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DYSTOCIA

Presenter-Dr Aakriti Bhandari


Moderated by- Dr. Ashok Kumar

Definition:
Dystocia is difficult labor or
abnormally slow progression of labor
( 4 hrs of < 0.5 cm/ hr dilatation
in the 1st stage
1 hr with no descent in the 2nd
stage)

Reducing Dystocia CS rate


Dystocia is the most common indication for
primary CS
There has been dramatic in CS rate with in
maternal mortality, morbidity, neonatal morbidity
& health care costs

WHAT IS LABOR?

Regular frequent uterine contractions


+
Cx changes (dilatation & effacement)

Normal labour curve Friedman et al

Friedmans curve

Diagnosis of Dystocia
Dystocia should not be diagnosed before
the active phase of labor
-IN Primiparous women the cervix
should have reached 3-4 cm
& 80-100% effacement.
-IN Multiparous women the cervix
should have reached 4-5 cm
& 70-80% effaced

1-Abnormalities of the powers


uterine contractility
maternal expulsive forces
2-Abnormalities of the passage
maternal bony pelvis
the soft tissue of the reproductive tract
3-Abnormalities of the passenger
presentation
position
development of the fetus
size

Evaluation of the power includes:


strenght, duration and frequency of uterine
contractions

Adequate powers contractions that


-last for 60 sec
-reach 20-30 mmHg of pressure
-occur every 1-2 min

Hypotonic contractions are responsible


for 2/3 of nulliparous dystocia

1.manual

palpation

of the maternal abdomen

during a contraction (subjective evaluation)


2.external

tocography

(more objective)

-an external strain gauge


-placed on the maternal abdomen
-records when the uterus tightnes and relaxes
-does not directly measure force the uterus is
generating for a given contraction

3.internal

tocography

(the most objective)

- an intrauterine pressure catether placed into the uterine cavity


- it transmits the actual intrauterine pressure to the external strain gauge,
which then records duration and frequency as well as the strength of the
contractions

For cervical dilatation to occur, each


contraction must generate at least 25
mm Hg of pressure.
optimal intrauterine pressure during
contraction is 50-60 mm Hg.
A minimum three contractions in a 10
minute window is usually considered
adequate

Montevedio units

simplest estimate of uterine work


Developed by Caldeyro- Barcia
the Montevideo unit is the peak intensity above resting pressure mul
the number of contractions in a 10-minute time interval.
Normal labor encompasses a wide range of uterine work 95395 M
The Alexandria unit is the Montevideo unit multiplied by the average
contraction in a 10-minute interval.

Reported Causes of Uterine Dysfunction

Epidural analgesia
Chorioamniitis
Maternal position during labour

Types of Active phase disorders


a slower-than- normal progress
protraction disorder
a complete cessation of progress
arrest disorder.

Normal labour time frames

Williams obtetrics 24ed.

Prolonged Latent Phase


relatively benign labor disorder
associated with a 2.5-fold increase in risk for
primary cesarean section
prolonged latent phase is diagnosed after 21 hours
in the nullipara or 14 hours in the multipara.
evaluate the patient carefully as 12 hours in latent
phase approaches
If there has been interval cervical effacement and
dilation or fetal descent (indicating that the patient
is not in false labor), a reasonable approach is to
begin oxytocin augmentation.
Drennan, K, Blackwell, S, et al,
Glob. libr. women's med., (ISSN:
1756-2228) 2008; DOI
10.3843/GLOWM.10132

Protracted Active Phase Dilation


For nulliparas, protracted active phase dilation should be
diagnosed when the dilation rate is less than 1 cm/h. For
the multipara, the lower limit of normal is 1.5 cm/h.

seems to be associated with


-mild cephalopelvic disproportion
-supine position
-use of narcotics
-Early epidural anesthesia
important risk for later labor dysfunction.
active management of labor constitutes an
efficacious and safe approach
Drennan, K, Blackwell, S, et al,
Glob. libr. women's med., (ISSN:
1756-2228) 2008; DOI
10.3843/GLOWM.10132

Secondary Arrest of Dilation


no change in cervical dilation for at least 2
hours.
This time criterion is the same for nulliparas and
multiparas
occurs in 510% of labors in most series
more frequent with term than preterm and with
larger than smaller fetuses.
the most severe of dilation abnormalities
because of its association with increased fetal
morbidity and mortality and with a considerably
increased risk of cesarean birth.
Drennan, K, Blackwell, S, et al,
Glob. libr. women's med., (ISSN:
1756-2228) 2008; DOI

Criteria for diagnosis of first-stage


labor arrest
the American College of Obstetricians and Gynecologists
(2013)

First, the latent phase has been


completed, and the cervix is dilated
4 cm or more.
Also, a uterine contraction pattern of
200 Montevideo units or more in a
10-minute period has been present
for 2 hours without cervical change.
2hr rule has been challnged by Rouse
and associates to 4 hr

Frequents cervical exams, Electronic monitoring


for evaluation of uterine contractions and fetal
heart ,Oxytocin augmentation
If there is evidence of fetal distress, the fetus
may be evaluated biochemically, but often
cesarean delivery is necessary.
If labor is not progressing normally within 23
hours after the beginning of the oxytocin
augmentation, cesarean section may be
indicated.
vaginal delivery.
immediate cesarean delivery for secondary arrest
is unwarranted.
Good outcomes can be obtained by way of
conservative (medical) management.

