SUBJECT OBSTETRICS

2010 PLMCM
Topic DYSTOCIA
Lecturer DR. THE
Date June 16, 2008
Trans grp bam.joel.toni.hannah

DYSTOCIA__________________________________ Multipara – average 20 min (1 to 2

o
hours)
 Difficult labor  Stage 3 - Fetal delivery to the expulsion of
 Abnormal slow progress of labor placenta
 Common whenever there is disproportion
between the presenting part of the fetus and Three Functional Division of Labor_______________
the birth canal
 Preparatory division – the connective tissue
ABNORMALITIES that may lead to components of the cervix change
DYSTOCIA_______ considerably (sedation and conduction of
analgesia
1. Abnormalities of the POWERS – uterine contractility  Dilatational division – dilatation proceeds at
and maternal expulsive effort. its most rapid rate, unaffected by sedation or
2. Abnormalities involving the PASSENGER – the conduction of analgesia.
fetus.  Pelvic division – deceleration phase or
3. Abnormalities of the PASSAGE – the pelvis. cervical dilatation. Where the cardinal fetal
movements of the cephalic presentation
Clinical Findings in Women with Ineffective (engangement, flexion, descent, internal
Labor___ rotation, extension, and external
rotation) takes place.
 Inadequate cervival dilatation or fetal descent
o Protracted labor – slow progress Two phases of Cervical Dilatation________________
o Arrested labor – no progress
o Inadequate expulsive effort –  LATENT PHASE
ineffective pushing • mother perceives regular contractions
 Fetopelvic disproportion • ends between 3 and 5 cm of
o Excessive fetal size dilatation (3 to 4 accdg to Dr. The)
o Inadequate pelvic capacity • prolonged latent phase – greater than
o Malpresentation or position of fetus 20 hours in nullipara and 14 hours in
 Ruptured membranes without labor multipara
 ACTIVE PHASE
Normal Labor________________________________ • Acceleration phase – determines the
ultimate outcome of labor
 Uterine contraction that bring about • Phase of Maximum slope – good
demonstrable effacement and dilatation
measure of overall efficacy of the
of the cervix
uterus
 Onset of labor as beginning at the time of
• Deceleration phase – 8 to 10 cm,
admission to the labor unit
reflects pelvic relation
 Painful uterine contractions accompanied by
any one of the following: (1) ruptured THE DILATATIONAL AND DESCENT
membranes, (2) bloody “show”, (3) CURVES________
complete cervical effacement

Stages of Labor______________________________

 Stage 1 – regular uterine contraction to full

cervical dilatation (10 cm)
 Stage 2 – Full cervical dilatation to fetal
delivery
o Nullipara – average 50 min (2 to 3
hours)

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 OBSTETRICS: DYSTOCIA – Dr. The
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o Caphalhematoma (beneath
10 -3 periosteum)

Abnormal Labor______________________________

• Protraction
o Slow rate of cervical dilatation or
descent 30% w/ protraction disorders
have cephalo-pelvic disproportion
• Arrest Disorders
o Does not descend after 2 hours

0 +3
Criteria for Diagnosis of Abnormal Labor Due to
Arrest or Protraction Disorders

(characteristic sigmoid & hyperbolic curve) Labor Pattern Nullipara Multipara

Protraction disorder
 Average rate of descent of fetal head • Dilatation < 1.2 cm/hr < 1.5 cm/hr
o Nullipara – 1 cm/hr; begins about 7 to • Descent < 1.0 cm/hr < 2.0 cm/hr
8 cm Arrest disorder
o Multipara – 2 cm/hr
• No > 2 hr > 2 hr
dilatation > 1 hr > 1 hr
• No descent

WHO partograph
• Failure in Descent
• Latent o Precipitate Labor – delivery in <3
hours
- Modified: 4 cm dilatation  active labor;
2 sets of observation: 1st set – relate to
the progress of cervical dilatation, 2nd set
– fetus
• Alert line (health facility line)
Nullipara Multipara
- Alert line drawn from 3 cm dilatation
Prolonged latent > 20 hours > 14 hours
represents the rate of dilatation of 1
phase
cm/hr
Protracted <1.2 cm/hr <1.5 cm/hr
- Moving to the right means referral to
active phase
hospital
Prolonged > 3 hours > 1 hour
• Action line
deceleration
- Labour crosses the active line, 4 hours to
Secondary > 2 hours > 2 hours
the right of the alert line and parallel to it
arrest of
- This is the critical line at which specific
dilatation
management decisions must be made at
Arrest of > 1 hour > 1 hour
the hospital
descent
- Active intervention – Oxytocin
Failure of - -
augmentation
descent
- Artificaial rupture of membrane after 6 (decelerates)
hours (4 cm)  oxytocin  observe Precipitated > 5 cm/hr > 10 cm/hr
active phase
Maternal Effects of (max. slope)
Dystocia________________________ Precipitate > 5 cm/hr > 10 cm/hr
descent
• Intrapartum infection
• Pathological ring of Bandl
• Uterine rupture Abnormalities of the Expulsive Forces
• Fistula formation (POWER)_____
• Pelvic floor injury
• Fetal effects • Contraction of the uterus  Cervical
o Caput Succedaneum dilatation & propulsion and expulsion of the
o Molding fetus (reinforced during the second stage by

