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DYSTOCIA
- Difficult labor
- Slow progress of labor

NORMAL LABOR

True labor
- Regular painful uterine contractions that bring about cervical dilation and
effacement

When does labor starts?
- painful contractions become regular; at the time of admission to
labor unit
- duration of labor: admission to delivery

Stages:
a. 1
st
stage: from regular uterine contraction to full cervical dilation
b. 2
nd
stage: from cervical dilation to delivery
Average:
Nullipara 50 mins (2-3 hours)
Multipara 20 mins (1-2 hours)
c. 3
rd
stage: from delivery of fetus to placental expulsion

Functional divisions of labor:
a. Preparatory comprised of latent and acceleration phases; sensitive to
sedation and analgesia; mechanism: change in connective tissue
component of cervix
b. Dilational occur at most rapid rate; corresponds to rapid dilation of cervix
c. Pelvic commences with deceleration phase; cardinal movements of
labor (Edfireere)

2 Phases of cervical dilation:
a. Latent preparatory division; starts from maternal perception of regular
uterine contraction to progressive cervical dilation and ends between 3-4
cm dilation; 10% are false labor
b. Active
1. Acceleration phase determines the ultimate outcome of labor
2. Phase of maximum slope overall efficiency of the machine
[uterus]
3. Deceleration phase reflects feto-pelvic relationship
*dilation of cervix sigmoid curve
*descent of fetus hyperbolic curve

Average rate of descent:
Nullipara: 1cm/hr (7-8cm)
Multipara: 2cm/hr

Modified WHO Partograph (2006)
- Start at 4 cm cervical dilation (active labor)
- 2 observations consist of:
o Cervical dilation and fetal descent
o Fetus (s.a. heart rate, fluids)


Alert line
- Refer to hospital when Cervical dilation moves to the right
- Management: AROM

Action line
- If curve crosses action line (4 hours to the right of action line)
- Mgt: administer oxytocin

Dystocia- difficult labor
-abnormally slow progress of labor
-most common indication for primary CS
-secondary to:
-abnormalities of power
-abnormalities of passenger
-abnormalities of passages
-abnormalities of birth canal other than bony pelvis

Maternal-Fetal Effects:
1. Intrapartum hemorrhage
2. Pathological ring of Bandl
3. Uterine rupture
4. Fistula formation
5. Pelvic floor injury
Dystocia
Dr. Bautista
June 6, 2011
I-1A
I-1
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6. Fetal effects (caput, molding, cephalohematoma signifies
bleeding injury to the periosteum)

Abnormal Labor
I. Protraction slow rate of dilation/descent; 30% have cephalo-
pelvic disproportion (CPD)
II. Arrest disorder either of dilation/descen; 45% CPD
III. Failure of descent
IV. Precipitate labor delivery < 3 hours; either dilation/descent,
may result in hemorrhage and intracranial hemorrhage

Nullipara Multipara
Prolonged latent > 20 hrs > 14 hrs
Protracted active < 1.2 cm/hr < 1.5 cm/hr
Prolonged deceleration > 3 hrs > 1 hr
Secondary arrest of dilation > 2 hrs > 2 hrs
Arrest of descent > 1 hr > 1 hr
Failure of descent
Precipitate active > 5 cm/hr > 10 cm/hr
Precipitate descent > 5 cm/hr > 10 cm/hr

Abnormalities:
I. Passenger
II. Passage
III. Power

A. Abnormalities in Power: (uterine dysfunction)
Normal contraction greatest and longest myometrial activity at fundus
-15 mm Hg - lower limit of contraction pressure required to dilate
-Normal spontaneous contraction = 60 mmHg
-Clinical labor starts when uterine activity: ~ 80-120 Montevideo units (cutoff:
180 MVU)
Types of uterine dysfunction:
1. Hypotonic
a. No basal hypertonus
b. Uterine contraction are synchronous
c. Slight increase in pressure insufficient to dilate cervix
Mgt: Augment with oxytocin

*oxytocin not effective by mouth
Each mL 10 IU
Half-life: 3mins

preparation: 10 U oxytocin in 1 L D5W; total dose <10 u; infusion rate not > 30-
40 mL/min

side effects:
a. Cardiovascular
Transient fall in BP; must be administered not as IV
bolus
ECG changes of MI: increase in CO
Increase in mean pulse rate
b. Water intoxication
Due to anti-diuretic action
2. Hypertonic
a. Increased basal tone
b. Pressure gradient distorted
c. Uterine contraction @ midsegment > fundus
Mgt: Sedate the patient
Hyperstimulation
1. Persistent tachysystole w/ fetal distress
2. Single uterine contraction > 2 min
3. UC w/in 1 min of each other

