Dystocia, Dysfunctional Labor, Cephalopelvic Dispro

This is prolonged and difficult labor. It is caused by an abnormality or a combination of abnormalities in the essential factors of labor

dystocia

This is the opposite of dystocia; it is defined as normal labor

eutocia

What are the 4 main components of the labor process?

• power

• passenger

• passageway

• psyche

Useful in assessing if pelvis is adequate, borderline, or contracted.

clinical pelvimetry

This test plots the patient’s labor progress (cervical dilation vs. duration in hour) on a labor curve

simplest test

Types of dystocia

• uterine dysfunctions

• abnormalities with passageway

• fetal dystocia

Types of uterine dysfunctions or abnormalities of powers

• Hypotonic uterine dysfunction

• Hypertonic uterine dysfunction

• Uncoordinated Contractions

• Inadequate secondary forces

Types of pelvic dystocia

• Inlet dystocia

• Midpelvis dystocia

• Outlet dystocia

Types of soft tissues dystocia

• Placenta previa that partially/completely obstructs birth canal

• Presence of tumors that obstruct birth canal

Types of fetal dystocia or abnormalities of the passenger

• Malposition (POPP)

• Breech presentation

• Face

• Brow

• Shoulder

• Multiple presentation

• Macrosomia

• Hydrocephalus

This type of dysfunction labor occurs at the onset of labor

primary

This type of dysfunctional labor occurs later in labor

secondary

Dilation, frequency, and duration of contractions in the latent phase

• 3 - 4 cm

• every 10 minutes

• 30 - 90 seconds

Dilation, frequency, and duration of each contractions in the active phase

• 4 - 7 cm

• 40 - 60s

• 3 - 5 minutes

Dilation, frequency, and duration of contractions in the transition phase

• 8 - 10 cm

• 60 - 90 seconds

• 2 - 3 minutes

• Characterized by weak & infrequent contractions which are insufficient to dilate the cervix.

• Not more than 2 or 3 occurring in a 10-minute period

• Usually occurs during active phase

• Uterus is easily indentable at peak of contraction

• Not exceedingly painful

hypotonic uterine contractions

These are contractions that may have already been weak and ineffective at the start of labor

primary uterine inertia

Causes of hypotonic uterine contractions

• Overdistention of the uterus – multiple pregnancy, hydramnios, LGA fetus

• Administration of analgesia

• Grand multiparity

• Malpresentation & malposition

• Pelvic bone contraction

• Unripe or rigid cervix

• Congenital abnormalities of the uterus

• Unknown causes

Management of hypotonic uterine contractions

• Palpate uterus & assess lochia q 15 mins

• Reevaluate pelvic size to rule out CPD

• Vaginal delivery:

  • Amniotomy if membranes are not yet ruptured

  • Augmentation of labor by oxytocin administration

  • If contracted pelvis is present, CS is method of delivery

• Marked by an increase in resting tone to more than 15 mm Hg

• Usually encountered in the latent phase of labor

• Characterized by contractions that are too frequent but uncoordinated, uterus does not relax completely in b/n contractions

• Tend to be more painful

hypertonic uterine contractions

Management of hypertonic uterine contractions

• Evaluation of pelvic size. If adequate, NSVD will be attempted

• Maintenance of fluid & electrolyte balance by infusion of IV fluids

• Therapeutic rest

• Keep bladder empty to provide more space for the passage of fetus

• Encourage side-lying position to maximize blood flow to the placenta and fetus

• Watch for danger signals: fetal distress, passage of meconium stained amniotic fluid

What position should we place the patient with hypertonic uterine contractions to maximize blood flow to the placenta and fetus

side-lying position

• Occurs when more than 1 pacemaker may initiate contractions, or receptor points in the myometrium may act independently of the pacemaker instead of initiating contractions at one pacemaker point in the uterus.

• May occur so closely together interfering the placental blood supply.

• It may be difficult for a woman to rest between contractions because contractions are erratic (one on top of another)

uncoordinated contractions

Causes of uncoordinated contractions

• Paralysis of abdominal musculature

• Excessive use of analgesia & general anesthesia

• Fear of intense pain

Management of uncoordinated contractions

• If cause is fear of intense pain during pushing, administration of analgesia to provide comfort to the mother is often helpful.

• Outlet forceps when the head is already crowning.

• If the cause is analgesia, wait until the effect of analgesia wears off.

