DYSTOCIA

ANDREW ROULDAN B. BUIZON, M.D., FPOGS, FSGOP

Assistant Professor
De La Salle University – Health Sciences Institute
 DYSTOCIA

• Literally means “Difficult Labor”

• Characterized by Abnormally SLOW
Progress of Labor
 Overview of the lecture
I – Normal and Abnormal Labor
II – Causes of Dystocia
III – Complications of Dystocia
 Factors that affect Labor
• Power
– First stage: uterine contractions
– Second stage: uterine contractions + intra-
abdominal pressure
• Passenger
– Fetal Attitude, Presentation, Position
– Ability to adapt through Passage
• Passage
– Birth canal
• *For Normal Labor to take place – Normal 3P’s
 Prognosis for Vaginal Delivery
• Power – force of uterine contractions
• Passenger:
– Presentation and Position
– Size of fetal head
– Adaptability of fetal head
• Passage – size and shape of maternal
bony pelvis
 Stages of Labor
First* - regular uterine contractions  fully

Second*- full cervical dilatation  delivery baby

Third - delivery of baby  placental delivery

“Fourth” -immediate postpartum

*Stages concerned with Dystocia
 First Stage of Labor
• Latent Phase
• Active Phase
– Acceleration Phase
• Predictive of outcome of labor
– Phase of Maximum slope
• Measure of efficiency of the “machine”
– Deceleration Phase
• Reflective of fetopelvic relationship
History of the Partograph
 Functional Divisions of Labor
• Preparatory Division
• Dilatational Division
• Pelvic Division
 Preparatory Division
• Latent Phase and Acceleration Phase
• Major event – cervical ripening
– Softening: changes in ground substance
– Effacement: obliteration of cervical canal
• Cervical dilatation – minimal
• Fetal descent – minimal to absent
• Sensitive to sedation and conduction
analgesia
Preparatory Division
 Functional Divisions of Labor
• Preparatory Division
• Dilatational Division
• Pelvic Division
 Dilatational Division
• Phase of Maximum Slope
• Major Event – cervical dilatation
• Cervical Dilatation – most rapid rate
• Fetal Descent – minimal
• Unaffected by sedation and conduction
analgesia
Dilatational Division
 Functional Divisions of Labor
• Preparatory Division
• Dilatational Division
• Pelvic Division
 Pelvic Division
• Deceleration Phase to Second Stage of labor
• Major Event – cardinal movements
• Cervical Dilatation – rapid rate
• Fetal Descent – maximal
• Minimally affected by sedation but ‘bearing
down’ effort largely affected by conduction
analgesia
Pelvic Division
 Cervical Dilatation and
Fetal Descent
• The only characteristics of the parturient
useful in assessing labor & its progression

• Time vs. Cervical Dilatation – sigmoid curve

• Time vs. Fetal descent – hyperbolic curve

 Mechanical Forces of Labor
• Factors responsible for progression and
completion of each stage
• First stage:
– Uterine power
– Cervical resistance
– Forward pressure of the fetal head
• Second stage:
– Mechanical relationship between fetal head
and pelvic capacity
 Diagnosis of Labor

True Labor False Labor

Regularity (+) (-)

Frequency > 1 / 10 min no pattern
Duration > 10 seconds variable
Intensity increasing no pattern
Effect of
walking aggravates no effect
 Criteria for Diagnosis of Labor
1. Documented uterine contractions (at Least once
in 10 minutes, or 4 in 20 min.) In the form of
direct observation or Electronically using a
cardiotocogram
2. Documented progressive changes in cervical
dilatation and effacement, as Observed by one
observer
3. Cervical effacement of greater than 75-80%
4. Cervical dilatation of greater than 3 cm
 Diagnosis of Normal Labor
LABOR NULLIPARA MULTIPARA
PATTERN
Latent Phase < 20 hours < 14 hours

Cervical > 1.2 cm/hr > 1.5 cm/hr

Dilatation
Fetal Descent > 1 cm/hr > 2 cm/hr
 Diagnosis of Abnormal Labor
LABOR NULLIPARA MULTIPARA
PATTERN
Prolongation Disorder
Latent Phase > 20 hours > 14 hours
Deceleration Phase > 3 hours > 1 hour
Protraction Disorder
Dilatation < 1.2 cm/hr < 1.5 cm/hr
Descent < 1 cm/hr < 2 cms/hr
Arrest Disorder
No Dilatation > 2 hours > 2 hours
No Descent > 1 hour > 1 hour
 Prolonged Latent Phase
• It is the only disorder diagnosable in the
Preparatory Division of Labor

