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
 Prolonged Latent Phase

10
Cervical Dilatation (cm)

8
6
4
2
0
8 12 16 20 24 28
Hours of Labor
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 of Labor
Descent

A
Dilatatio

B
n
 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
Descent

A
Dilatatio

D
n
 Arrest Disorders
• Criteria before diagnosing Arrest disorders:
– Latent phase completed (Cx > 4 cms)
– Intensity of Uterine contractions > 200 MvU x 2 h
• “2-hour rule” for diagnosis of arrest in active phase
of labor has recently been challenged
• 542 women included where CS delivery was
delayed until there were at least 4 hours of a
sustained uterine contraction of >200 MvU or a
minimum of 6 hours oxytocin augmentation if the
contraction pattern could not be achieved
 Arrest Disorders
• 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

 Arrest Disorders
• Etiology:
– Cephalopelvic disproportion
– Hypotonic uterine contraction
– Malposition
– Excessive sedation / anesthesia

• Management:
– CS = 52% have CPD
– Augment labor, if no CPD
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

Normal Labor Pattern

Spontaneous rupture
of membranes
Oxytocin
Arrest in Cervical Dilatation

AMNIOTOMY

OXYTOCIN
Prolonged Deceleration Phase

AMNIOTOMY

OXYTOCIN
Arrest of Descent

AMNIOTOMY

OXYTOCIN
 Overview of the lecture
I – Normal and Abnormal Labor
II – Causes of Dystocia
III – Complications of Dystocia
 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
– Uterine contractility
– Expulsive Powers (“Bearing down” in the 2nd
Stage of Labor)
• PASSENGER
– Presentation, Position, or Development of the Fetus

• PASSAGE
– Maternal Bony Pelvis (Pelvic Contraction)
– Soft Tissues of the Reproductive Tract
Physiology of Uterine Contractions
Methods to Quantify Uterine
Activity
palpation

external
tocodynamometry

internal uterine
pressure sensors
Physiology of Uterine Contractions
Uterine contractions characterized by a
gradient of myometrial activity:

3. Fundal Dominance
• Onset, intensity & duration
• Cornual area – ‘pacemaker’ of the uterus
• Greatest & longest activity at the fundus
• Diminishing towards the cervix
Physiology of Uterine Contractions

2. Triple Descending Gradient

• Gradient of contractions diminishes from
upper to lower segment
• Upper uterine segment retracts about the
fetus as the fetus descends through birth
canal
Physiology of Uterine Contractions
• Uterine activity – Montevideo units (MU)
– MU = Intensity x Frequency / 10 minutes
• Intensity (intrauterine pressure) = peak contraction
minus baseline contraction
• 200 MU = adequate uterine contractions
 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
 UTERINE DYSFUNCTION
CLINICAL CRITERIA HYPOTONIC HYPERTONIC

Occurrence 4% 1%
Phase of Labor Active Latent
Clinical Symptoms Painless Painful
Fetal Distress Late Early
Reaction to Oxytocin Favorable Unfavorable
Value of Sedation Little Great
Gradient Pattern Normal but Abnormal
of Activity decreased
 UTERINE DYSFUNCTION
Causes of Hypotonic Uterine Dysfunction
• Uterine overdistention
• Grandmultiparity
• Sedation
• Regional anesthesia
 HYPERTONIC UTERINE
DYSFUNCTION
Also called ‘incoordinate’ uterine dysfunction
Causes:
• Contraction uterine midsegment
• Asynchrony of impulses originating from
each cornu
 UTERINE DYSFUNCTION
REMEMBER, normally there is:
• LOW uterine activity in ‘Latent phase of labor
• HIGH “ “ ‘Active “ “
So that, if there is:
• HIGH uterine activity in Latent phase of labor
=> HYPERTONIC uterine dysfunction
• LOW uterine activity in Active phase of labor
=> HYPOTONIC uterine dysfunction
CAUSES OF UTERINE DYSFUNCTION
A. Epidural analgesia
• Lengthens both 1st and 2nd stage of labor
• Slows down rate of fetal descent
B. Chorioamnionitis
C. Maternal position during labor
• Uterus contracts more frequently with less
intensity in supine vs. lateral decubitus position
• Uterus contracts with more frequency and
intensity in sitting or standing position
William’s Obstetrics, 21st ed.
 TREATMENT OF HYPOTONIC
UTERINE DYSFUNCTION
• Ascertain parturient is in active labor & no CPD:
– Cervix > 4 cms
– Clinical pelvimetry is adequate in all levels
– Presenting part is occiput and engaged