voluntary or involuntary muscular action of
the abdominal wall.
1. Uterine Contraction
 Fundus – increase force
 LL of contraction – 15 mmHg to dilate
cervix
 Normal spontaneous contraction – 60
mmHg
 Clinical Labor starts when uterine
activity = 80 to 120 MVU
 Montevideo Units (MVU) – increase
uterine pressure above baseline (not
less than <180 MVU)
 Montevideo units (MVUs) refer to the
strength of contractions in mm of
mercury multiplied by the frequency
per 10 minutes as measured by
intrauterine pressure transducer.
o The uterine contraction
pattern must repeat every 2-3
minutes.
o The uterine contractile force
produced must exceed 200
MVUs/10 min for active labor
to be considered adequate.
For example, 3 contractions
in 10 minutes that each reach
a peak of 60 mm Hg are 60 X
3 = 180 MVUs.
o An arrest disorder cannot be
diagnosed until the patient is
in the active phase and the
contraction pattern exceeds
200 MVUs for 2 hours with no
cervical change.
Two types of Uterine Dysfunction
1. Hypotonic uterus
o No basal hypertonus
o Uterine contractions have a normal
gradient pattern (synchronous)
o Slight rise in pressure during
contraction is insufficient to dilate
cervix
o Management: Augment labor w/
Oxytocin
2. Hypertonic uterus
o Incoordinate uterine dysfunction
o Basal tone is elevated appreciably
o The pressure gradient is distorted
o Gradient distortion may result from
contraction of the mid-segment of the
uterus with more force than the
fundus or from complete
asynchronism of the impulse
originating in each cornu (or a
combination of these two)
OBSTETRICS: DYSTOCIA – Dr. The
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Abnormalities in Passenger_____________________
(Abnormal fetal presentation)
ASYNCLITISM – deflection of sagittal suture
anteriorly or posteriorly
a) Anterior Asynclitism – Naegel’s obliquity
b) Posterior Asynclitism – Litzman Obliquity
A. Face Presentation
• Head is hyperextended
• Occiput is in contact with the fetal back
• Chin or mentum is the presenting part
• Submentobregmatic diameter is 9.5 cm
• Mentum anterior – can be delivered vaginally
• Problem: mentum posterior because the brow
is compressed against the maternal
symphysis pubis preventing the flexion of the
head
• Incidence: 1:600 or 0.17%
• Diagnosis:
- Vaginal Exam – fetal mouth, malar
bones, orbital ridges
- X-ray – hyperextended hands
• Etiology
- marked enlargement of the head or
coils of cords
- contracted pelvis
- anencephalic features
- very large uterus
- pendulous abdomen
- high parity
• Mechanism of labor: engagement 
descent  internal rotation  flexion 
accessory movement of extension and
external rotation  expulsion
• Management
- no contracted pelvis + effective labor
= vaginal delivery
- CS delivery is frequently indicated
except for mentum anterior which
may be delivered vaginally
B. Brow Presentation
• Fetal head occupies a position midway
between full flexion and extension
• Rarest presentation; unstable
• Portion of the head is between the orbital
ridge and anterior fontanel present at the
pelvic inlet
• Verticomental diameter = 13.5 cm
• Fully dilated cervical diameter = 10.5 cm
• Engagement of the head and the subsequent
delivery cannot take place
• Diagnosis:
- abdominal examination – both the chin
and occiput can be palpated on
engagement
- vaginal exam – frontal sutures, large
anterior fontanel, orbital ridges, eyes