The second stage in nulliparas was


limited to 2 hours
For multiparas, 1 hour (extended to
2 hours with regional analgesia. )
Caution at 45 min
Upper limit for both is 3 hr

Drennan, K, Blackwell, S, et al,


Glob. libr. women's med., (ISSN:
1756-2228) 2008; DOI

Protracted Descent
diagnosed in nulliparous labor when descent is proceeding at
less than l cm/h and in multiparous labor when descent is
proceeding at less than 2 cm/h.
electronic fetal monitoring.
If labor has been otherwise normal, augment with oxytocin.
In the nullipara, if full cervical dilation has not been achieved
and there is a persistent anterior cervical lip that becomes
edematous, the chance of atraumatic vaginal delivery is
markedly reduced. In the multipara, it is sometimes possible
to support the anterior lip and have the patient bear down,
allowing the achievement of full dilation and significant
descent.
frequently is associated with the presence of a persistent
occiput posterior

Arrest of Descent
when descent has stopped entirely for at least
1 hour in the nullipara and 0.5 hour in the
multipara
When arrest of descent has not been preceded
by other dysfunctional labor patterns,
extremely sensitive to oxytocin augmentation.
If the patient already is receiving oxytocin
augmentation or full dilation has not been
attained, proceeding to cesarean section is
probably the best approach

Normal labour time frames

Williams obtetrics 24ed.

Management
Augmentation refers to stimulation of
uterine contractions when spontaneous
contractions have failed to result in
progressive cervical dilation or descent of
the fetus.
Augmentation should be considered if the
frequency of contractions is less than 3
contractions per 10 minutes or the
intensity of contractions is less than 25
mm Hg above baseline or both.

Once a second-stage arrest disorder


is diagnosed, the obstetrician has 3
options
1) continued observation
2) operative vaginal delivery
3) cesarean delivery.

Evaluation of the passenger


This includes:
- estimation of the expected fetal weight
-clinical evaluation of fetal lie,
presentation, position
If the estimated fetal weight is > 4000 g
the incidence of dystocia, including
shoulder dystocia or fetopelvic
disproportion is greater.

Cephalopelvic disproportion is a
disparity between the size or shape
of the maternal pelvis and the fetal
head

Persistent occiput posterior positions are also


associated with longer labors (about 1 hour in
multiparous patients and 2 hours in
nulliparous patients)

Fetal anomalies like hydrocephaly and soft


tissue tumors may also cause dystocia. The
use of prenatal ultrasound significantly
reduces the incidence of unexpected dystocia
for these reasons

Brow presentation
(forehead - the largest cephalic diameter is 36 cm)
the partially extended head presents
with the occipitomental diameter of 13.5
cm in the average term fetus
associated with pelvic contraction,
small or large fetuses, and nuchal
masses.
Two thirds spontaneously convert to
either a face or an occipital
presentation.
Manual or forceps conversion is no
longer advocated.
Cesarean birth is recommended if the
brow presentation persists except in
cases of a small fetus.

Face presentation
The fetal head is completely
hyperextended
The incidence is about 1:600
deliveries.
Associated factors include
anencephaly and brow
presentations.
requires cesarean section in
most cases, although a
mentum anterior presentation
(chin toward mothers
abdomen) sometimes may be
delivered vaginally

Causes of face presentation

Preterm
Marked enlargement of neck
Fetal malformation
Hydramnios
anencephaly

Evaluation of the passage


Types of Pelvimetry
Internal pelvimetry (manually)
External pelvimetry
Pelvimeter
Imaging pelvimetry: X-ray /
Computerised tomography (CT) /
Magnetic resonance imaging (MRI)

CT pelvimetry

fetal dose from a limited CT


pelvimetry study (low doses lateral
and frontal digital radiographs with a
single axial slice through the femoral
heads to measure interspinous
diameter) is under 0.1 rad.

MRI pelvimetry
The use of MRI in pelvimetry allows
for the first time the influence of soft
tissue to be examined in this
connection.
MRI has a higher resolution,
especially for soft tissue, than other
conventional radiologic media
no known side effects which could
induce a fetomaternal disease.