• Oxytocin stimulation
TREATMENT OF HYPOTONIC
UTERINE DYSFUNCTION
Oxytocin
effect uterine activity
• cervical change
• fetal descent

avoid uterine hyperstimulation &/or

development of non-reassuring fetal heart
status
TREATMENT OF HYPOTONIC
UTERINE DYSFUNCTION
– Oxytocin should be DISCONTINUED
• If uterine contractions persist >5 in a 10-
minute period or 7 in a 15-minute period
• If the contractions LAST LONGER than 60-
90 seconds
• FHR pattern becomes non-reassuring

William Obstetrics 21st edition

Complications of Overinfusion of
Oxytocin
hypotension Hyperstimulation

tachycardia Uterine rupture

water retention Fetal distress

 TREATMENT OF HYPERTONIC
UTERINE DYSFUNCTION

• Characterized by uterine pain out of

proportion to intensity of contractions and
in effacing & dilating the cervix
• Placental abruption must always be
considered
• Fetal distress (+) – CS
(-) - sedation
The Passenger
 The Fetus
– Position

• Presentation

• Development
 The Passenger
• Normal Position – Occiput anterior
• Malpositions:
– Persistent Occiput transverse (POT)
– Persistent Occiput posterior (POP)
 The Passenger
• Normal Presentation – Vertex / Cephalic
• Malpresentations:
– Brow
– Face
– Breech
– Transverse
• Fetal attitude – relationship bet fetal head & body
– Occiput = completely flexed
– Sinciput = partially flexed
– Brow = partially extended
– Face = completely extended
 The Passenger
• Etiology of deflection attitudes – factors
that favor extension or prevent head
flexion:
– Neck masses
– Anencephaly
– Large babies
– Cord coils
– Contracted pelvis
– Pendulous abdomen
 The Passenger – Fetal Head Diameters
ATTITUDE PRESENTING DENOMINATOR
DIAMETER
Flexion* Suboccipitobregmatic Occiput
(SOB) = 9.5 cm
Military** Occipitofrontal Occiput
(FO) = 11.5 cm
Partial Occipitomental Forehead (Brow)
Extension** (MO) = 12.5 cm
Complete Submentobregmatic Chin / Mentum
Extension* (SMB) = 9.5 cm (Face)
* Vaginal delivery
** Unstable / transient presentation – dystocia high
 BROW PRESENTATION
• Head is partially extended
• Midway between full flexion & extension
• Rarest presentation
• Longest presenting diameter = 12.5 cm
• Unstable/transient – converts to Face or
Occiput presentation
 BROW PRESENTATION -
Diagnosis
• Abdominal Exam
– > ½ of head above symphysis pubis,
– Since OM, Vaginal delivery not possible
– Leopold’s Maneuver 2 & 3:
• Cephalic prominence same side as fetal back
• Occiput and chin palpable
– Occiput palpable at higher level than Sinciput
• Occuiput = Posterior fontanel
• Sinciput = anterior fontanel
 BROW PRESENTATION -
Diagnosis
• Vaginal examination
– Anterior fontanel
– Frontal sutures
– Orbital ridges
– Eyes
– Root of nose
 BROW PRESENTATION –
Three possible outcomes during course of Labor:

Possible Mechanism Manner of

outcome Delivery
Vertex if head flexes Vaginal

Face if head Vaginal

completely
extends
Persistent if no change in CS
position
 FACE PRESENTATION
• Fetal head is fully extended / hyperextended
• Occiput in contact w/ fetal back, chin presents
• Abdominal exam:
– groove felt bet Occiput & Fetal Back
• Vaginal exam:
– Distinct facial features
– Sinciput & occiput not palpable
• Etiology:
– Any factor that favors extension or prevents
flexion (e.g. Anencephaly)
 FACE PRESENTATION –
Course of Labor
• Chin / mentum anterior:
– Expect vaginal delivery -
– CS if obstructed labor
• Chin / mentum posterior:
– Vaginal delivery possible only if Internally Rotate
anteriorly
– Cause of obstructed labor: fetal brow (bregma)
pressed against maternal symphysis pubis
– Short neck cannot span the curvature of sacrum
 BREECH PRESENTATION
TYPE THIGHS KNEES SACRUM FEET

Complete Flexed Flexed + _

Incomplete Flexed Flexed _ +

(Footling)

