Abnormal labor and

Dystocia
Soochow university
Xu Jianying
Abnormal Labor : Dystocia


Abnormal labor ,also called dystocia.

When we last talked about childbirth ,there
are four major influencing factors. When one
or more factors abnormal or uncoordinated
as abnormal labor. that may exist singly or
in combination.


Definition
Generally, abnormal labor is very common
whenever there is disproportion between the
presenting part of the fetus and the birth canal.


Dystocia literally means difficult labor and is
characterized by abnormally slow progress of labor.

Categories of dystocia

According to the factors divided to 3 types

Abnormalities of the powers (uterine contractility and
maternal expulsive effort)
either uterine forces insufficiently strong or
inappropriately coordinated to efface and dilate the
cervix uterine dysfunction or inadequate voluntary
muscle effort during the second stage of labor.

Categories of dystocia
Abnormalities of passenger (the fetus)
excessive fetal size , malpositions ,congenital
anomalies , multiple gestation

Abnormalities of the passage (the birth
canal)
pelvic contraction , soft tissue abnormalities of the
birth canal , masses or neoplasia , aberrant placental
location


1.Abnormalities of the powers
Uterine dysfunction
hypotonic primary
uterine inertia secondary
Uterine hypertonic
Dysfunction
uterine hypercontractility

Abnormalities of the powers
-----uterine inertia
1.Etiology of uterine inertia

Cephalopelvic disproportion or Fetal malposition
Abnormal of uterine muscle
psychical-factors

Imbalance of endocrine system
Administration of analgesia
Others
Cephalopelvic disproportion or
Fetal malposition

The fetal head or presenting part could not close
presses to the cervix and lower uterine segment.
fetopelvic disproportion arises from diminished pelvic
capacity, excessive fetal size, or malpresentation

Failure to progress in either spontaneous or stimulated
labor .This term is used to include lack of progressive
cervical dilatation or lack of fetal descent.

Abnormal of uterine muscle
Uterine muscle malfunction can result from uterine
overdistention or obstructed labor, or both. Muscle fiber
excessive elongation and contractility decline .
Polyhydramnios , macrosomia, Multiple births (twins).

Muscle fiber degeneration (Past history of repeat uterus
infection , abortion , induction of labor ,or operation),
myoma , pelvic tumors, myogenic dysplasia or malformed
uterus (didelphus uterus , unicornous uterus ).
psychical-factors

Fearing labor pain , anxiety, tension
Worried about fetal safety, labor hemorrhage, injury and
dystocia
which eventually lead to Uterine dysfunction
and occur uterine inertia

Other factors
hormonal mechanism of uterine activity
(deficiency of oxytocin , estradiol, prostaglandin)
excessive sedation ,anesthesia ,unripe cervix
fatigue , early abdominal pressure,
overactive bladder filling (fetal presentation
descent) .

2.Clinical findings

hypotonic uterine dysfunction (coordinated):
Although there are still normal uterine contraction
and maintain the polarity , symmetry, and a certain
rhythm, but the contraction is weak and feeble,
with short duration , long Interval and irregular.
when the contractions in the acme, no uterus uplift
and stiffen.
When uterine contractions:
the intrauterine pressure in the lower, and often <15
mmHg,
As a finger pressing on the fundus of uterus a
depression could appear

Maternal relative quiet , prolonged process.
(painless or can endure )
fetal heart rate changes lately (no anoxia
or lately)
2.Clinical findings
hypertonic uterine inertia and Uncoordinated
contractions : often occur together ,elevated resting
tone of the uterus

the exciting site of contraction is not from the
horn of uterus, and in a particular or multiple
site, and with uncoordinated rhythm, polarity
inversion

when uterine contracts the fundus is no firm,
and the mid or lower uterine segment harder
than that.

