Abnormal labor and abnormal

uterine contractions
(dystocia)

Dr Samar Sarsam

DEFINITION
Dystocia is defined as difficult labor or childbirth.
It may be associated with abnormalities involving:
Abnormalities of the Passage
Abnormalities of the Passenger
Abnormalities of the Powers
or a combination of these factors

INCIDENCE
Over the last quarter of a century, the cesarean
section rate in the United States has risen to
approximately 25% of deliveries done each year.
Dystocia is currently the most common indication
for primary cesarean section, and is about three
times more common than either non reassuring
fetal status or malpresentation.





0
2
4
6
8
10
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2 4 6 8 10 12 14 16
Latent phase
Active phase
2nd
stage
1st stage
max slope
acceleration
dec
Time (hours)
Cervical dilatation
(cm)
Friedman labor curve in nulliparous
ABNORMAL PATTERNS OF LABOR
The progress of labor is evaluated primarily
through estimates of cervical dilatation and
descent of the fetal presenting part. Normal
labor patterns in primigravidas and multiparas
have been described in detail by Friedman and
others.

Friedman also described four abnormal
patterns of labor: (1) prolonged latent phase,
(2) protraction disorders (protracted active-
phase dilatation and protracted descent), (3)
arrest disorders (prolonged deceleration
phase, secondary arrest of dilatation, arrest of
descent, and failure of descent), and (4)
precipitate labor disorders.

1. Prolonged Latent Phase
The latent phase of labor begins with the onset of
regular uterine contractions and extends to the
beginning of the active phase of cervical dilatation. The
duration of the latent phase averages 6.4 hours in
nulliparas and 4.8 hours in multiparas.
Causes of prolonged latent phase include:
excessive sedation or sedation given before the end of
the latent phase.
labor beginning with an unfavorable cervix.
uterine dysfunction characterized by weak, irregular,
uncoordinated, and ineffective uterine contractions.
fetopelvic disproportion.

Treatment options:
therapeutic rest with sedation and hydration.
active management of labor.
85% of patients spontaneously enter the active phase
of labor.
Ten percent of patients will have been in false labor,
and may be allowed to return home to await the onset
of true labor if fetal status is reassuring.
In the remaining 5% of patients, uterine contractions
remain ineffective in producing dilatation; in the
absence of any contraindication, active stimulation of
labor with oxytocin infusion may be effective in
terminating the latent phase of labor.


2. Protraction Disorders
Protracted cervical dilatation in the active phase of labor
Protracted descent of the fetus constitute the protraction
disorders.
Protracted active-phase dilatation is characterized by an
abnormally slow rate of dilatation in the active phase, ie,
less than 1.2 cm/h in nulliparas or less than 1.5 cm/h in
multiparas.
Protracted descent of the fetus is characterized by a rate of
descent under 1 cm/h in nulliparas or under 2 cm/h in
multiparas.
The second stage of labor, which normally averages 20
minutes for parous women and 50 minutes in nulliparous
women, is protracted when it exceeds 2 hours in nulliparas
or 1 hour in multiparas, or 3 and 2 hours respectively in the
presence of conduction anesthesia.

The underlying pathogenesis of protracted
labor is probably multifactorial.
Fetopelvic disproportion.
minor malpositions such as occiput posterior.
improperly administered conduction
anesthesia.
excessive sedation.
pelvic tumors obstructing the birth canal.

Treatment of protraction disorders
Cesarean section is indicated in the presence
of confirmed fetopelvic disproportion.
In the absence of fetopelvic disproportion,
conservative management, consisting of
support and close observation, and therapy
with oxytocin augmentation both carry a good
prognosis for vaginal delivery.


3. Arrest Disorders
The four patterns of arrest in labor:
(1) prolonged deceleration, with deceleration
phase lasting more than 3 hours in nulliparas or
more than 1 hour in multiparas.
(2) secondary arrest of dilatation, with no
progressive cervical dilatation in the active phase
of labor for 2 hours or more.
(3) arrest of descent, with descent failing to
progress for 1 hour or more.
(4) failure of descent, with descent failing to
occur during the deceleration phase of dilatation
and during the second stage.