• Etiology
o marked enlargement of the head or
coils of cords
o contracted pelvis
o anencephalic features
o very large fetus
o pendulous abdomen
o high parity
• Mechanism of labor: engagement is possible,
but caput is over the forehead
C. Transverse Lie
• Long axis of the fetus is approximately
perpendicular to that of the mother
• Shoulder over the pelvic inlet
• Back may be directed anteriorly or posteriorly
(dorsoanterior or dorsoposterior)
• Incidence: 0.3%
• Etiology:
o Unusual relaxation of the abdominal
wall
o Preterm fetus has bigger head
o Placenta previa
o Abdominal uterus
o Polyhydramnios
o Contracted pelvis
• Diagnosis:
o Abdomen usually wide
o No fetal pole detected at the fundus
o Ballotable head found in iliac fossa
• Course of labor
o Spontaneous delivery of fully
developed infant is impossible
o Neglected transverse lie
o CONDUPLICATO CORPORE – fetus
doubles upon itself (the dead fetus
assumes an almost folded posture)
• Management:
o With onset of labor, CS is indicated
o External version (only after weeks
AOG) – doctor inserts hand into the
uterus, pulls one foot, the other
follows and delivers the baby)
D. Compound Presentation
• An extremity prolapses alongside the
presenting part
• Incidence: 1:700-1,000 deliveries
• Etiology
o preterm at birth
• If persistent, CS is indicated
• Macrosomia – increased abdominal
circumference
E. Persistent Occiput Posterior
OBSTETRICS: DYSTOCIA – Dr. The
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• Spontaneous rotation
• Occiput rotate to the symphysis pubis
through 1350 instead of 900 to 400
• Generous episiotomy is usually indicated (cut
until the perineal body)
F. Shoulder Dystocia
• Incidence occur due to bigger babies (babies
of diabetic mothers: high glucose  stimulate
 increased fetal insulin secretion 
increased glycogen stores  increased size
• Maternal - Fetal consequence
o Postpartum hemorrhage
o Transient brachial plexus palsies
o Clavicular fractures (most common)
o Humeral fractures
• Risk factors
o Obesity
o Multiparity
o Diabetes
ACOG (1997-2000)_________________________________
1. Most cases of SD cannot be predicted or
prevented because there are no accurate
methods to identify which fetus will develop
this complication
2. UTZ measurement to eliminate macrosomia
have limited accuracy
3. Planned CS delivery based on suspected
macrosomia is not reasonable
4. Planned CS delivery may be reasonable for
nondiabetic patients with EFW>5kg or
diabetic with fetus EFX>4.5 kg
Management:
Initial attempt of traction assisted by
maternal expulsive effort is recommended and large
episiotomy and large anesthesia.
Maneuver:
• Moderate suprapubic pressure
• Mc Roberts
• Wood Corkscrew
• Delivery of the posterior shoulder
• Rubin
• Hibbard
• Zavanelli
• Deliberate fracture of the clavicle
• Cleidotomy
• Symphysiotomy
Shoulder Dystocia Drill
1. Call for help
2. Generous episiotomy
3. Suprapubic pressure
 OBSTETRICS: DYSTOCIA – Dr. The
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4. McRoberts maneuver Fetal HT – 140 bpm

5. Delivery of the posterior arm
6. Other techniques Prenatal Care
5x with regular intake of vitamins and iron
Abnormality in Passages_______________________
Family History
A. Contracted Pelvic Inlet
Mother – Diabetes
• Obstetric Conjugate Paternal Grandfather – HPN
o Shortest AP diameter <10 cm or diagonal
conjugate <11.5cm Course in the Wards
• True/Anatomic Conjugate
o Distance from upper symphysis pubis to Time Dilatation Effacement C. Station
sacral promontory (hour) (cm) (%)
o Diagonal conjugate + 2 cm On 2 80 -2 (+ BOW)
• Obstetric Conjugate admission
o Distance from the midpoint of pubis to 2 AD 3 80 -2
sacral promontory 4 AD 4 80 -2
o Shortest diameter 6 5 80 -2
o AP diameter ≤ 10 cm 8 6 80 -2
o Diagonal conjugate – 1.5 to 2 cm 10 7 100 (FE) -1
11 8 100 (FE) -1
B. Contracted Midpelvis 13 8 100 (FE) -1
14 9 100 (FE) 0
• If < 10 cm, contracted pelvis average of 15 9 100 (FE) 0
10 cm 16 9 0
• Shortest diameter (midplane)
• Bispinous/Interspinous diameter , 8 cm
• Interspinous diameter + posterior sagittal
1. Compute for the AGE OF GESTATION, Estimate fetal
diameter ≤ 13.5 cm
weight
• Normal 2. Plot curve
o Average transverse 3. What abnormal labor patterns is/are described on
interspinous diameter = 0.5 this case? What are the possible causes?
cm 4. Probable outcome?
o AP diameter = 11.5 cm
o Posterior sagittal = 5 cm
o Interspinous + posterior Classmates  if ever po may corrections paki sabi na
sagittal = 15.5 cm lang po lalu na sa case para masabi po sa class.
• Suggest
Thank you very much! God bless 
o Spines are prominent
o Pelvic walls are converged
o Sacral sciatic notch is narrow

C. Contracted Pelvic Outlet (Intertuberous

Diameter)

•Interischial tuberous diameter , 8 cm

•Outlet contraction without concomitant
contraction is rare
o Spines are palpable
o Pelvic walls are converged
o Sacral sciatic notch is narrow
- END -
OBSTETRICS CASE

18 years old, G1P0, admitted for labor pain

LMP – Sept. 21, 2007
EDC – June 28, 2008

Vital Signs – Normal

Fundic Height – 35 cm
OBSTETRICS: DYSTOCIA – Dr. The
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