1. Abnormal labor and Dystocia
Soochow university
Xu Jianying

2. Abnormal Labor : Dystocia
Abnormal labor ,also called dystocia.
When we last talked about childbirth ,there are four major influencing factors. When one or more factors abnormal or uncoordinated as abnormal labor. that may exist singly or in combination.

3. 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.

4. Categories of dystocia
According to the factors divided to 3 types
Abnormalities of the powers (uterine contractility and maternal expulsive effort)
either uterine forces insufficiently strong or inappropriately coordinated to efface and dilate the cervix — uterine dysfunction — or inadequate voluntary muscle effort during the second stage of labor.

5. Categories of dystocia
Abnormalities of passenger (the fetus)
excessive fetal size , malpositions ,congenital anomalies , multiple gestation
Abnormalities of the passage (the birth canal)
pelvic contraction , soft tissue abnormalities of the birth canal , masses or neoplasia , aberrant placental location

6. 1.Abnormalities of the powers
Uterine dysfunction
hypotonic primary
uterine inertia secondary
Uterine hypertonic
Dysfunction
uterine hypercontractility

7. Abnormalities of the powers -----uterine inertia
1.Etiology of uterine inertia
Cephalopelvic disproportion or Fetal malposition
Abnormal of uterine muscle
psychical-factors
Imbalance of endocrine system
Administration of analgesia
Others

8. Cephalopelvic disproportion or Fetal malposition
The fetal head or presenting part could not close presses to the cervix and lower uterine segment. fetopelvic disproportion arises from diminished pelvic capacity, excessive fetal size, or malpresentation
Failure to progress in either spontaneous or stimulated labor .This term is used to include lack of progressive cervical dilatation or lack of fetal descent.

9. Abnormal of uterine muscle
Uterine muscle malfunction can result from uterine overdistention or obstructed labor, or both. Muscle fiber excessive elongation and contractility decline .
Polyhydramnios , macrosomia, Multiple births (twins).
Muscle fiber degeneration (Past history of repeat uterus infection , abortion , induction of labor ,or operation),
myoma , pelvic tumors, myogenic dysplasia or malformed uterus (didelphus uterus , unicornous uterus ).

10. psychical-factors Fearing labor pain , anxiety, tension
Worried about fetal safety, labor hemorrhage, injury and dystocia
which eventually lead to Uterine dysfunction and occur uterine inertia

11. 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) .

12. 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.

13. When uterine contractions:
the intrauterine pressure in the lower, and often <15 mmHg,
As a finger pressing on the fundus of uterus a depression could appear
Maternal relative quiet , prolonged process. (painless or can endure ) fetal heart rate changes lately (no anoxia or lately)

14. 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

15. 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)

16. 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

17. Lack of fetal descent
Prolonged descent >1cm/h
Protracted descent >1h
Prolonged labor >24hs (the total stage of labor)

19. Labor-process range plan

20. 4.Effect on maternal and fetus
maternal fatigue (Prolonged progress)
acidosis , or dehydration
infection (Prolonged progress , prom)
postpartum hemorrhage (insufficient contractility)
cesarean section rate
laceration
fetus distress , (uterine blood flow and fetal oxygenation )
birth injury ,Intracranial trauma (obstructed labor , rare)
prolapse of umbilical cord
stillbirth

21. 5.management
Hypotonic: the rule of treatment--Strengthen contractions and prevent PPH
the first stage of labor
General management : rest, eat more liquid food ,sedation, correct acid , intravenous injection
Physical methods: massage uterus ,
emptying the bladder
stimulation nipple ,
artificial rupture of membrane (AROM)
enema

22. diazepam 10mg iv Drugs : (Softening the cervix)
oxytocin 2.5U + 5%GS 500ml ( 5mU/ml ,8drop／min, at the begining)
diazepam　10mg iv
(Softening the cervix)

23. Cesarean section :
Following the above management still ineffective or fetal distress

24. The second stage of labor
Forceps or vacuum extractor : second stage of labor ,cervical fully dilated, membranes ruptured and fetal survival, presenting part below the level of ischial spine
Cesarean section : presenting part upward the level of ischial spine or fetal distress

25. Hypertonic: the rule of treatment-- Adjusted contractions and resume a normal polarity and rhythm
Sedative: Dolantin or Morphine for adjusted and resume to a normal contractions
Cesarean section Otherwise

26. Abnormalities of the powers ----- uterine hypercontractility
1.Clinical findings and diagnosis
Coordinated uterine hypercontractility :
uterine contraction is normal and maintain the normal polarity , symmetry, and a certain rhythm, but the intensity strength and frequency enhanced
the contraction with :
long duration , short Interval

