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Dystocia(II)

An hongmin
Department Of Obstetrics & Gynecology
Definition
Dystocia literally means difficult
labor and it is characterized by
abnormally slow progress of labor

It is the consequence of four distinct


abnormalities that may exist
singly or combination

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Categories of dystocia

Abnormal of the powers(uterine contractility


and maternal expulsive effort)
Abnormalities of the passage (the birth canal)
Abnormalities of passenger (the fetus)

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Hypotonic dysfunction is uterine
Hypotonic dysfunction activity characterized by contraction
of the uterus with insufficient force(
< 24mmHg), irregular or
infrequent rhythm, or both.
Hypertonic dysfunction Hypotonic dysfunction responds
well to oxytocin.
Uncoordinated dysfunction

Hypertonic uterine contractions and uncoordinated


contraction often occur together and are characterized
by elevated resting tone of the uterus and frequent
intense uterine contractions. Oxytocin administration
is generally of no value. Sedation is generally
effective in converting hypertonic contractions to
normal labor patterns.
Dystocia
Second part: abnormalities of the
passage and the passenger
Abnormalities of the passage

◆ Bony abnormalities
◆ Soft tissue obstruction of the birth canal
◆ Abnormal placental location
Pelvic types
Pelvimetry( 骨盆测量 )
X-ray pelvimetry
Pelvic contraction
Birth canal
 bony canal
 soft canal
abnormal bony canal: pelvic
contraction
 any contraction of the pelvic diameters
that diminishes the capacity of the pelvis
can creat dystocia during labor
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Pelvic contraction classification

Contraction of the pelvic inlet


contraction of the midpelvis and
pelvic outlet
general contraction of the pelvis
pelvic deformities

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Abnormalities of birth canal

1.Bony pelvic
1)Contracted pelvic inlet
simple flat pelvis (单纯性扁平性骨盆)
rachitic flat pelvis( 佝偻病性扁平性骨盆 )

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Contracted pelvic inlet

Anteroposterior (前后径) d<10cm


diagonal conjugate (对角径)
d<11.5cm
external conjugate( 骶耻外径 ) d<18cm
2)Contracted midpelvis
(anthropoid pelvis 类人猿型骨盆 )
interischial spinous diameter is smaller than 8cm(spines
are prominent, the pelvic side walls converge or the
sacrosciatic notch is narrow)

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3)Contracted pelvic outlet
(funnel shaped pelvis 漏斗型骨盆 )
diminition of the interischial tuberous diameter to 8cm or less.

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4) Generally contracted pelvis
2cm or more shorter than normal
5) Pelvic deformities
osteomalacic (骨软化的) pelvis
obliquely contracted pelvis ( 斜狭骨盆 )

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Clinical signs of contracted pelvis
2) Contracted pelvic inlet
3) Contracted midpelvis
4) Contracted pelvic outlet

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Diagnosis :
History
Physical examination
Pelvimetry
external pelvimetry
internal pelvimetry
diagonal conjugate 12.5~13cm
bi-ischial diameter 10cm
incisura ischiadica 5~6cm
angle of subpubic arch 90

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Effects on mather and fetus
MOTHER:Inlet
 Malpresentation and malposition
 prolonged labor
 insufficient uterine contraction
midpelvis and outlet
 persistant occipitotransverse or occipitoposterior
position
 fistula formation
 intrapartum infection
 threatening rupture or rupture

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Fetus
Prom
Prolapse
Distress 2. Abnormal of soft birth canal

Death
Injury
Infection

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2. Abnormal of soft birth canal
Lower segment of uterus
cervix
vaginal

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Abnormal of soft birth canal

Congenital anomalies
Scarring of the birth canal
Pelvic masses
Low-lying placenta

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Fetal malposition
Occipitoanterior position 90%
malposition 10%
abnormal cephalic posion 6-7%
breech presentation 3-4%
others

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Abnormalities of the passenger
A. malposition and malpresentation
a. vertex malposition
persistent occiput posterior
persistent occiput transverse 5%
sincipital presentation 1.08%
anterior asynclitism( 前不均 位 )
posterior asynclitism ( 后不均 位) 0.5%~0.81%
b. brow presentation 0.03%~0.1%
c. face presentation 0.08%~0.27%
d. breech presentation 3%~4%
e. abnormal fetal lie transverse or oblique lie
0.25%

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Persistant occipitoposterior
(transverse) position

Causes
 abnormal pelvis:transverse narrowing
of the midpelvis
 flexion not well
 hypotonic uterine dysfunction

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Face presentation

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Breech presentation
Incidence
 breech presentation is common
remote from term.
 3-4% of singleton deliveries
Position
 LSA, LST LSP. RSA, RST, RAP

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Causes
Uterine relaxation
limited uterine cavity
fetal head obstructed

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the lower extremities are flexed at the hips
and extended at the knees, and thus the
feet lie in close proximity to the head.
Breech presentation It appears most commonly

complete(mixed) breech presentation


frank breech presentation (伸腿臀先露)
incomplete breech presentation
knee or footling presentation
differs in that one or both knees are
flexed
one or both hips are not flexed and
one or both feet or knees lie below
the breech, that is, a foot or knee is
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lowermost in the birth canal
Effects
Maternal
 greater frequency of operative delivery
 higher maternal morbidity and slightly higher mortality
 PROM
 secondary hypotonic uterine dysfunction
 puerperium infection
 postpartum haemorrhage
 laceration of cervix
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Effects
Fetus
 PROM
 cord prolapse
 fetal distress even death
 newborn asphyxia
 brachial plexus injury

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Extraction of breech

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Compound presentation
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B. Fetal macrosomia
large for gestational
age(LGA) ≥400 0g
shou lder dystosia

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C. Fetal malformation

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Operative delivery
1)forceps
operations
2)Vacuum
extractor

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2)Vacuum
extractor

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3)Cesarean section

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Main point of dystocia
managemnet

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思考题 :
1.The definition and classification
of dystosia
2.How to deal with uterine inertia
during the first stage of labor ?

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THANKS FOR YOUR ATTENTION

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