Transcript Dystocia
DYSTOCIA
=
DIFFICULT / ABNORMAL LABOR
Greek
'dys' = 'difficult, painful, disordered, abnormal'
'tokos' meaning 'birth'.
Dr. E Gdansky
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
First Stage of Labor
Duration
Primip. 6-18
Multip. 2-10
Dystocia
Abnormal patterns of labor
Prolonged latent phase
Protracted dilatation
Protracted descent
Protracted 2nd stage
Arrest of dilatation
Arrest of descent
Precipitate labor
Primipara
Multipara
(Normal mean = 6.4 h)
(Normal mean = 4.8 h)
>20 h
>14 h
<1.2 cm/h
<1 cm/h
<1.5 cm/h
<2 cm/h
(Normal mean = 50 min)
(Normal mean = 20 min)
>2 h (+1 h)
>1 h (+1 h)
>2 h
>1 h
>2 h
>1 h
<3 h from onset of
contractions
Powers
Contractions
Expulsive forces
Passage
Maternal pelvis
Passenger
The fetus (Malposition/
Malpresentation)
A combination of these factors
Dystocia
Classification
Dystocia
Causes
Dysfunctional uterine contractions
Hypotonic uterine contracions
Malpresentation (Asynclitism, OP, DTA,
face, braw)
Treatment
Sedation
Hydration
Augmentation of labor
(amniotomy, oxytocin)
Cephalo-pelvic disproportion = CPD
Epidural
Pelvic tumor
Instrumental delivery
Cesarean section
Dystocia
Abnormalities of the passage
Inlet
Mid-pelvis
Outlet
Current Diagnosis & Treatment Obstetrics & Gynecology - 10th Ed. (2007)
Dystocia
Abnormalities of the passage
Bony pelvis
- Gynecoid (50%)
- Android (33% white, 15% black)
- Anthropoid (50% black, 20% white)
-Platypelloid (<3%)
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
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
X-ray
US
MRI
Clinical pelvimetry
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)
Dystocia
Obstructed labor
Bandl’s retraction ring & Uterine rupture
Vescicovaginal & rectovaginal fistula
Pelvic floor injury
Increased neonatal morbidity & mortality
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)
Dystocia
Abnormalities of the powers
External/ internal Tocodynamometer
Montevideo unit
>200 mmHg is sufficient for normal progress
Dystocia
Abnormalities of the powers
Hypotonic Amniotomy
Oxytocin augmentation
Hypertonic Decrease/stop oxytocin
Tocolysis
Sedation in latent phase
Oxytocin (?)
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
Dystocia
Precipitate labor
<3 h from onset of contraction
Precipitate dilatation
Primipara
>5 cm/h
Multipara
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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