• Criteria:
– Nulli > 20 hrs
– Multi > 14 hrs
Etiology of Prolonged Latent Phase
• False Labor = 50% of the time
• Excessive sedation
• Unfavorable cervix (thick, uneffaced, closed)
• Uterine / Labor dysfunction
• Unknown
 Management of
Prolonged Latent Phase
• Therapeutic Rest
– if no C/I to delay for 6-10 hrs
– Strong sedatives
– Upon waking, 85% = enter active phase
15% = false labor
• Amniotomy
– will not accelerate latent phase
• Caesarean section
– Not usually done unless with indications
 Diagnosis of Abnormal Labor
LABOR NULLIPARA MULTIPARA
PATTERN
Prolongation Disorder
Latent Phase > 20 hours > 14 hours
Deceleration Phase > 3 hours > 1 hour
Protraction Disorder
Dilatation < 1.2 cm/hr < 1.5 cm/hr
Descent < 1 cm/hr < 2 cms/hr
Arrest Disorder
No Dilatation > 2 hours > 2 hours
No Descent > 1 hour > 1 hour
 Protraction Disorders
• Protracted Active Phase
• Protracted Descent
• Etiology :
– Malposition
– Excessive sedation / conduction analgesia
– Cephalopelvic disproportion
• Management:
– Augment of labor
– CS = 28% have CPD
 Diagnosis of Abnormal Labor
LABOR NULLIPARA MULTIPARA
PATTERN
Prolongation Disorder
Latent Phase > 20 hours > 14 hours
Deceleration Phase > 3 hours > 1 hour
Protraction Disorder
Dilatation < 1.2 cm/hr < 1.5 cm/hr
Descent < 1 cm/hr < 2 cms/hr
Arrest Disorder
No Dilatation > 2 hours > 2 hours
No Descent > 1 hour > 1 hour
 Arrest Disorders
• Criteria before diagnosing Arrest disorders:
– Latent phase completed (Cx > 4 cms)
– Intensity of Uterine contractions > 200 MvU x 2 h
• Etiology:
– Cephalopelvic disproportion
– Hypotonic uterine contraction
– Malposition
– Excessive sedation / anesthesia
• Management:
– CS
– Augment labor
• “2-hour rule” for diagnosis of arrest in active
phase of labor has recently been challenged

• 542 women included where CS delivery was

not performed for labor arrest until there were
at least 4 hours of a sustained uterine
contraction of >200montivedeo units or a
minimum of 6 hours oxytocin augmentation if
the contraction pattern could not be achieved
• Protocol resulted in high rate of vaginal delivery
(92%) w/ no severe adverse maternal or fetal
outcomes

• “Thus extending the minimum period of oxytocin

augmentation for active arrest from 2 hours to 4
hours appears effective”

ACOG Practice Bulletin, Compendium 2004

Management of Abnormal Labor
Labor pattern Preferred Exceptional
Treatment Treatment
Prolongation Disorders
Latent Phase Bed rest Augment / CS
Protraction Disorders
Dilatation Expectant / CS for CPD /
Descent Support Augment
Arrest Disorders
Prol Decel Augment if no Rest if exhausted
2o Arrest of Dil CPD
Arrest of Descent CS if + CPD CS
Failure of descent
 Abnormal Labor
(Based on Friedman’s curve)
Prolonged Deceleration Phase
Failure of Descent
Protracted Descent
Arrest of Descent

Arrest in Cervical Dilatation

Protracted Active Phase

Prolonged Latent Phase

 DYSTOCIA - Abnormal Labor
• Other names: Dysfunctional labor, Ineffective
labor, Failure to progress

• Worldwide - Accounts for 43% of all

primary cesarean sections
• Philippines - it accounts for 38.85%
Textbook of Obstetrics, 2002
 Risk Factors for Dystocia
• Associated w/ longer 2nd stage
- epidural analgesia
- occiput posterior position
- longer 1st stage of labor
- nulliparity
- short maternal stature
- birthweight
- high station at complete cervical dilatation
ACOG Practice Bulletin
Compendium 2004
 DYSTOCIA - Abnormal Labor
Three categories causing Dystocia: (Abnormalities of 3Ps)

• POWERS
– Expulsive powers:
• Uterine dysfunction, or
• inadequate voluntary muscle effort

• PASSENGER
– Presentation, Position, or Development of the Fetus

• PASSAGE
– Maternal Bony Pelvis (Pelvic Contraction)
– Soft Tissues of the Reproductive Tract
 Normal Uterine Contractions
Parameter Latent Phase Active Phase
to
Second Stage
Frequency / 3-5 mins 2-3 mins
Interval
Duration 30 – 40 secs 40 – 60 secs

Intensity Mild to Moderate -

moderate strong
Methods to Quantify Uterine
Activity
palpation

external
tocodynamometry

internal uterine
pressure sensors
 Normal Uterine Contractions
• Characterized by a gradient of myometrial activity:
greatest and lasting longest at the fundus (fundal
dominance) & diminishing toward the cervix
 UTERINE DYSFUNCTION
Hypotonic Uterine Dysfunction
• More common
• No basal hypertonus
• Uterine contractions have a normal
pressure gradient pattern (synchronous)
• IUP < 25 mmHg insufficient to dilate cervix
 UTERINE DYSFUNCTION
Hypertonic Uterine Dysfunction
• Also called incoordinate uterine
dysfunction
• Either basal tone is elevated or
pressure gradient is distorted by
contraction of the midsegment of the
uterus with more force than the fundus
or by complete asynchronism or a
combination of both
CAUSES OF UTERINE DYSFUNCTION

• Epidural analgesia
• Chorioamnionitis
• Maternal position during labor
• Birthing position in 2nd stage labor

William’s Obstetrics, 21st ed.