DYSTOCIA

Lecturer: Dr. Sylvia A. Cornero | August 5, 2019

Transcriber: Marinela Malo, hindi nagboard exam ;)

OUTLINE MECHANISMS OF DYSTOCIA

PART 1 PART 2 At the end of pregnancy: PATHOLOGIC-OBSTETRICS
I. Dystocia Abnormalities
Dr. Sylvia of Presentation
A. Cornero | August 5, 2019  Obstacles for the fetal head as it traverse the birth canal:
II. Abnormalities of Expulsive and Position → Thicker lower uterine segment
Forces I. Face Presentation → Undilated cervix
A. Types of Uterine II. Brow Presentation → Less developed and less powerful fundal muscles
Dysfunction III. Transverse Lie
B. Labor Disorders IV. Oblique Lie
 Factors influencing the progress of the 1st stage of labor:
III. Ruptured Mebranes V. Compound Presentation → Uterine contractions
Without Labor At Term VI. Persistent Occiput → Cervical resistance
IV. Precipituous Labor and Posterior Presentation → Forward pressure of the presenting part
Delivery VII. Shoulder Dystocia  SECOND STAGE OF LABOR (FULLY DILATED CERVIX):
V. Fetopelvic Disproportion [Link] → Fetopelvic proportion is observed – relationship of the
A. Pelvic Capacity fetal head size, position with pelvic capacity
B. Pelvic Fractures → Uterine muscle malfunction results in uterine
C. Pelvic Capacity overdistension or obstructed labor or both
Estimation
D. Fetal Dimensions *THUS, INEFFECTIVE LABOR IS A POSSIBLE WARNING SIGN OF
VI. Effects of Dystocia FETOPELVIC DISPROPORTION.

REVISED DYSTOCIA DIAGNOSIS

American College of Obstetrician and Gynecologist (Spong.2012)
 New Definitions for arrest in labor progress to prevent unnecessary
PART 1 first cesarean deliveries
 Adequate time for normal latent and active phases of labor
I. DYSTOCIA  Second stage should be allowed as long as the maternal and fetal
Difficult labor characterized by abnormally slow progress of labor conditions permit
 Time allowed for each of the stages are longer than the traditional
FOUR DISTINCT ABNORMALITIES
1. Abnormalities of the expulsive forces
EVIDENCE FOR ADEQUATE AND ARRESTED LABOR
- uterine contractions and expulsive efforts made by
 ARREST OF LABOR – should not be made until adequate time has
the mother during the second stage of labor
elapsed
2. Abnormalities of presentation, position, or development of
the fetus (such as fetal size)  ADEQUATE LABOR – greater than 6 cm dilatation with membrane
3. Abnormalities of the maternal bony pelvis rupture and 4 or more hours of adequate contractions(greater than
- measurements of the diameters of the pelvis that 200 Montevideo) or 6 hours or more if contractions are inadequate
are disproportionate to the size of the fetus with no cervical change
4. Abnormalities of soft tissues of the reproductive tract  SECOND STAGE OF LABOR – no progress for more than 4 hours in
- anything in the reproductive tract which can nulliparous in women with epidural, more than 3 hours without
obstruct the passage of the baby aside from the epidural
bony pelvis, like myomas in the lower uterine  No cesarean section before this limits in the presence of reassuring
segment, or an ovarian tumor in the lower portion of maternal and fetal status
the abdomen
-
CATEGORIES ACCORDING TO ACOG II. ABNORMALITIES OF EXPULSIVE FORCES
1. Abnormalities of the powers—uterine contractility and  1ST STAGE OF LABOR: Contractions of the uterus -> cervical
maternal expulsive effort dilatation, propulsion and expulsion of the fetus
2. Abnormalities involving the passenger—the fetus.  2ND STAGE OF LABOR: Voluntary or involuntary muscular action
3. Abnormalities of the passage—the pelvis. of abdominal wall—“PUSHING”

