Soochow university
Xu Jianying
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)
Categories of dystocia
Abnormalities of passenger (the fetus)
excessive fetal size , malpositions ,congenital anomalies , multiple gestation
canal) pelvic contraction , soft tissue abnormalities of the birth canal , masses or neoplasia , aberrant placental location
Uterine dysfunction
hypotonic uterine inertia Uterine Dysfunction hypertonic uterine hypercontractility primary secondary
psychical-factors
Fearing labor pain , anxiety, tension
Worried about fetal safety, labor hemorrhage, injury and dystocia
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.
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)
fetus
5.management
Hypotonic: the rule of treatment--Strengthen contractions and prevent PPH
Drugs :
diazepam 10mg iv
(Softening the cervix)
Cesarean section :
Following the above management still ineffective or fetal distress
Cesarean section
Otherwise
3.management
Prophylaxis reduced obstetric brutal operation.
Must be gentle , slightly and carefully
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
Midpelvicoutlet contraction
Funnel shaped pelvic
protracted active phase or prolonged second stage secondary uterine inertia Uterine rupture , perineal tears obstructed labor
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).
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 900
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
term fetus (birthweight > 3000g) needed cesarean section The fetus is not big , fetopelvic is adaptation and without complication can try to labor
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 .
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.
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 .
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
Midwifery
Cesarean section
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