27. precipitate delivery ( multiparas )
the total stage of labor <3hs ,
The process of labor is too fast
Birth injuries lacerations of the soft birth canal
fractures, intracranial hemorrhage of the newborn
Postpartum hemorrhage,
uterine inversion,
Infections,
fetal distress, death

28. 2.Effect on maternal and fetus
rupture of uterus
PPH , infection
soft birth canal trauma
fetal distress
fetal death
stillbirth

29. 3.management
Prophylaxis reduced obstetric brutal operation. Must be gentle , slightly and carefully
Tocolytic therapies sedatives inhibited contractions : meperidine, magnesium sulfate.
Forceps , Vacuum extractor
Cesarean section.

30. 1)forceps operations
2)Vacuum extractor

31. 3)Cesarean section

32. Abnormalities of passage
the birth canal
pelvic contraction ,
soft tissue abnormalities of the birth canal ,
masses or neoplasia ,
aberrant placental location

33. Contractions of the pelvic
Bony pelvis a main composing part of birth canal ,its size and shape have the direct relation to the course of labor and delivery.
Any contraction of pelvic diameter that diminishes the capacity can create dystocia.
There may be contractions of the pelvic inlet, the midpelvis, the pelvic outlet, or a generally contracted pelvis caused by combinations of these.

34. Contracted pelvic inlet
1.simple flat pelvis
promontory of sacrum ( dotted line )
forward dislocation
2.rachitic flat pelvis
(past history of rickets)

35. Contracted pelvic inlet
Clinical findings:
Fetopelvic disproportion , malposition or malpresentation face and shoulder presentations are encountered three times more frequently
uterine inertia and prolonged progress of labor prolonged latent phase , early active phase and protracted active phase
cord prolapse ( loophole) occurs four to six times more frequently

36. Midpelvic—outlet contraction
Funnel shaped pelvic
the spines are prominent, the pelvic sidewalls converge

37. Midpelvic—outlet contraction
Clinical findings:
Fetopelvic disproportion persistent occiput posterior position or deep transverse arrest , molding of head and caput succedaneum
protracted active phase or prolonged second stage secondary uterine inertia
Uterine rupture , perineal tears obstructed labor

38. Generally contraction pelvic
Each pelvic plane is 2cm less than normal value or more
Can be seen in shape more short and small , well-balanced women of type of figure.

39. 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).
Physical examination height, spine, lower limb disability
(Height <150cm , lateral curvature usually associated with contracted pelvis)

40. Diagnosis Pelvic measurement external pelvimetry internal pelvimetry
sterile vaginal examination

41. Diagnosis Pelvimetry diagonal conjugate 12.5~13cm
bi-ischial diameter cm
incisura ischiadica 5~6cm
angle of subpubic arch 900

42. 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)

43. 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

44. management true inlet contracted : cesarean section
Midpelvic—outlet 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 Midpelvic—outlet contraction

45. management
Generally contraction pelvic term fetus (birthweight > 3000g) needed cesarean section
The fetus is not big , fetopelvic is adaptation and without complication can try to labor
Deformed pelvic cesarean section

46. 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 .
cesarean section is generally required

47. 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.

48. malposition and malpresentation
a. vertex malposition
persistent occiput posterior
persistent occiput transverse 5%
sincipital presentation %
anterior asynclitism
posterior asynclitism %~0.81%
b. brow presentation %~0.1%
c. face presentation %~0.27%
d. breech presentation %~4%
e. abnormal fetal lie transverse or oblique lie 0.25%

49. Persistent occiput posterior or transverse position (POP, POT)
Definition : Up to later stage of delivery the occiput can’t rotate anteriorly , persistent occiput posterior (POP) or transverse position (POT). Most often , the result of malrotation of occiput anterior position during labor(2/3).
Etiology :
Abnormal pelvic Anthropoid and android , transverse narrowing of the midpelvis , the fetal head often engages in OP or OT

50. Etiology
Bad flexion fetal backbone near the maternal backbone , which disadvantages fetus flexion .
Uterine inertia influence fetal descent , flexion , internal rotation .
Cephalopelvic disproportion the pelvic cavity is narrow , which limits fetal descent , flexion , internal rotation .
Others placenta praevia , filling of bladder ,myoma

51. 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

52. 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 , u)
Cesarean section after treatment the labor is still not progressing or fetal distress occurs

53. The treatment of the second stage
Midwifery BPD arrive the ischial spine plane or below , s> +2 , to rotate the occiput to OA , vaginal delivery forceps
Cesarean section fetal head is much high or CPD

54. 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

55. thanks!