dr sanam moradan full professor semnan university of

DR SANAM MORADAN

Full PROFESSOR

SEMNAN UNIVERSITY OF MEDICAL SCIENCE

Dystocia

Causes of Dystocia

►Uterine Dysfunction

►Abnormal presentation-

Position & development of fetus

►Pelvic contraction.

►Abnormal birth canal(soft tissue abnormalities)

The most common causes of Dystocia:

* uterine Dys function.

&

* pelvic contraction.

The most common causes of primary cesacrean is Dystocia.

Labor diagnosis Uterine contraction → Dilatation & effacemen

Stages of labor:

First stage of labor:

► From labor pain → full Dilatation

Latent.p.

- Tow Phases of cervical dil.

Active.p.

Second stage of labor

Full Dilation → Delivery

Multipara : 20'

Nullipara : 50'

Third Stage of labor.►Delivery of Fetus → Delivery of Placenta

Abnormal labor Patterns

►Prolonged latent phase > 20hr > 14hr

►Rx → rest. Oxytocin or c/s in urgent

problem

Protracted disorders

►Protracted Active phase Dil → n< 1/2 cm/hr

m< 1/5 cm/hr

►Protracted descend → n<1 cm/hr

m< 2 cm/hr

►Rx → Expectant & support.

►C/S with CPD.

Arrest Disorders

1) prolonged deceleration phase → >3 hr >1 hr

2) secondry arrest of Dilat. → >2hr >2hr

3)Arrest of Deseent → >1hr >1hr

4) failure of Descent → No Descend

►Rx →

1) without CPD → rest & relaxation

2) with CPD → C/s

3) With CPD → C/s

4) C/s

Causes of Dystocia

Uterine Dysfunction

►Hypertonic ut . Dysfunction.

►Hypotonic ut . Dysfunction.

Dystocia because Abnl. presentationPosition & Development of fetus

► Breech presentation

1- In term pregnancy is Rare ,about 3-4%

2- Breech presentation

Frank breech

complete breech

Incomplete breech or footling

► Breech delivery → NVD is Difficult

► Because …

►

1. Head compression → fetal distress ,acidosis

2. Trauma to fetus.

3. No molding.

4. In preterm delivery head escape is with trauma.

5. In hyperextention of head trauma to spinal cord is common.

In breech pres. fetal and maternal Morbidity &

mortality is high Than cephalic prese.

► Face presentation:

1. hyperextention of head of fetus

2. 1/600 Delivery.

3. In vaginal exam face is palpable

Etiology

1) marked enlargement of neck

2) coil of cord about the neck

3) anencephalic fetuses.

4) macrosomia of fetus.

5) pelvic contraction.

6) multiparity.

Rx → No CPD with effective labor

Pain → NVD

Brow presentation

► Rarest presentation

► Unstable pres → face or occiput.

Etiology►The same of face presentation

►Rx → small fetus with No CPD → NVD

Transverse lie:

Shoulder presentation:

Etiology

1. multiparity

2. preterm fetus

3. placenta previa.

4. Abnormal uterus.

5. Polyhydramnious.

6. Contracted pelvic

Route of Delivery → C/S.

Compound presentation

► 1/700 pregnancy.

► Preterm delivery is the common cause.

Route of Delivey → NVD

Persistant occiput posterior Position

► %10 No spontanous rotation

► Mid pelvic narrawing is a factor

►Delivey →

►spontanous delivery.

►Forceps delivery.

►Manual rotation.

►Forceps rotation

►Outcome → Prolongation of labor

↑laceration.

Persistent occiput transverse position

►A transient position → oA.

►With or without rotation NVD is possible

Route of Delivery → NVD

1. spontanous Delivery.

2. Forceps Delivery

3. Manual rotation Delivery.

Shoulder Dystocia

►Maneuvers require for delivey of shoulders

►Maternal consequece

1)P.P.hemorrahage(Atonia)

2)vag & cervical laceration.

3) P.P. infections.

Fetal consequences

1- fetal mortality

2- brachial plexus injury & erbe,s palsy.

C5-C6 → shoulder arm palsy.

C7-t1→ hand palsy.

3- clavicular fracture

prediction & prevention of sh.dys.

Risk factors

1) maternal obesity

2) multiparity.

3) diabetes.

4) postterm pregnancy

Macrosomia of fetus → sh.Dystocia.

%50 shoulder dys. In Non obese fetuses

Rx

1) call for help.

2) Drain of bladder.

3) large mediolateral episiotomy.

4) suprapubic pressure.

5) macRoberts maneuver.

6) wood maneuver.

7) Delivery of post arm.

8) others techniques

Hydrocephalus as a cause of Dystocia

►Accumulation of csf in ventricles

►1/2000 fetuses.

►Head circumfrence≥50cm

Diagnosis → sonography.

Rx → cephalocentesis vaginal or abdominal.

Dystocia Due to pelvic contraction

Classifications :

1. contraction of pelvic inlet

2. contraction of midpelvic

3. contraction of outlet.

4. Generally contracted pelvic.

Contracted pelvic inlet

Shortest Ap Diameter <10cm

Largest transverse diameter <12 cm

Or

Diagonal conjugte<11/5 cm

BPD of fetus → 9/5 -9/80

Complication

↑Abnl presentation: Face presentation

Shoulder pres. →↑threetimes.

Cord prolapse → ↑4-6 times

maternal effects

a) Abnormality of cx. Dilatation

b) uterine rupture.

c) fistula formation.

d) intrapartum. Infection

fetal effects

a) Caput succedaneum.

b) molding.

c) cord prolapse.

Rx→ NVD

If NVD impossible → C/S.

Oxytocin is contraindicated

Contracted midpelvic

nl. Diameter of mid pelvic : interspinous →

10/5 cm

Ap Diameter → 11/5 cm

Post . sagittal → 5 cm

Intespinous + postsagittal < 13/5cm

↓ ↓

(Nl : 15/5 cm) contracted mid pelvic

midpelvic

1. Prominent ischial spine

2. Pelvic side wall converge

3. Narrowing of sacrosiatic noth.

Rx

►spontanous delivery.

►Forceps delivery is contraindicated.

Unless pass of BPD from contracted area.

Oxytocin is contraindicated

Contracted pelvic outlet

►Interischial tuberous diameter < 8 cm

►Without mid pelvic contraction has good prognosis.