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Abnormal Labor

Dystocia
u

Difficult labor

Characterized by abnormally slow labor progress

TABLE 23-1. Common Clinical Findings in


Women with Ineffective Labor
uInadequate

cervical dilation or fetal descent:

Protracted laborslow progress


Arrested laborno progress
Inadequate expulsive effortineffective pushing
uFetopelvic

disproportion:

Excessive fetal size


Inadequate pelvic capacity
Malpresentation or position of the fetus
uRuptured

membranes without labor

Mechanism of Dystocia
uFactors

influencing progress of first stage of labor

Uterine contractions
Cervical resistance
Forward pressure exerted by leading fetal part
UTERINE DYSFUNCTION

Mechanism of Dystocia
uSecond

stage of labor

mechanical relationship between fetal head size and position and pelvic
capacity.
FETOPELVIC PROPORTION become apparent in 2nd stage of labor

REVISED DYSTOCIA DIAGNOSIS


TABLE 23-3. Evidence for Adequate and Arrested Labor
uArrest

of labor: . . . the diagnosis of arrest of labor should not be made until adequate
time has elapsed.
uAdequate

labor: . . . includes greater than 6 cm dilation with membrane rupture and 4


or more hours of adequate contractions (e.g., greater than 200 Montevideo units) or 6
hours or more if contractions inadequate with no cervical change. . . .
uSecond-stage

labor: . . . no progress for more than 4 hours in nulliparous women with an


epidural, more than 3 hours in nulliparous women without an epidural. . . .
No cesarean before these time limits . . . in the presence of reassuring maternal and
fetal status.
u

ABNORMALITIES OF EXPULSIVE FORCES


uThree

significant advances in treatment of uterine dysfunction

1. Undue labor prolongation may contribute to maternal and perinatal


morbidity and mortality.
2. IV infusion of oxytocin is used for treatment of certain types of uterine
dysfunction.
3. CS is selected rather than difficult mid forceps delivery when oxy fails or
its use is inappropriate.

ABNORMALITIES OF EXPULSIVE FORCES


uTypes

of uterine Dysfunction

hypotonic uterine dysfuction


Hypertonic uterine dysfunction or incoordinate uterine dysfunction

Reported Causes of Uterine Dysfunction


u

Epidural Analgesis- Epidural anesthesia can slow labor

Chorioamnionitis- Infection itself contributes to abnormal uterine activity

Maternal position during labor-

ABNORMALITIES OF EXPULSIVE FORCES


uActive-Phase

Disorder

Protraction Disorder- Slower than normal progress of labor


Arrest Disorder- Complete cessation of progress
uSecond

stage Disorder

Nullipara- Limited to 2 hours


Multipara- Limited to 1 hour

uPROM
uPrecipitous

labor and delivery- Extremely rapid labor and deliver

Maternal Effects- Uterine rupture, extensive laceration, danger of amniotic


fluid embolism, uterine atony
Fetal and Neonatal Effects- Intracranial trauma, fetus may fall to the floor

Fetopelvic Disproportion
uPelvic

Capacity

- Contracted inlet- contracted if its AP diameter is <10cm or greatest


transverse diameter is <12cm
- Contracted Midpelvis- more common than inlet contraction
Contracted Outlet- Inter ischial tuberous diameter of 8cm or less. Outlet
contraction without midpelvic contraction is rare

Face Presentation
u

The head is hyper extended so that occiput is in contact with fetal back.

Either mentum anterior or posterion relative to symphysis pubis

Most convert spontaneously to anterior

If not the fetal brow is pressed against the maternal symphysis pubis

Cardinal movement of face presentation


uDescent
uInternal

engagement
rotation

uFlexion

descent
flexion

uExtension

internal rotation

uExternal

extension

rotation

external rotation

Etiology of face presentation


u

Preterm infants

Marked enlargement of the neck

Cord coil

Fetal malformation

Contravted pelvis

High parity

Brow presentation

Transverse Lie
u

Long axis of the fetus is perpendicular to that of the mother

The shoulder is usually positioned over the pelvic inlet

Neglected transverse lie

Etiology of transverse lie


u

high parity

Placenta previa

Abnormal uterine anatomy

Hydramnios

Contracted pelvis

Compound presentation
uExtremity
uBoth
uIn

prolapses alongside the presenting part

present simultaneously in the pelvis

most cases it should be left alone unless it interferes

with progress of labor

Complications with dystocia


uIntrapartum
uPost

chorioamnionitis

partum hge

uUterine

tears

uuterine

rupture- after development of pathological retraction ring of Bandl

uFistula
uPelvic

formation

floor injury

Complications with Dystocia


uFetal

complication

fetal sepsis
Mechanical trauma such as nerve injury, fracture
cephalhematoma

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