COMMON CLINICAL FINDINGS IN WOMEN WITH A. TYPES OF UTERINE DYSFUNCTION

INEFFECTIVE LABOR
 DILATATION OR FETAL DESCENT Hypotonic Uterine Dysfunction Hypertonic/Incoordinate Uterine
→ Protracted labor – slow progress Dysfunction
→ Arrested labor – no progress  More common  Basal tone is elevated
→ Inadequate expulsive effort – ineffective pushing  No basal hypertonus  Pressure gradient is distorted
 Uterine contractions have a (asynchronism)
 FETOPELVIC DISPROPORTION
normal gradient pattern  Treatment: Sedation
→ Excessive fetal size (synchronous)  Occurs during latent phase
→ Inadequate fetal capacity  Slight rise in pressure during a  If fetal distress will occur, it will
→ Malpresentation or position of the fetus contraction is insufficient to occur earlier with hypertonic
 RUPTURED MEMBRANES WITHOUT LABOR dilate the cervix than hypotonic
 Treatment: Oxytocin
 Occurs during active phase

Dystocia Marinela Malo 1 of 14

CAUSES OF UTERINE DYSFUNCTION II. ACTIVE PHASE DISORDERS
I. EPIDURAL ANALGESIA CLASSIFICATION
→ Lengthening of both first- and second-stage labor and  Protraction Disorder (slower than normal)
slowing of the rate of fetal descent  Arrest Disorder (complete cessation of progress)
II. CHORIOAMNIONITIS
III. MATERNAL POSITION DURING LABOR CRITERIA FOR THE DIAGNOSIS OF ARREST DURING FIRST-STAGE
→ Conflicting reports on which position is better LABOR (ACOG 1989)
(Recumbent or ambulating)  The latent phase has been completed, with the cervix dilated 4 cm or
IV. BIRTHING POSITION IN SECOND STAGE LABOR more.
→ Upright: shorter delivery interval to delivery (4mins); less  A uterine contraction pattern of 200 Montevideo units or more in a
pain, lower non reassuring fetal status, operative 10-minute period has been present for 2 hours without cervical
deliveries change.
→ Disadvantages of upright position:
a. Increased blood loss, CRITERIA FOR THE DIAGNOSIS OF ABNORMAL LABOR DUE TO
b. Fibular nerve nephropathy (SQUATTING) ARREST OR PROTRACTION DISORDERS
V. WATER IMMERSION Labor Pattern Nullipara Multipara
→ Excessive fetal size Protraction Disorder
→ Less epidural anesthesia Dilatation < 1.2cm/hr < 1.5cm/hr
→ Decreased BP Descent < 1.0cm/hr < 2.0cm/hr
→ Not associated with uterine infection Arrest Disorder
→ Neonatal complications: drowning, hyponatremia, No Dilatation > 2hrs > 2hrs
waterborne infection, cord rupture, polycythemia
No Descent > 1hr > 1hr
THREE SIGNIFICANT ADVANCES IN THE TREATMENT OF UTERINE
DYSFUNCTION NICE TO KNOW:
At least 4 hours is necessary before concluding that the active phase of
 Realization that prolongation of labor leads to perinatal morbidity
labor has failed.
and mortality
 Dilute intravenous infusion of oxytocin in the treatment of There are four recommendations by the Consensus Committee (2016)
hypotonic uterine dysfunction applicable to management of the first-stage labor.
 Use of cesarean delivery rather than difficult midforceps delivery
(when oxytocin fails or its use is inappropriate 1. During the first-stage of labor, a prolonged latent phase is not an
indication for cesarean delivery.
B. LABOR DISORDERS 2. Slow but progressive labor in the first stage should not be an indication
The described types of uterine dysfunction can in turn lead to labor for cesarean delivery.
abnormalities: 3. Cervical dilatation of 6 cm—not 4 cm—should be considered the
I. LATENT PHASE PROLONGATION threshold for active-phase of most women in labor, and therefore before 6
II. ACTIVE PHASE DISORDERS cm dilatation is achieved, standards for active-phase progress should not be
III. SECOND STAGE DESCENT DISORDERS applied.
4. Cesarean delivery for active phase arrest in the first stage of labor should
*Naglagay po ako ng review ng Conduct of Normal Labor sa Appendix, if ever na gusto be reserved for women at or beyond 6 cm of dilation with ruptured
nyo aralin uli.  If di nyo need ng refresher, no need to print the appendix part. Thank membranes (who fail to progress despite 4 hours of adequate uterine
you ate Lea Pacis! If gusto nyo mas detailed basahin nyo nalang uli yung trans nya nung
activity), or at least 6 hours of oxytocin administration with inadequate
2nd year tayo  contractions and no cervical change.