The uterus can not be completely relaxed,
uterine cavity pressure lasting with higher
state, but the cervix no dilation and fetal head
no descent progressively

Maternal lasting abdominal pain and fidgety

fetal heart rate changes early (anoxia)

2.Clinical findings

Failure to progress
Lack of progressive cervical dilatation (primiparas)
Prolonged latent phase >16hs
Prolonged active phase >8hs , cervix dilation<1.2cm/hs
Protracted active phase >2hs
Prolonged second stage >2hs


Lack of fetal descent
Prolonged descent >1cm/h
Protracted descent >1h
Prolonged labor >24hs (the total stage of
labor)

Labor-process range plan
4.Effect on maternal and fetus

maternal fatigue (Prolonged progress)
acidosis , or dehydration
infection (Prolonged progress , prom)
postpartum hemorrhage (insufficient contractility)
cesarean section rate
laceration
fetus distress , (uterine blood flow and fetal oxygenation )
birth injury ,Intracranial trauma (obstructed labor , rare)
prolapse of umbilical cord
stillbirth

5.management

Hypotonic: the rule of treatment--Strengthen
contractions and prevent PPH

the first stage of labor
General management : rest, eat more liquid
food ,sedation, correct acid , intravenous injection
Physical methods: massage uterus ,
emptying the bladder
stimulation nipple ,
artificial rupture of membrane (AROM)
enema
Drugs :
oxytocin 2.5U + 5%GS 500ml
( 5mU/ml ,8dropmin, at the begining)

diazepam 10mg iv
(Softening the cervix)


Cesarean section :
Following the above management still
ineffective or fetal distress


The second stage of labor
Forceps or vacuum extractor : second stage of
labor ,cervical fully dilated, membranes ruptured and
fetal survival, presenting part below the level of
ischial spine
Cesarean section : presenting part upward the level
of ischial spine or fetal distress
Hypertonic: the rule of treatment-- Adjusted
contractions and resume a normal polarity and
rhythm
Sedative: Dolantin or Morphine for adjusted and
resume to a normal contractions
Cesarean section Otherwise



Abnormalities of the powers
----- uterine hypercontractility
1.Clinical findings and diagnosis
Coordinated uterine hypercontractility :
uterine contraction is normal and maintain the
normal polarity , symmetry, and a certain rhythm, but
the intensity strength and frequency enhanced
the contraction with :
long duration , short Interval

precipitate delivery ( multiparas )
the total stage of labor <3hs ,
The process of labor is too fast

Birth injuries lacerations of the soft birth canal
fractures, intracranial hemorrhage of the
newborn
Postpartum hemorrhage,
uterine inversion,
Infections,
fetal distress, death
2.Effect on maternal and fetus

rupture of uterus
PPH , infection
soft birth canal trauma
fetal distress
fetal death
stillbirth


3.management

Prophylaxis reduced obstetric brutal operation.
Must be gentle , slightly and carefully
Tocolytic therapies sedatives inhibited
contractions : meperidine, magnesium sulfate.
Forceps , Vacuum extractor

Cesarean section.

1)forceps operations 2)Vacuum extractor
3)Cesarean section
Abnormalities of passage
the birth canal
pelvic contraction ,
soft tissue abnormalities of the birth canal ,
masses or neoplasia ,
aberrant placental location



Contractions of the pelvic
Bony pelvis a main composing part of birth
canal ,its size and shape have the direct relation to
the course of labor and delivery.

Any contraction of pelvic diameter that diminishes
the capacity can create dystocia.

There may be contractions of the pelvic inlet, the
midpelvis, the pelvic outlet, or a generally contracted
pelvis caused by combinations of these.

Contracted pelvic inlet
1.simple flat pelvis
promontory of sacrum
( dotted line )
forward dislocation

2.rachitic flat pelvis
(past history of rickets)


Contracted pelvic inlet
Clinical findings:

Fetopelvic disproportion , malposition or malpresentation face and
shoulder presentations are encountered three times more frequently
uterine inertia and prolonged progress of labor prolonged latent phase ,
early active phase and protracted active phase
cord prolapse ( loophole) occurs four to six times more frequently


Midpelvicoutlet contraction
Funnel shaped pelvic


the spines are prominent, the pelvic sidewalls converge
Midpelvicoutlet contraction
Clinical findings:
Fetopelvic disproportion persistent occiput
posterior position or deep transverse arrest , molding
of head and caput succedaneum
protracted active phase or prolonged second
stage secondary uterine inertia
Uterine rupture , perineal tears obstructed labor

Generally contraction pelvic
Each pelvic plane is 2cm less than normal value
or more

Can be seen in shape more short and small ,
well-balanced women of type of figure.
Diagnosis
A history of Rickets, bone tuberculosis, polio or pelvic
fracture (warrants careful review of previous radiographs
and possibly computed tomographic pelvimetry later in
pregnancy).