Dysfunctions at the 1st stage of labor

• Prolonged Latent Phase

• Protracted Active Phase

• Prolonged Deceleration Phase

• Secondary Arrest Dilatation

Dysfunctions at the 2nd stage of labor

• prolonged descent

• arrest of descent

Defined as exceeding 20h in nulliparas & more than 14h for multiparas.

prolonged latent phase

Causes of prolonged latent phase

• Poor cervical condition – most common cause

  • characterized by unripe, rigid & firm cervix

• Excessive sedation during latent phase

• Conduction of analgesia

Management of prolonged latent phase

• therapeutic rest

• adequate fluid for hydration

• administering pain relief (morphine, sulfate, epidural)

• active intervention

  • oxytocin stimulation if without CPD and UCs inadequate

  • cesarean birth and amniotomy

• Cervical dilatation does not occur at a rate of at least 1.2 cm/hour in a nullipara or 1.5 cm/hour in a multipara

• Active phase last longer than 12 hours in primigravida or 6 hours in multigravida

• usually associated with CPD and fetal malposition

protracted active phase

Management of protracted active phase

• if the cause of delay is fetal malposition or CPD, CS may be necessary

• If fetal malposition is not present, oxytocin augmentation

This type of protraction disorder:

• Less than 1 cm fetal descent per hour in nulli para.

• Less than 2 cm fetal descent per hour in multipara.

protracted descent

• When deceleration phase extends beyond 3 hrs in nullipara or 1 hr in multipara.

• Often results from abnormal head position.

• C/S frequently required.

prolonged deceleration phase

• Occurs if there’s no progress in cervical dilatation for longer than 2 hrs.

• C/S maybe necessary

secondary arrest of dilatation

• Active phase disorder characterized by lack of fetal descent & dilatation.

• The uterine contractions are occurring normally (at least 3 UC in 10 minutes with strength of at least 25 mmHg) yet the cervix does not dilate and the fetus does not descend

• It has same cause & given same management as protraction disorders.

arrest disorders

This type of arrest disorder is the absence of progress in cervical dilatation for more than 2hrs in nulliparas & 1h in multiparas.

arrest dilatation

This type of arrest disorder is the absence of progress of fetal descent for more than one hour in nulliparas & primiparas.

arrest of descent

This type of arrest disorder is the:

• Absence of fetal descent in 2nd stage of labor.

• Absence of descent for 2 hrs in nullipara & 1 hr in multipara.

• Occurs when expected descent of the fetus does not begin or engagement or movement beyond 0 station does not occur

failure of descent

• Descent is less than 1cm/hr in nullipara & 2cm/hr in multipara.

• Suspected if 2nd stage lasts over 2 hrs in multipara

prolonged descent

Management of prolonged descent

• Everything is w/in normal except for faulty contractions, CPD, & poor fetal presentation: rest & fluid intake.

• CS for CPD; IV w/ Oxy; amniotomy; & positioning.

This position is recommended to speed descent

semi-fowler position

• Absence of descent for 2 hrs in nullipara & 1 hr in multipara.

• Movement beyond 0 station does not occur.

• Common cause is CPD; CS is necessary.

• No CPD- NSVD w/ oxytocin

arrest of descent

• Occurs when uterine contractions are so strong a parent gives birth with only a few rapidly occurring contractions

• Labor that occurs w/in 3 hrs from onset of contraction to delivery of baby

• Occurs w/o warning

precipitate labor

This type of precipitate labor:

• When cervical dilatation is progressing at a rate of 5 cm or more per hour in nulliparas

• 10 cm/hour or more in multiparas

precipitate dilatation

This type of precipitate labor:

• When fetal descent is progressing at a rate of 5 cm/hr or more in nulliparas

• 10 cm/hr or more in multiparas

precipitate descent

Predisposing factors of precipitate labor

• Multiparity

• Large pelvis

• Lax unresisting maternal tissue

• Small baby in good position

• Induction of labor: amniotomy & oxytocin administration

• Absence of painful sensation & thus a lack of awareness of vigorous labor

Maternal complications of precipitate labor

• Laceration of birth canal & uterine rupture

• Postpartum hemorrhage

• Amniotic fluid embolism

Fetal complications of precipitate labor

• Hypoxia

• Intracranial hemorrhage due to sudden change of pressure

• Erb-Duchenne palsy

• Premature separation of placenta

• Injuries such as falling to the floor in unattended birth

• A condition causing arm weakness or paralysis due to brachial plexus damage, often occurring during childbirth, especially with shoulder dystocia.

