1. DYSTOCIA = DIFFICULT / ABNORMAL LABOR Greek 'dys' = 'difficult, painful, disordered, abnormal' 'tokos' meaning 'birth'. Dr. E Gdansky

2. Dystocia Incidence  Overall? Retrospective/Unreported in normal vaginal delivery  Primiparous women ~25% have dystocia  Most common indication for primary CS  ~50% of CSs are related to dystocia

3. First Stage of Labor Duration Primip. 6-18 Multip. 2-10

4. PrimiparaMultipara Prolonged latent phase (Normal mean = 6.4 h) >20 h (Normal mean = 4.8 h) >14 h Protracted dilatation<1.2 cm/h<1.5 cm/h Protracted descent<1 cm/h<2 cm/h Protracted 2 nd stage (Normal mean = 50 min) >2 h (+1 h) (Normal mean = 20 min) >1 h (+1 h) Arrest of dilatation>2 h Arrest of descent>1 h Precipitate labor <3 h from onset of contractions Dystocia Abnormal patterns of labor

5. Dystocia Classification  Powers  Passage  Passenger  Contractions  Expulsive forces  Maternal pelvis  The fetus (Malposition/ Malpresentation) A combination of these factors

6. Dystocia  Dysfunctional uterine contractions  Hypotonic uterine contracions  Malpresentation (Asynclitism, OP, DTA, face, braw)  Cephalo-pelvic disproportion = CPD  Epidural  Pelvic tumor  Sedation  Hydration  Augmentation of labor (amniotomy, oxytocin)  Instrumental delivery  Cesarean section CausesTreatment

7. Dystocia Abnormalities of the passage Current Diagnosis & Treatment Obstetrics & Gynecology - 10th Ed. (2007) Inlet Mid-pelvis Outlet

8. Dystocia Abnormalities of the passage  Bony pelvis - Gynecoid (50%) - Android (33% white, 15% black) - Anthropoid (50% black, 20% white) -Platypelloid (<3%) True conjugate Obstetric Diagonal A-P mid-pelvis

9. Dystocia Abnormalities of the passage Classification:  Contraction of the pelvic inlet  Contraction of the mid-pelvis and pelvic outlet  General contraction of the pelvis  Pelvic deformities traumatic fracture, rickets, chondrodystrophic dwarfism, kyphosis & scoliosis, exostosis, bone neoplasia

10. Dystocia Abnormalities of the passage  Conjugate - diagonal (<11.5) - obstetric (<10 cm) - true  Transverse diameter (<12 cm)  Interspinous diameter (<8 cm)  Intertuberous diameter (<8 cm) Pelvimetry 4 X-ray 4 US 4 MRI 4 Clinical pelvimetry

11. Dystocia Abnormalities of the passage  Soft tissue (uterine or vaginal congenital anomalies, scarring of the birth canal)  Pelvic mass / neoplasia  Placental location (low implantation / previa)

12. Dystocia Obstructed labor  Bandl’s retraction ring & Uterine rupture  Vescicovaginal & rectovaginal fistula  Pelvic floor injury  Increased neonatal morbidity & mortality

13. Dystocia Abnormalities of the powers  Normal contractions - Fundal dominance - Intensity >24 mmHg (40-60 mmHg) - Synchronized - Basal pressure 12-15 mmHg - Frequency 3-5/10 min - Duration 60-90 sec - Rhytm & force are regular  Hypotonic (causes: excessive sedation, early epidural, over-distended uterus)  Hypertonic (causes: abruptio, oxytocin, CPD, fetal malpresentation, latent phase of labor)

14. Dystocia Abnormalities of the powers  External/ internal Tocodynamometer  Montevideo unit >200 mmHg is sufficient for normal progress

15. Dystocia Abnormalities of the powers  Hypotonic  Amniotomy Oxytocin augmentation  Hypertonic  Decrease/stop oxytocin Tocolysis Sedation in latent phase Oxytocin (?)

16. Dystocia Management of Labor  In any case of CPD (relative or absolute) or failure treat abnormal progress  CS  Second stage disorder with no evidence of CPD can, in certain conditions, be treated with:  Vacuum - Assisted Delivery  Forceps Delivery

17. Dystocia Precipitate labor  <3 h from onset of contraction Primipara Multipara  Precipitate dilatation >5 cm/h 10 cm/h  Causes: Extremely strong contractions low birth canal resistance Oxytocin (+ associate with placental abruption)  Treatment: Stop oxytocin beta mimetics (terbutaline / ritodrine)

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