I. LATENT PHASE PROLONGATION Background for the 6-cm rule:

 Defined as exceeding 20 hours in the nullipara and 14 hours in the Progress is slow between 4 and 6 cm but accelerates thereafter. This could
multipara. reasonably be interpreted as the active phase beginning at 6 cm.
 In some, uterine contractions cease, suggesting false labor.
 In the remainder, an abnormally long latent phase persists and is III. SECOND-STAGE DISORDERS
often treated with oxytocin stimulation.  Incorporates many of the cardinal movements necessary for the fetus
to negotiate the birth canal
 Disproportion of the fetus and pelvis frequently becomes apparent

DURATION OF 2ND STAGE

 Nulliparas – 2 hours
▪ 3 hours if with regional analgesia
 Multiparas – 1 hour
▪ 2 hours if with regional analgesia
“Bearing down” or “pushing” – contraction of the abdominal
musculature to generate increased intra-abdominal pressure
together with uterine contractions → propulsion of the fetus
downward.

NICE TO KNOW:
Active Pushing
 Notice the red dots, hindi na umakyat (because hindi na nagdilate, - Fetal head is low; no need to ask the patient to bear down
hindi na nagexceed sa 3cm, hindi na napunta ng active phase)
Passive Pushing
- Cervix is fully dilated but fetal head is still high; ask the patient to

Pathologic Obstetrics Dystocia 2 of 14

 bear down. APPLICATION
(from Clangaroo)
Newer guidelines recommend allowing a nullipara to push for at least
3 hours and a multipara to push for at least 2 hours before second-
stage labor arrest is diagnosed. Maternal and fetal status should be
reassuring.

Relationship between First- and Second-Stage Labor Duration

 The length of the second stage significantly increased
concomitantly with increasing length of the first stage.

FETAL STATION AT ONSET OF LABOR

 Significant association between higher station at the onset of
labor and subsequent dystocia  The dashed, ascending line represents the dilatation curve and the
 Fetal station at the time of arrested labor was also a risk solid, descending line represents the descent curve
factor for dystocia →Y axis on the left – Cervical dilatation (cm)
 The prognosis for dystocia, however, was not related to →Y axis on the right – Station
incrementally higher fetal head stations above the pelvic →X axis – Elapsed time in labor (hours)
midplane (0 station) →Preparatory division = Latent phase + Dilatational phase
 86 % of nulliparous women without fetal head engagement at → Pelvic division = Deceleration phase + Second Stage of Labor
diagnosis of active labor delivered vaginally  As the cervix dilates up to the 10 cm, this is when we expect the
head to go down
FACTORS THAT PREVENT SPONTANEOUS VAGINAL DELIVERY  Head will only descend if it is already engaged, which happens
 Compromised force created by contractions of abdominal during the deceleration phase
musculature
 Heavy sedation or regional analgesia (lumbar epidural or DESCENT CURVE
spinal) that reduces the reflex urge to push  Normally (refer to the image above), during the pelvic division,
 Urge to push is overridden by the intense pain created by what is happening is more of the descent (notice the change from
bearing down. a more horizontal to a more vertical graph where the descent
becomes more rapid during the pelvic division, reaching station
ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA, AND METHODS +5 in 16 hours).
OF TREATMENT (I think it’s important to memorize this bc most of the cases
are based from this table!) FAILURE OF DESCENT
Diagnostic Criteria
Labor Pattern Nulliparas Multiparas Preferred Exceptional
Treatment Treatment
Prolongation Disorder
Prolonged > 20 hrs > 14 hrs Bed rest Oxytocin or
latent phase cesarean delivery
for urgent
problems
Protraction Disorders
Protracted < 1.2 cm/hr < 1.5 Expectant Cesarean delivery
active-phase cm/hr and for CPD
dilatation support (cephalopelvic
 In this image, the station doesn’t go beyond zero; this is Failure of
Protracted < 1.0 cm/hr < 2 cm/hr disproportion)
Descent. Take note of how the line becomes relatively more
descent
horizontal when it entered the pelvic division.
Arrest Disorders
ARREST OF DESCENT
Prolonged > 3 hrs > 1 hrs Oxytocin Rest if exhausted
deceleration without
phase CPD
Secondary > 2 hrs > 2 hrs
arrest of
dilatation
Arrest of >1 hr > 1 hr Cesarean Cesarean
descent delivery delivery
Failure of >1 hr, > 1 hr with CPD
descent with no
descent in
deceleration
phase or  If it went beyond zero, just like in the image above, it is Arrest of
second stage Descent. Like failure of descent, progress stopped when the
descent entered the pelvic division, but the main difference is the
station