Causes:
About 50% of patients with arrest disorders
demonstrate fetopelvic disproportion.
various fetal malpositions (eg, occiput
posterior, occiput transverse, face, or brow).
inappropriately administered anesthesia, or
excessive sedation.
If fetopelvic disproportion is established,
cesarean section is done.
If fetopelvic disproportion is not present and
uterine activity is less than optimal, oxytocin
stimulation is generally effective in producing
further progress.

4. Precipitate Labor Disorders
Precipitate dilatation occurs if cervical dilation
occurs at a rate of 5 or more centimeters per
hour in a primipara or at 10 cm or more per
hour in a multipara. Precipitate descent occurs
with descent of the fetal presenting part of 5
cm or more per hour in primparas and 10 cm
or more per hour in multiparas.

Causes:
1-extremely strong uterine contractions
2-low birth canal resistance.
abnormal contractions may be associated with
administration of oxytocin and abruptio placentae.
If oxytocin administration is the cause of abnormal
contractions, it may simply be stopped. The problem
typically resolves in less than 5 minutes.
If excessive uterine activity is associated with fetal heart
rate abnormalities, and this pattern persists despite
discontinuation of oxytocin, a b-mimetic such as
terbutaline or ritodrine can be given and magnesium
sulfate also
Lacerations of the birth canal are common.
maternal amniotic fluid embolism.
predisposing to postpartum hemorrhage.
Perinatal mortality is increased secondary to hypoxia,
possible intracranial hemorrhage, and risks associated with
unattended delivery.

PATHOGENESIS & TREATMENT
--Abnormalities of the Passage
Causes:
bony abnormalities (pelvic dystocia).
soft tissue obstruction of the birth canal.
abnormal placental location.
Pelvic dystocia, is the most common cause of passage
abnormalities.
The etiology and diagnosis of pelvic abnormalities
begins with the shape, classification, and clinical
assessment of the adult female pelvis..
Ultrasound, magnetic resonance imaging (MRI), and x-
rays have been used to investigate pelvic size and
shape for evidence of pelvic contraction obstructing
the normal progress of labor.

X-ray pelvimetry has now fallen into limited use.
Clinical pelvimetry has been largely used in the routine
evaluation of most obstetric patients.
The diagnosis of fetopelvic disproportion has generally
become a diagnosis of exclusion, after fetal factors and
uterine dysfunction have been ruled out.
However, x-ray pelvimetry retains a role in the
evaluation of a pelvis for the feasibility of vaginal
breech delivery and in the assessment of gross bony
distortion such as previous pelvic fracture or rachitic
deformity.
Contractions of the pelvis are generally classified as:
contractions of the inlet, midpelvis, or outlet, or as a
combination of these elements.

Inlet contraction is suspected if the anteroposterior
diameter of the pelvis is less than 10 cm, the
transverse diameter is under 12 cm, or both.
floating vertex presentation with no descent during
labor,
abnormal presentation,
prolapsed cord or extremity.
considerable molding of the fetal head,
caput succedaneum formation,
and prolonged rupture of the membranes.
If allowed to continue, abnormal thinning of the lower
uterine segment may occur, with development of a
Bandl's retraction ring, or even frank uterine rupture.
Cesarean section is the treatment of choice in true
inlet contraction.

Midpelvis contraction it is more frequent than inlet
dystocia because the midpelvis is smaller than the inlet
and positional abnormality is more common at this
level.
Presentation:
Arrest of descent
Poor application of the head to the cervix
Abnormal rate of cervical dilatation
Contraction of the outlet is extremely unusual unless
found in association with a Midpelvis contraction.
Criteria for assessing pelvic outlet adequacy include
intertuberous diameter greater than 8 cm and a sum of
the intertuberous diameter and the anteroposterior
diameter greater than 15 cm.

Midpelvic outlet obstruction is detected
clinically on the basis of convergent side walls,
prominent ischial spines, or a narrow pelvic
arch.
It may present as a prolonged second stage,
persistent occiput posterior position,
deep transverse arrest.
Molding of the fetal head and caput
succedaneum formation are common.

