1. Lecture 16
ABNORMAL LABOR:
DYSTOCIA
Prof. Vlad TICA, MD, PhD

2. ABNORMAL LABOR: DYSTOCIA
When we last talked about childbirth, there are 4 major influencing factors
When one or more factors are abnormal or uncoordinated = abnormal labor
That may exist singly or in combination

3. ABNORMAL LABOR: DYSTOCIA
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)
Abnormalities of passenger (the fetus)
Abnormalities of the passage (the birth canal)

5. 1. ABNORMALITIES OF THE POWERS
Abnormalities of the 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 2nd stage of labor

6. 2. ABNORMALITIES OF PASSENGER (THE FETUS)
excessive fetal size
malpositions
congenital anomalies
multiple gestation

7. 3. ABNORMALITIES OF THE PASSAGE (THE BIRTH CANAL)
pelvic contraction
soft tissue abnormalities of the birth canal
masses or neoplasia
aberrant placental location

8. 1. ABNORMALITIES OF THE POWERS
UTERINE DYSFUNCTION
hypotonic primary
uterine inertia secondary
Uterine hypertonic
Dysfunction
uterine hypercontractility

9. 1. ABNORMALITIES OF THE POWERS: UTERINE INERTIA
1. ETIOLOGY
Cephalopelvic disproportion / Fetal malposition
Abnormal of uterine muscle
Psychical factors
Imbalance of endocrine system
Administration of analgesia
Others

10. 1. ABNORMALITIES OF THE POWERS
i. Cephalopelvic disproportion / 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
malpresentation
Failure to progress in spontaneous / stimulated labor
This term is used to include lack of progressive cervical dilatation or lack of fetal descent

11. 1. ABNORMALITIES OF THE POWERS
ii. 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
Myomas, pelvic tumors, myogenic dysplasia or malformed uterus (didelphus, unicornous uterus)

12. 1. ABNORMALITIES OF THE POWERS
iii. 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

13. 1. ABNORMALITIES OF THE POWERS
iv. 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)

14. 1. ABNORMALITIES OF THE POWERS
iv. 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)

15. 1. ABNORMALITIES OF THE POWERS
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

16. 1. ABNORMALITIES OF THE POWERS
2.CLINICAL FINDINGS
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)

17. 1. ABNORMALITIES OF THE POWERS
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 / multiple site, and with uncoordinated rhythm, polarity inversion

18. 1. ABNORMALITIES OF THE POWERS
2.CLINICAL FINDINGS
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)

19. 1. ABNORMALITIES OF THE POWERS
2.CLINICAL FINDINGS
Failure to progress
Lack of progressive cervical dilatation (primiparas):
Prolonged latent phase > 16 hrs
Prolonged active phase > 8 hrs, cervix dilation < 1.2 cm/hrs
Protracted active phase > 2 hrs
Prolonged 2nd stage > 2 hrs

20. 1. ABNORMALITIES OF THE POWERS
2.CLINICAL FINDINGS
Lack of fetal descent
Prolonged descent > 1 cm/h
Protracted descent > 1 h
Prolonged labor > 24 hrs (the total stage of labor)

22. LABOR-PROCESS RANGE PLAN

23. LABOR-PROCESS RANGE PLAN

24. 1. ABNORMALITIES OF THE POWERS
3. 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

25. 1. ABNORMALITIES OF THE POWERS
4. 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 acidosis
intravenous injection
Physical methods:
massage uterus
emptying the bladder
stimulation nipple
artificial rupture of membranes (AROM)

26. 1. ABNORMALITIES OF THE POWERS
4. MANAGEMENT
THE FIRST STAGE OF LABOR
Drugs:
Oxytocin: 2.5 U + 5% GS 500ml ( 5mU/ml, 8drop/min, at the beginning)
Diazepam: 10 mg iv (softening the cervix)
Cesarean section:
Following the above management still ineffective or fetal distress

27. 1. ABNORMALITIES OF THE POWERS
4. MANAGEMENT
THE SECOND STAGE OF LABOR
Forceps or vacuum extractor:
second stage of labor
cervical fully dilated
membranes ruptured
fetal survival, presenting part below the level of ischial spine
Cesarean section:
presenting part upward the level of ischial spine or fetal distress

28. 1. ABNORMALITIES OF THE POWERS
4. MANAGEMENT
HYPERTONIC - the rule of treatment = Adjusted contractions and resume a normal polarity and rhythm
Sedative: Dolantin or Morphine - adjusted and resume to a normal contractions
Cesarean section: otherwise

29. 1. 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
the intensity strength and frequency enhanced
Contraction with:
long duration
short interval

30. 1. ABNORMALITIES OF THE POWERS: UTERINE HYPERCONTRACTILITY
1. CLINICAL FINDINGS AND DIAGNOSIS
Precipitate delivery (multiparas)
the total stage of labor < 3 hrs
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

31. 1. ABNORMALITIES OF THE POWERS: UTERINE HYPERCONTRACTILITY
2. EFFECT ON MATERNAL AND FETUS
Rupture of uterus
PPH , infection
Soft birth canal trauma
Fetal distress
Fetal death
Stillbirth