• Fetal complication of precipitate labor

Erb-Duchenne palsy

S/S of precipitate labor and delivery

• Patient complains of a sudden, intense urge to push

• Sudden increase in bloody show

• Sudden bulging of the perineum

• Sudden crowning of the presenting part

If accelerated labor pattern occurs during oxytocin administration, what should be done?

stop infusion right away and turn woman on her side

What maneuver should be done when delivering the head of the baby during precipitate labor?

ritgen’s manuever - nondominant hand applies pressure against the fetal chin through the perineum, while the other hand controls the fetal occiput to manage the delivery speed and maintain neck flexion

What should we tell the woman to do to give time to drain amniotic fluid from the baby’s mouth during precipitate labor?

tell woman to continue panting

What should be applied until the anterior shoulder of the body delivers from under the pubic arch and becomes visible during precipitate labor

apply gentle downward pressure on the head

• A hard band that forms across the uterus at the junction of the upper & lower uterine segments & interferes w/ fetal descent.

• Termed as pathologic retraction ring

• Ring usually appears during 2nd stage of labor & can be palpated as a horizontal indentation across abdomen.

bandl’s pr retraction ring or contraction ring

This is administered to a woman with a relax uterus

morphine sulfate

If morphine sulfate is ineffective, this is done to prevent uterine rupture

C/S for immediate delivery of the fetus

What happens if Bandl’s ring develops during the placental stage?

woman is placed under anesthesia and placenta is removed manually

This refers to positions other than an occipitoanterior position

fetal malposition

This type of fetal malposition has the following characteristics:

• Arrested labor may occur when head does not rotate and/or descend.

• Delivery may be complicated by perineal tears or extension of an episiotomy

occipitoposterior position

Posterior positions tend to occur in birthing patients with what type of pelvis?

• android

• anthropoid

• contracted

This type of fetal malposition has the following characteristics:

• Incomplete rotation of OP to OA results in fetal head being in a horizontal or transverse position

occipitotransverse position

• Most common cause of prolonged labor, a malposition of vertex presentation

• Labor is prolonged because fetus must rotate a longer distance (180 degrees) to reach the symphisis pubis

• Mother experiencing much back pain due to pressure exerted by the fetal head as it moves against the sacrum

Persistent Occiput Posterior Position (POPP)

This can be done to relieve intense back pressure and pain caused by occipitoposterior position

applying counterpressure on the sacrum by doing back rubs

This is the jiggling and massaging the uterus to assist the fetus to rotate into a better position

rebozo method

This type of occipitoposterior rotation has the following characteristics:

• Fetus in cephalic presentation LOP position

• View is from outlet

• The fetus rotates 135 degrees from this position

left occipitoposterior rotation

This type of occipitoposterior rotation has the following characteristics:

• Baby is lying in the pelvis facing forward & slightly to the right, so that the baby would be looking out the left thigh.

right occipitoposterior rotation

This type of fetal malposition is when head initially engages correctly but fails to rotate & remains in a transverse position.

occipito-transverse position

Types of fetal malpresentation

• vertex presentation

• breech presentation

• shoulder presentation

Types of vertex presentation

• brow

• face

• sincipital

This type of vertex presentation has the following characteristics:

• Rarest of all presentations

• Causes are the same as those of face presentation

• Is commonly unstable, it usually converts to face or vertex presentation

• Babies born vaginally from this presentation experience extreme facial edema

• tell parents that their babies’ unsightly appearance will disappear in a few days

brow presentation

This type of vertex presentation has the following characteristics:

• Occurs when head is hyper extended & the chin (mentum) is the presenting part.

• On IE, examining finger feels the mouth, nose, malar bones & orbital ridges.

• no engagement in Leopold’s maneuver may suggest this type of presentation

face presentation

A fetal head presenting at a different angle than expected is termed as what?

asynclitism

What is the mechanism of labor in face presentation?