Figure 1d. T1-weighted spin-echo MR pelvimetric images (300/8, 7-mm section


thickness, no section gap) obtained in a patient who underwent cesarean section
for extremely small pelvic dimensions. (a) Midsagittal section shows the obstetric
conjugate of 8.9 cm and sagittal outlet of 7.6 cm. Transverse sections (b) the
intertuberous distance of 8.3 cm. (c) Oblique section shows the transverse diameter
of 10.8 cm.
Radiology,
http://pubs.rsna.org/doi/abs/10.1148/radiol.2271011658
Published in: Thomas M. Keller; Annett Rake; Sven C. A. Michel; Burkhardt Seifert;
Gl Efe; Karl Treiber; Renate Huch; Borut Marincek; Rahel A. Kubik-Huch;

Pelvic Inlet
1. Palpation of pelvic
brim:
The index & middle
fingers are moved
along the pelvic brim.
Note whether round
or angulated, causing
the fingers to dip into
a V-shaped depression
behind the symphysis.

Diagonal conjugate:
Measured from the lower border of the
pubis to the sacral promontory using the tip
of the second finger and the point where the
index finger of the other hand meets the
pubis
Normally 12.5 cm & cannot be reached.
If it is felt the pelvis is contracted
True conjugate = diagonal conjugate 1.5
Not done if the head is engaged.

The Midpelvis
1) Symphysis: Height, thickness &
curvature
2) Sacrum: Shape & curvature Concave
usually. Flat or convex shape may
indicate AP constriction throughout the
pelvis.
3) Side walls: Straight, convergent or
divergent starting from the pelvic brim
down to the base of ischial spines.
Normally almost parallel or divergent

4) Ischial spines prominence


5) Interspinous diameter: If both
spines can be touched
simultaneously, the interspinous
diameter is 9.5 cm i.e. inadequate

6) Sacrospinous ligament: Its length is


assessed by placing one finger on the
ischial spine & one finger on the sacrum in
the midline. The average length is 3
fingerbreadths.
7) Sacrosciatic notch: If the sacrospinous
ligament is 2.5 fingers, the sacrosciatic
notch is considered adequate. Short
ligament suggests forward curvature of the
sacrum & narrowed sacrosciatic notch.

Pelvic Outlet
1) Subpubic angle: Assessed by
placing a thumb next to each inferior
pubic ramus and then estimating the
angle at which they meet.
Normally, it admits 2 fingers. (90o )
Angle 90 degrees suggests
contracted transverse diameter in
the midplane and outlet.

Bituberous diameter: Done by first


placing a fist between the ischial
tuberosities. An 8.5 cm distance (4
knuckles) is considered to indicate an
adequate transverse diameter

Adequate Pelvis Data Finding


Forepelvis (pelvic brim) -Round.
Diagonal conjugate 11.5 cm.
Symphysis Average thickness, parallel to
sacrum.
Sacrum Hollow, average inclination.
Side walls Straight.
Ischial spines Blunt.
Interspinous diameter 10.0 cm.
Sacrosciatic notch 2.5 -3 finger - breadths. S
ubpubic angle 2fingerbreadths (90o).
Bituberous diameter 4 knuckles (> 8.0 cm).
Coccyx Mobile. Anterposterior diameter of
outlet 11.0 cm.

Soft Tissue Dystocia


Soft tissue abnormalities in the pelvis occasionally can
result in dystocia.
Uterine myomas most common
obstruct the birth canal or cause malpresentation of
the fetus.
Other possible causes of upper genital tract dystocia
include
-ovarian tumors
-bladder distention
-a pelvic kidney
-excess adipose tissue
-uterine malposition
- cervical stenosis or neoplasm.
Lower genital tract dystocia can be caused by partial
vaginal or vulvar atresia, severe edema or
inflammation, Bartholins or Gartners duct cysts,

Complications of dystocia
Maternal

Perinatal

Uterine rupture

Caput and moulding

Pathological retraction ring

Trauma

Fistula formation

sepsis

Pelvic floor injuries

App

Level A recommendations
Patients should be counseled that
walking during labor does not
enhance or improve progress in labor
nor is it harmful.
Continuous support during labor from
caregivers should be encouraged
because it is beneficial for women
and their newborns.

Level B recommendations
Active management of labor may shorten
labor in nulliparous women, although it has
not consistently been shown to reduce the
rate of cesarean delivery.
Amniotomy may be used to enhance
progress in active labor, but may increase
the risk of maternal fever.
X-ray pelvimetry alone as a predictor of
dystocia has not been shown to have
benefit, and, therefore, is not recommended.

Level C recommedations
Intrauterine pressure catheters may
be helpful in the management of
dystocia in selected patients, such as
those who are obese.
Women with twin gestations may
undergo augmentation of labor

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YOU