32. 1. ABNORMALITIES OF THE POWERS: UTERINE HYPERCONTRACTILITY
3. MANAGEMENT
Prophylaxis - reduced obstetric brutal operation
Must be gentle, slightly and carefully
Tocolytic sedatives inhibited contractions:
Meperidin
Magnesium sulfate
Forceps / Vacuum extractor
Cesarean section

34. CESAREAN SECTION

35. 2. ABNORMALITIES OF PASSAGE
THE BIRTH CANAL
pelvic contraction
soft tissue abnormalities of the birth canal
masses or neoplasia
aberrant placental location

36. 2. ABNORMALITIES OF PASSAGE
PELVIC CONTRACTION
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

38. 2. ABNORMALITIES OF PASSAGE
CONTRACTED PELVIC INLET
1. simple flat pelvis
promontory of sacrum
(dotted line)
forward dislocation
2. rachitic flat pelvis
past history of rickets

39. 2. ABNORMALITIES OF PASSAGE
CONTRACTED PELVIC INLET
1. CLINICAL FINDINGS
Fetopelvic disproportion, malposition or malpresentation (face and shoulder presentations are encountered 3x more frequently)
Uterine inertia and prolonged progress of labor (prolonged latent phase, early active phase and protracted active phase)
Cord prolapse occurs 4-6 x more frequently

40. 2. ABNORMALITIES OF PASSAGE
MIDPELVIC-OUTLET CONTRACTION
Funnel shaped pelvic
The spines are prominent, the pelvic sidewalls converge

41. 2. ABNORMALITIES OF PASSAGE
MIDPELVIC-OUTLET CONTRACTION
CLINICAL FINDINGS
Fetopelvic disproportion persistent occiput posterior position or deep transverse arrest, molding of head and caput succedaneum
Protracted active phase / prolonged second stage (secondary uterine inertia)
Uterine rupture, perineal tears obstructed labor

42. 2. ABNORMALITIES OF PASSAGE
GENERALLY CONTRACTION PELVIC
Each pelvic plane is 2 cm less
than normal value or more
Can be seen in shape more
short and small, well-balanced
women of type of figure

43. 2. ABNORMALITIES OF PASSAGE
GENERALLY CONTRACTION PELVIC
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)

44. 2. ABNORMALITIES OF PASSAGE
GENERALLY CONTRACTION PELVIC
DIAGNOSIS
Pelvic measurement:
external pelvimetry
internal pelvimetry
(sterile vaginal examination)

45. 2. ABNORMALITIES OF PASSAGE
GENERALLY CONTRACTION PELVIC
DIAGNOSIS
Pelvimetry
diagonal conjugate = cm
bi-ischial diameter = 10 cm
incisura ischiadica = 5-6 cm
angle of subpubic arch = 90°

46. 2. ABNORMALITIES OF PASSAGE
GENERALLY CONTRACTION PELVIC
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)

47. 2. ABNORMALITIES OF PASSAGE
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 vaginal examination should be performed early in the course of labor
With continuous fetal monitoring, fetal well-being may be ensured

48. 2. ABNORMALITIES OF PASSAGE
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; otherwise cesarean section
Administration of oxytocin should avoided in true midpelvic-outlet contraction

49. 2. ABNORMALITIES OF PASSAGE
MANAGEMENT
Generally contraction pelvic term fetus (birthweight > 3000 g) needed cesarean section
The fetus is not big, fetopelvic is adaptation and without complication can try to labor
Deformed pelvic: cesarean section

50. SOFT-TISSUE DYSTOCIA Soft tissue canal:
lower part of uterus, cervix, vagina previous scar of the birth canal laceration
cervical conization and cauterization
cesarean section
rape injury in a small child
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

51. 3. ABNORMALITIES OF PASSENGER
FETAL DYSTOCIA
caused by:
malposition and malpresentation
excessive size of the fetus
fetal malformation
If no disproportion exists, the head readily enters the pelvis, and vaginal delivery can be predicted

52. 3. ABNORMALITIES OF PASSENGER
i. MALPOSITION AND MALPRESENTATION
a. vertex malposition
persistent occiput posterior
persistent occiput transverse %
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/oblique lie 0.25%

53. 3. ABNORMALITIES OF PASSENGER
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)

54. 3. ABNORMALITIES OF PASSENGER
ETIOLOGY:
Abnormal pelvic - Anthropoid and android, transverse narrowing of the midpelvis, the fetal head often engages in OP or OT
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

55. 3. ABNORMALITIES OF PASSENGER
CLINICAL FINDING AND SYMPTOMS
Fetal head engages later at the onset of labor
Concordant uterine inertia and slow dilatation of cervix, induces prolonged active phase or 2nd stage
Early use abdominal pressure before the cervix full dilate

56. 3. ABNORMALITIES OF PASSENGER
TREATMENT
The 1st stage:
strengthen contractions, trial labor
Latent phase:
sufficient rest and nourishment (Pethidine or Diazepam)
Active phase:
AROM - cervix 3-4 cm, membranes intact. 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

57. 3. ABNORMALITIES OF PASSENGER
TREATMENT
The 2nd 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

58. 3. ABNORMALITIES OF PASSENGER
TREATMENT
The 3rd stage:
To prevent PPH - prolonged labor readily cause bleeding of uterine inertia
Oxytocin - large dose, intravenous drip infusion (20 u)
Suture lacerations
Antibiotic

59. THANKS !