Uterine tachysystole: > 6 UC in 10 mins

Uterine hyperstimulation: lasting > 2mins; fetal heart rate changes

B. Abnormalities in Passenger:
1. Abnormal presentation/position
a. Face presentation
head is hyperextended
occiput in contact with fetal back
mentum/chin is the presenting part
submento-bregmatic diameter = 9.5 cm (presenting
diameter)
Problem: If mentum posterior, the brow is compressed
against the symphysis pubis preventing the flexion of the
head

Diagnosis:
1. Vaginal exam-fetal mouth, malar bones, orbital ridges
2. X-ray- hyperextended head

Etiology of face presentation:
I. Marked enlargement of the neck
II. Anencephalic fetuses
III. Contracted pelvis
IV. Very large fetus
V. Pendulous abdomen
VI. High parity

Mgt: CS is indicated
No contracted pelvis + effective labor = vaginal bleeding

b. Brow presentation
- rarest;unstable presentation (military position)
- fetal head occupies a position midway between full flexion and
extension
- vertico-mental diameter = 13.5 cm therefore delivery cant take
place (fetal head between orbital ridge and fontanel)

Diagnosis:
1. Abdominal exam- chin and occiput can be palpated
2. vaginal- frontal sutures; eyes

Etiology: same as face
Mechanism: engagement

c. Transverse lie
long axis of fetus perpendicular to the mother; shoulder is the
presenting part; either dorso-anterior or dorso-posterior

Etiology:
1. Preterm
2. Placenta previa
3. Abnormal uterus
4. Polyhydramnos
5. Contracted pelvis

Diagnosis:
- Abdomen is unusually wide, no fetal pole detected,
ballotable head in iliac fossa

Course:
- Spontaneous delivery is impossible; CS is indicated
Conduplicato corpore: fetus doubled upon itself

Mgt: CS

d. Compound presentation
extremity prolapses alongside the presenting part
Etiology: preterm


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e. Persistent Occiput Posterior (POP)
precise reasons for failure of spontaneous rotation is unknown;
painful labor; generous episiotomy is indicated; occiput has to rotate
135
o
instead of 45
o
thru symphysis

f. Shoulder dystocia
anterior shoulder against symphysis pubis; incidenc due to bigger
babies

Maternal-fetal Consequences:
I. Post partum hemorrhage
II. Transient brachial plexus palsies
III. Clavicular and humeral fractures

Risk factors:
I. Obesity
II. Diabetes
III. Multiparity

ACOG
1. most cases cant be predicted
2. planned CS delivery reasonable for nondiabetic with EFW> 5
kg or diabetic with fetus EFW> 4.5 kg
3. UTZ limited accuracy
4. Planned CS based on ___ (di ko mabasa notes ko!!!) is not
reasonable

Mgt:
- Initial gentle attempt at traction assisted by maternal expulsive effort
+ large episiotomy and adequate analgesia

Maneuvers:
1. Moderate suprapubic pressure
2. McRoberts maneuver pelvic outlet 1.5-2cm
3. Wood corkscrew maneuver
4. Delivery of posterior shoulder
5. Rubin maneuver
6. Zavanelli maneuver fetus head is pushed back then CS
7. Cleidotomy
8. Symphysiotomy

Drills (for shoulder dystocia):
1. Call for help
2. Generous episiotomy
3. Moderate suprapubic pressure
4. McRoberts maneuver
5. Wood corkscrew maneuver
6. Delivery of posterior shoulder

2. Fetal malformation:
- Hydrocephalus
- Abdominal tumors
- Cystic hygroma
- Conjoined Twins

C. Abnormalities in Passages:
1. Pelvic inlet diameters
2. Pelvic midplane
3. Pelvic outler










A. Antero posterioir diameter

a. Obstetric conjugate- shortest distance between sacral
promontory and symphysis pubis; > 10 cm;
OC= DC- 1.5 to 2 cm

b. Diagonal conjugate - can be measured clinically
from lower margin of pubis to sacral promontory; >11.5 cm

c. True/ Anatomic conjugate- upper margin of pubic to sacral
promontory > 11 cm
TC= DC-1.2cm

Contracted pelvic inlet OC < 10cm or DC < 11.5cm

B. Pelvic Midplane Diameter- at the level of ischial spine

a. Interspinous diameter- 10.5 cm; shortest of the whole pelvic
cavity
b. AP diameter- 11.5 cm
c. Post-sagittal- 4.5 cm; between sacrum and line created by IS
diameter
d. IS + PS= 15 cm

Contracted mid-pelvis IS < 8cm or IS + PS < 13.5cm

Suggests contraction:
-spines are prominent
-pelvic sidewalls converge

C. Pelvic outlet
-2 triangular areas having common base

a. AP diameter: lower margin of pelvis to tip of sacrum; 9.5-11.5
cm
b. Transverse: between inner ridges of ischial tuberosities; 11
cm
c. PS: >7.5 cm

Contracted pelvic outlet IS < 8cm

Mgt: do episiotomy