Physical examination height, spine, lower limb disability
(Height <150cm , lateral curvature usually associated with contracted
pelvis)
Diagnosis
Pelvic measurement
external pelvimetry
internal pelvimetry
sterile vaginal examination


Diagnosis
Pelvimetry
diagonal conjugate 12.5~13cm
bi-ischial diameter 10cm
incisura ischiadica 5~6cm
angle of subpubic arch 90
0


Diagnosis
The fetal position and dynamic monitoring of
labor
after onset of labor ,in primipara ,fetal head
unengagement ,breech, shoulder presentation;
birth process has been slow. (Prompt the contraction of
pelvis)


management

Trial labor under the effective uterine contractions
observed the progress of labor

There is no reliable method for evaluating the adequacy of
the lower pelvic, the sterile vaginal examination should be
performed early in the course of labor.

with continuous fetal monitoring ,fetal well-being may be
ensured
management

true inlet contracted : cesarean section

Midpelvicoutlet contraction: fetal head
biparietal diameter reached the level of the spines,
and can be depressed farther ,the fetal presentation
beyond station plus 2 , vaginal delivery usually is
possible .midwifery. otherwise cesarean section.

Administration of oxytocin should avoided in true
Midpelvicoutlet contraction

management

Generally contraction pelvic term fetus
(birthweight > 3000g) needed cesarean section

The fetus is not big , fetopelvic is adaptation and
without complication can try to labor

Deformed pelvic cesarean section




Soft--tissue dystocia
Soft tissue canal :lower part of uterus,
cervix, vagina previous scar of the birth canal
laceration , cervic conization and cauterization ,
cesarean section , rape injury in a small child , or
caustic abortifacient injury to vaginal vault and cervix.
Previous scaring of the birth canal may cause tissue
rigidity and dystocia .
cesarean section is generally required



Abnormalities of passenger
Fetal dystocia
caused by malposition or malpresentation ,
excessive size of the fetus ,or fetal
malformation.
If no disproportion exists, the head readily
enters the pelvis, and vaginal delivery can be
predicted.
malposition and malpresentation
a. vertex malposition
persistent occiput posterior
persistent occiput transverse 5%
sincipital presentation 1.08%
anterior asynclitism
posterior asynclitism 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%


Persistent occiput posterior or
transverse position (POP, POT)
Definition : Up to later stage of delivery the occiput cant
rotate anteriorly , persistent occiput posterior (POP) or
transverse position (POT). Most often , the result of
malrotation of occiput anterior position during labor(2/3).

Etiology :
Abnormal pelvic Anthropoid and android , transverse
narrowing of the midpelvis , the fetal head often engages
in OP or OT

Etiology
Bad flexion fetal backbone near the maternal
backbone , which disadvantages fetus flexion .
Uterine inertia influence fetal descent , flexion ,
internal rotation .
Cephalopelvic disproportion the pelvic cavity is
narrow , which limits fetal descent , flexion , internal
rotation .
Others placenta praevia , filling of bladder ,myoma
Clinical finding
Symptoms

Fetal head engages later at the onset of labor
Concordant uterine inertia and slow dilatation of
cervix ,induces prolonged active phase or second stage
Early use abdominal pressure before the cervix full
dilate
Treatment
The first stage Strengthen contractions , trial labor

Latent phase:
sufficient rest and nourishment . ( Pethidine or diazepam )

Active phase:
AROM cervix 3-4cm , membranes intac . To induce fetal head descending ,
strengthen contraction , and internal rotation .
Oxytocin intravenous drip infusion (small dose , 2--2.5u)
Cesarean section after treatment the labor is still not progressing or fetal
distress occurs



The treatment of the second stage
Midwifery BPD arrive the ischial spine plane or
below , s> +2 , to rotate the occiput to OA , vaginal
delivery forceps

Cesarean section fetal head is much high or
CPD

The treatment of the third stage
To prevent PPH prolonged labor readily
cause bleeding of uterine inertia .

Oxytocin large dose , intravenous drip infusion (20u)
Suture lacerations
Antibiotic