Frank Flexed Extended + _

 BREECH PRESENTATION
• Leopold’s Maneuver:
• Vaginal Examination:
– Ischial Tuberosities
– Anus
– External Genitalia
– Sacrum
– Feet
 BREECH PRESENTATION
• Possible Etiologies:
– Prematurity
– Uterine relaxation / Multiparity
– Multiple pregnancy
– Hydramnios
– Oligohydramnios
– Hydrocephalus
– Anencephaly
– Uterine anomalies / tumor
– Placente Previa
– Habitual breech
 BREECH PRESENTATION
• Antenatal Period:
– External version may be attempted
• Standard of Care:
– Planned CS – to reduce perinatal M & M
– Vaginal - In advanced labor of imminent delivery
• Frank / complete
• Spontaneous
• Partial BE
• Total BE
 BREECH PRESENTATION
MATERNAL FACTORS FETAL FACTORS
•Pelvic Contraction •Large fetus
•Delivery is indicated – •Hyperextended head
patient not in labor “stargazing breech”
•Uterine dysfunction •Healthy preterm fetus
•Lack of Experience where delivery is
Operator indicated
•Severe IUGR
Previous Perinatal
Death/ Birth Trauma
 BREECH PRESENTATION
• Complications
– Perinatal M & M – preterm birth, birth trauma,
congenital anomalies
– Low Birth Weight – prematurity, IUGR
– Prolapsed cord – small fetus, fetus not in
frank breech
– Placenta Previa
– Uterine anomalies / Tumors
 TRANSVERSE PRESENTATION
• Long axis of fetus perpendicular to mother
• NO MECHANISM OF LABOR, always CS
• Abdomen: SQUAT UTERUS
– Usually wide
– Fundus only slightly above umbilicus
• Leopold’s Maneuver:
– 1 : empty
– 2 : fetal back readily identified
• If anteriror: hard resistant plane
• If posterior: irregular nodulations (FSP)
 TRANSVERSE PRESENTATION
• Vaginal examination:
– Palpate acromion and hands
– “Gridiron” – can feel the ribs
• Etiology:
– Lax abdominal wall - allows uterus to fall forward, to be
deflected away from long axis of birth canal into an Oblique
or Transverse Position
– Prematurity
– Placenta previa
– Contracted pelvic
– Tumor previa
– Multiple pregnancy
– Fetal uterine anomalies
– polyhydramnios
TRANSVERSE PRESENTATION –

Course of Labor
• Neglected Transverse Lie
– Prolonged ROM
– Stretched / thinned out LUS
– Intrauterine infection
– Fetal impaction
– Prolapsed cord / arm
– Dead baby
TRANSVERSE PRESENTATION –

Management
• It’s a serious malpresentation
• Management should not be left to nature
• Spontaneous vaginal delivery impossible
• Must deliver by CS immediately
 Overview of the lecture
I – Normal and Abnormal Labor
II – Causes of Dystocia
III – Complications of Dystocia
 MATERNAL COMPLICATIONS
• Hemorrhage & Shock – uterine atony
• Intrapartum infection – ascending type:
chorioamnionitis, decidua, chorionic vessels,
bacteremia, sepsis
• Uterine rupture – progressive thinning out of LUS in
prolonged labor, esp high parity & previous surgery
• Fistula formation – presenting part wedged into
pelvic inlet during prolonged labor, tissues of birth
canal bet it & pelvic wall subjected to pressure,
ischemia, necrosis
– Fistula: two cavities joined together (e.g.
rectovaginal or vesicovaginal fistulae)
 MATERNAL COMPLICATIONS
• Postpartum lower extremity injury:
– Foot drop:
• common peroneal n. + LS plexus or sciatic n.
– Inappropriate leg positioning in stirrups
– Resolve w/in 6 months postpartum
• Pelvic floor injury:
– Directly to pelvic floor m. or their nerve supply
 FETAL COMPLICATIONS
• Caput succedaneum:
– Soft tissue / scalp edema of most dependent
portion of fetal head
– Overlies the periosteum, cross over periosteal
limitations
• Cephalhematoma:
– Subperiosteal hemorrhage
– Confined by periosteal limits
 FETAL COMPLICATIONS –
Nerve Injuries
• Spinal injury – overstretching with hemorrhage
• Brachial plexus –
– Duchenne / Erb paralysis: (Upper roots)
• Deltoid, infraspinatus, flexor m of forearm
• Entire arm fall limply close to side of the body,
forearm extended & internally rotated
• Function of hand retained
• Excesssive lateral traction upon head, sharply
flexing head toward one of shoulders
– Klumpke paralysis: (Lower roots)
• Paralysis of the hand