Uterine rupture may occur in prolonged labor
complicated by midpelvic outlet obstruction, and
vesicovaginal or rectovaginal fistula formation
may result with pressure necrosis of the
surrounding tissues of the birth canal by the fetal
head.
Cesarean section is therefore the delivery
method of choice in this complication.
Other anatomic abnormalities of the
reproductive tract may cause dystocia is soft
tissue dystocia may be caused by uterine or
vaginal congenital anomalies, scarring of the birth
canal, pelvic masses, or low implantation of the
placenta.

--Abnormalites of the Passenger
**A. malposition and malpresentation:
Fetal malpresentations are abnormalities of fetal
position, presentation, attitude, or lie. They
collectively constitute the most common cause of
fetal dystocia, occurring in approximately 5% of
all labors.
1. Vertex malpositions
a. Occiput posterior
b. Occiput transverse
2. Brow presentationBrow presentations
usually are transient fetal presentations with
deflexion of the fetal head.

3. Face presentationIn face presentation,
the fetal head is fully deflexed from the
longitudinal axis.
4. Abnormal fetal lieIn transverse or oblique
lie, the long axis of the fetus is perpendicular
to or at an angle to the maternal longitudinal
axis.

5. Breech presentation

**B. fetal macrosomia
**C. fetal malformation
The most common malformation is
hydrocephalus, enlargement of the fetal
abdomen caused by distended bladder,
ascites, or abdominal neoplasms; or other
fetal masses, including meningomyelocele or
cystosarcoma.

Abnormalities of the Powers
Normal uterine activity during labor:
(1) the relative intensity of contractions is greater in
the fundus than in the midportion or lower uterine
segment (this is termed fundal dominance); (2) the
average value of the intensity of contractions is more
than 24 mm Hg. (3) contractions are well synchronized
in different parts of the uterus; (4) the basal resting
pressure of the uterus is between 12 and 15 mm Hg;
(5) the frequency of contractions progresses from one
every 35 minutes to one every 23 minutes during
the active phase; (6) the duration of effective
contraction in active labor approaches 60 seconds; and
(7) the rhythm and force of contractions are regular.

Quantification of uterine activity during labor
by:
-external tocodynamometry
-intrauterine pressure catheter measurement.
Uterine dysfunction generally comprises 3
categories:
hypotonic dysfunction,
hypertonic dysfunction,
uncoordinated dysfunction.

Hypotonic dysfunction is uterine activity characterized
by contraction of the uterus with insufficient force (>
24 mm Hg), irregular or infrequent rhythm, or both.
Seen most often in primigravidas in the active phase of
labor, it may be caused by excessive sedation, early
administration of conduction anesthesia, twins,
polyhydramnios, or overdistention of the uterus.
Hypotonic dysfunction responds well to oxytocin;
however, care must be taken to first rule out
cephalopelvic disproportion and malpresentation.
Active management of labor has been shown to
decrease perinatal morbidity and cesarean section
rates.

hypertonic uterine contractions and uncoordinated
contraction often occur together and are characterized
by elevated resting tone of the uterus, dyssynchronous
contractions with elevated tone in the lower uterine
segment, and frequent intense uterine contractions. It
is generally associated with abruptio placentae,
overuse of oxytocin, cephalopelvic disproportion, fetal
malpresentation, and the latent phase of labor.
Treatment:
tocolysis, decrease in oxytocin infusion
cesarean section as indicated for concomitant
malpresentation, cephalopelvic disproportion, or fetal
distress.

When these patterns occur in the latent phase
of labor:
sedation may be effective in converting
hypertonic contractions to normal labor patterns.
Inadequate pushing in the second stage of labor
is common and may be caused by conduction
anesthesia, oversedation, exhaustion, or
neurologic dysfunction such as paraplegia or
hemiplegia of various causes, or by psychiatric
disorders.
Mild sedation may improve expulsive efforts.
outlet forceps or vacuum delivery may be of help.