALARMER
> 5kg or diabetic with fetus EFW > Ask for help
4.5 kg Lift/Hyperflex leg
Initial gentle attempt at traction assisted Anterior shoulder disimpaction
by maternal expulsive effort is
Management Rotation of posterior shoulder
recommended + large episiotomy and
adequate analgesia Manual removal of posterior shoulder
Episiotomy
MANEUVERS FOR SHOULDER DYSTOCIA Roll over onto all fours position
1. Moderate Suprapubic Pressure- most frequently used,
very effective A Ask for help
2. Delivery of Posterior Shoulder L McRoberts Maneuver
3. Symphysiotomy Orients the symphysis pubis more horizontally
4. Deliberate Fracture of the Clavivle Inc outlet by 1.5-2cm
5. Cleidotomy - cutting the clavicle with scissors
6. McRoberts Maneuver
pelvic outlet 1.5-2cm
removing the legs from
the stirrups and sharply
flexing them up onto the
abdomen

7. Wood Corkscrew Manuever

Pressure is applied to A Mazzanti Maneuver (abdominal)
the anterior aspect of Suprapubic pressure applied with the heel of
the posterior shoulder, clasped hands from the posterior aspect of the
and an attempt is made anterior shoulder to dislodge it
to rotate the posterior
shoulder to the anterior
position

8. Rubin Maneuver
the more easily
accessible fetal shoulder
is pushed toward the
anterior chest wall of the
fetus (arrow) Rubin Maneuver (vaginal)
Most often, this results Shoulder is pushed towards the chest
in abduction of both
shoulders, reducing the
shoulder-to-shoulder
diameter and freeing the
impacted anterior
shoulder

R Wood screw-like Maneuver

9. Zavanelli Maneuver
The first part of the Step 1: Abduction of the posterior Shoulder
maneuver consists of
returning the head to the
occiput anterior or
posterior position. The
operator flexes the head
and slowly pushes it
back into the vagina,
following which cesarean
Step 2: Counterclockwise Rotation
delivery is performed
10. Hibbard Maneuver
Pressure be applied to
the fetal jaw and neck in
the direction of the
maternal rectum, with
strong fundal pressure
applied by an assistant
as the anterior shoulder
is freed

DRILLS FOR SHOULDER DYSTOCIA

1. Call for help
2. Generous episiotomy
3. Moderate suprapubic pressure/ Mazzanti maneuver
4. McRoberts maneuver
5. Wood corkscrew maneuver M Manual removal of posterior shoulder
6. Delivery of posterior shoulder

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E Level Level of ischial spine

Interspinous diameter (IS)
o 10.5 cm
o Shortest of the whole pelvic cavity

AP diameter
Description o 11.5 cm
Post-sagittal (PS)
o 4.5 cm
o Between sacrum and line created by
IS
IS + PS = 15 cm

CONTRACTED MID-PELVIS
IS < 8 cm
R Gaskin Maneuver IS + PS < 13.5 cm
With gentle downward pressure on the posterior Abnormality
shoulder, the anterior shoulder may become more Suggests contraction
impacted (with gravity), but will facilitate the Spines are prominent
freeing up of the posterior shoulder Pelvic sidewalls converge
Narrow sacro-sciatic notch
*Transverse Diameter: between linea terminals
FETAL MALFORMATIONS
-13.5 cm (largest diameter)
Hydrocephalus- can be diagnosed antenatal
Abdominal tumors (Wilms tumor)
Cystic hygroma PELVIC OUTLET
Conjoined twins

ABNORMALITIES IN PASSAGES
PELVIC INLET

Level Level of ischial tuberosity

Consist of approximately 2 triangular
areas having a common base
AP diameter
Level Level of symphysis pubis o Lower margin of pelvis to tip of
ANTERO PORSTERIOR DIAMETER (T- sacrum
O-D) Description o 9.5-11.5 cm
Transverse
True/Anatomic conjugate (TC) o Between inner ridges of ischial
o upper margin of pubic to sacral tuberosities
promontory o 11 cm
o Normal TC = > 11 cm PS > 7.5 cm
o TC= DC-1.2cm CONTRACTED PELVIC OUTLET
Obstetric conjugate (OC)
Intertuberous diameter/transverse
o Shortest distance of pelvic inlet diameter < 8 cm
Description o shortest distance between sacral
IS + PS < 13.5 cm
promontory and midportion of Abnormality
symphysis pubis
Outlet contraction without concomitant
o normal is > 10 cm
o OC= DC- 1.5 to 2 cm midplane contraction is rate
Management: Episiotomy
Diagonal conjugate (DC)
o can be measured clinically
o from lower margin of pubis to sacral Friedman WHO Zhang
promontory Purpose To define To improve labor To prevent
o Normal DC = >11.5 cm normal management, premature
CONTRACTED PELVIC INLET labor reduce CS
Abnormality OC < 10 cm patterns maternal/perinatal
DC < 11.5 cm morbidity/
mortality due to
PELVIC MIDPLANE obstructive labor
Shape of Sigmoid Diagonal straight Exponential
labor curve line staircase
Progression Active Alert line at 4cm
Progression
pattern phase Action line:
is slow
-starts at -4hrs after alert
before 6cm
4cm line
-duaration
-1.2cm/hr -<1cm/hr
is shorter
(nulli)
than 4hrs
-1.5cm/hr
after 6cm
(multi)

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Quiz:
1. Average duration of 2nd stage labor in multipara
2. Characteristic curve of fetal descent
3. Functional division of labor where cardinal movements of
labor occur
4. Maternal complications of dystocia
5. Management of hypotonic uterus
6. Adequate uterine contraction
7. Define tachysystole
8. Presenting diameter in brow presentation
9. Management of transverse lie
10. Maneuver for shoulder dystocia that requires returning the
head inside the uterus and delivering the baby abdominally
or via CS
11-12. Criteria for contracted pelvic inlet
13. Shortest diameter in pelvic cavity
14. Measured from the lower margin of pubis to sacral promontory
15. Define true labor

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