Pathologic Obstetrics Dystocia 3 of 14

PROTRACTED DESCENT PROLONGED DECELERATION PHASE
FAILURE OF DESCENT

 In Protracted Descent, there is progress but it takes a long time

during the pelvic division. What differentiates this from the two is  In this case, cervical dilatation progressed until 9 cm but stayed like
that the expected downward slope of the graph is still present here, that for 4 hours. Also, take note that descent is only in station 0
but the progress is too slow compared to normal. even though the cervix is already 9 cm dilated.
Diagnosis: Prolonged Deceleration Phase, Failure of Descent
 Take note that cervical dilatation is in the deceleration phase (hindi
NOTE: DO NOT diagnose any abnormality in descent before the ko sure kung ang tinitingnan dito ay yung gitna ng horizontal part
pelvic division or when the cervix has not yet reached nung graph or yung kung saan siya nag-end).
complete/full dilatation (or 8 to 10 cm according to doc).
NOTE: Diagnose arrest in cervical dilatation if it has not reached
DILATATION CURVE
8 cm. Prolonged cervical dilatation if it has exceeded 8 cm.
PROTRACTED CERVICAL DILATATION
PROLONGED SECOND STAGE
ARREST OF DESCENT

 In Protracted Cervical Dilatation (red curve), progress is relatively

slower compared to normal (dotted lines).
 In the green arrow pointed, because there has been spontaneous  In this case, cervix is fully dilated, descent is +1. This went on for
rupture of membranes and administration of oxytocin, the labor about 3 hours during the second stage. Diagnosis: Prolonged
progressed until it reached full dilatation (the descent also fully Second Stage, Arrest of Descent
progressed) and this resulted in a vaginal delivery.

ARREST OF CERVICAL DILATATION III. RUPTURED MEMBRANES W/O LABOR AT TERM

 (Calkins, 1952) – Management: stimulation of contractions when
labor did not begin after 6 to 12 hours
 (Hanna and Associates, 2000) – Concluded that induction with
oxytocin immediately is better than expectant due to lower
incidence of intrapartum and postpartum infections
 Parkland Hosp – Induction is done after admission

IV. PRECIPITUOUS LABOR AND DELIVERY

DEFINITION: Extreme rapid labor and delivery (less than 3 hours)
CAUSES:
 Abnormally low resistance of the soft parts of the birth canal
 In the image above, cervical dilatation progressed but upon reaching
6 cm, it stopped for 4 hours. Diagnosis is Arrest of Cervical  Abnormally strong uterine and abdominal contractions,
Dilatation.  Rarely, absence of painful sensations and thus a lack of awareness of
 Descent (blue curve) has no problem (even though it is still in station vigorous labor
0) because it has not yet entered the pelvic division and cervical
dilatation is only 6 cm. SHORT LABORS
 Rate of cervical dilatation
→ Uterine contractions
- 5 cm/hr for nulliparas
- 10 cm/hr for multiparas
Pathologic Obstetrics Dystocia 4 of 14
 Associated with:  Related to abnormal presentations/asynclitism
→ Uterine contractions  Descent does not take place until after labor onset
→ Abruption (20 percent)  A contracted inlet plays an important part in the production of
→ Meconium abnormal presentations
→ Postpartum hemorrhage  In normal nulliparas, the presenting part at term commonly
→ Cocaine abuse descends into the pelvic cavity before the onset of labor. In
→ Low Apgar scores contracted inlet, descent usually does not take place until after the
→ Multiparity onset of labor, if at all.