• descent

• internal rotation

• flexion

• extension

• external rotation

• expulsion

Causes of face presentation

• Large fetus

• Contracted pelvis

• Multiple pregnancy

• Lax uterus due to multiparity

• Occipitiposterior position because of the tendency of the fetus of extending the head instead of flexing it

This type of feeding is recommended for babies born in face presentation

gavage feeding

• Any presentation other than the occiput increases the risk of dystocia

• It is the most common cause of fetal malpresentation

breech presentation

With a breech presentation, fetal heart sounds are usually heard where?

high in the abdomen

This can occur because of cervical pressure on the buttocks and rectum due to a breech presentation

meconium staining

Types of breech presentation

• frank

• complete or incomplete

• double or single footling

Causes of breech presentation

• Prematurity

• Fetal abnormalities – hydrocephalus, anencephalus

• Hydramnios & oligohydramnios

• Congenital abnormalities of the uterus – bicornuate uterus

• Space occupying mass in the uterus that prevents the head from fitting into the lower portion such as placenta previa and fibroids

• Uterine relaxation due to multiparity

• Multiple gestation

• Contracted Pelvis; Previous breech delivery; Unknown causes

Complications of breech presentation

• Prolapse cord

• Birth trauma: fracture of the skull, clavicle, humerus, intracranial hemorrhage, rupture of abdominal organs

• Prolonged labor

• Intrauterine anoxia

• Early rupture of the membranes

• Fetal death

3 general techniques of vaginal breech delivery

• spontaneous breech delivery

• partial breech extraction

• total breech extraction

This type of vaginal breech delivery is when infant is born without traction or manipulation from OB

spontaneous breech delivery

This type of vaginal breech delivery is when infant is delivered spontaneously up to umbilicus the rest of the body is extracted

partial breech extraction

This type of vaginal breech delivery is when the entire body of infant is extacted by the OB

total breech extraction

This maneuver for breech delivery:

• Used to extract the head after delivery of the infant’s body.

mauriceau maneuver - The goal is to maintain the fetal head in flexion to facilitate its passage through the birth canal. This is achieved by applying gentle pressure to the fetal maxillae (cheekbones) and occiput (back of the head).

This maneuver for breech delivery:

• Used when the fetal back fails to rotate to the anterior

prague maneuver - involves grasping the shoulders of the fetus from below with two fingers of one hand while the other hand draws the feet up and over the maternal abdomen. This helps to rotate the baby around the maternal symphysis pubis, facilitating the delivery of the head.

This maneuver for breech delivery:

• Fetal suspension in this position aided by strong uterine contraction & moderate suprapubic pressure can result in spontaneous delivery of the rest of the body.

bracht maneuver - involves grasping the fetal body with support of the thumbs on the posterosuperior iliac spines, and the thighs and back are involved with the other fingers. The fetal trunk is elevated and projected towards the maternal abdomen, maintaining flexion of the thighs over the abdomen during execution of the maneuver

This maneuver for breech delivery:

• Involves intrauterine manipulation

• Entire hand of OB is inserted into vagina to convert frank breech to footling breech.

pinard manuever

This maneuver for breech delivery:

• When the fully deflexed head is entrapped & can’t be delivered vaginally after the rest of the body has come out, fetus is replaced higher in the vagina & uterus

• Followed by C/S

abdominal rescue

This maneuver for breech delivery:

• Cutting of shoulder using scissors of dead fetus to facilitate delivery

• Also used in shoulder dystocia

cleidotomy

• Fetus assumes a transverse or oblique lie.

• Is suspected when upon palpation the fetal head occupies one side of the uterus & the buttocks the other side.

• It can also be observed that the shape of the uterus is more horizontal than vertical.

shoulder presentation

Causes of shoulder presentation

• Lax uterine & abdominal muscles due to multiparity - most common cause

• Contracted pelvis

• Fibroids & congenita abnormality of uterus

• Preterm fetus, hydrocephalus

• Placenta previa

• Multiple pregnancy

• Refers to oversized infant, typically weigh more than 4000 grams or 10 pounds

• Also called large for gestational age (LGA).

macrosomia

Causes of macrosomia

• Common in male infants

• Maternal Diabetes; Obesity

• Hereditary; hx of fetal macrosomia

• Postterm pregnancy

• Excessive weight gain during preg

• Maternal age - older than 35y.o

Complications of macrosomia

• shoulder dystocia

• trauma to birth canal

• brachial plexus injury

• dislocation of cervical vertebrae

• fracture of the clavicle - most common

• cerebral hemorrhage

Two main procedures to complete at the onset of every shoulder dystocia

• McRobert’s manuever

• suprapubic pressure

In this procedure, the patient is asked to or assisted to deeply flex their thighs back toward their abdomen and then rotate their thighs laterally to make a wide V

McRobert’s manuever