MATERNAL EFFECTS CLINICAL FINDINGS

 Uterine rupture  Fetal head floats over pelvic inlet or in one iliac fossa (floating head
 Extensive lacerations of the cervix, vagina, vulva, or perineum means head is above the pelvic brim/inlet)
 Amnionic fluid embolism  Face and shoulder presentations are three times more frequent
 Postpartum hemorrhage from uterine atony (hemorrhage from the  Cord prolapse – four to six times more frequent
placental implantation site)
INCIDENTS THAT WOULD RAISE SUSPICION OF A
Serious maternal complications are RARE if: CONTRACTED PELVIC INLET:
 The cervix is effaced and compliant  Malpresentation
 The vagina has been stretched previously  Ruptured bag of waters
 The perineum is relaxed  On IE, diagonal conjugate < 11.5 cm

FETAL/NEONATAL EFFECTS MIDPELVIS

OBSTETRICAL PLANE OF THE MIDPELVIS
 Perinatal mortality and morbidity due to decreased uterine blood
flow and fetal oxygenation.  Inferior margin of the symphysis pubis through the ischial spines
(Station 0=Most dependent portion of the head/Engaged head)
 Intracranial trauma(rare)
and touches the sacrum near the junction of the fourth and fifth
 Erb or Duchenne brachial palsy vertebrae
 Injury from fall  A transverse line connecting the ischial spines divides the midpelvis
into anterior and posterior portions:
Treatment: any oxytocin agents being administered should be → ANTERIOR MIDPELVIS – bounded anteriorly by the
stopped lower border of the symphysis pubis and laterally by the
ischiopubic rami
→ POSTERIOR MIDPELVIS – bounded dorsally by the
V. FETOPELVIC DISPROPORTION sacrum and laterally by the sacrospinous ligaments
 Diminished pelvic capacity
 Excessive fetal size AVERAGE MIDPELVIS MEASUREMENTS:
 More commonly - combination of both.

A. PELVIC CAPACITY
1. CONTRACTED PELVIC INLET
2. CONTRACTED MIDPELVIS
3. CONTRACTED PELVIC OUTLET

* I suggest na ireview ung Bony Pelvis sa Physio OB 

 Transverse (interspinous) = 10.5 cm (IS)
CONTRACTED PELVIC INLET  Anteroposterior = 11.5 cm Lower border of the symphysis pubis to
the junction of S4– S5)
 Posterior sagittal = 5 cm (PSM) From the midpoint of the
interspinous line to the same point on the sacrum

CONTRACTED MIDPELVIS

 Shortest anteroposterior diameter – less than 10 cm

- The shortest AP diameter of the pelvic inlet is the

 more common than inlet contraction
obstetric conjugate
 causes transverse arrest of the fetal head
 Greatest transverse diameter – less than 12 cm
 interischial spinous diameter is < 8cm (N: 10.5 cm)
 Diagonal conjugate – less than 11.5 cm
 IS + PSM is less than 13.5 cm
 Fetal biparietal diameter – average of 9.5 - 9.8 cm
 Cervical dilatation is facilitated by:
 CLINICAL PELVIMETRY in Contracted Midpelvis:
- Hydrostatic action of the unruptured membranes → Spines are prominent
- Direct application of the presenting part against the → Pelvic sidewalls converge
cervix (after rupture) → Narrow sacrosciatic notch
 CPD INLET – if no direct pressure on the cervix and lower uterine → If sacrum is flat, AP diameter is also shortened. A well-curved
segment  membrane rupture and less effective uterine contractions sacrum is ideal/adequate.
Pathologic Obstetrics Dystocia 5 of 14
 PELVIC OUTLET VI. EFFECTS OF DYSTOCIA
PELVIC OUTLET LIKENED TO 2 TRIANGLES: MATERNAL EFFECTS
→ Anterior triangle  Intrapartum Infection
 Base – interischial tuberous diameter
 Uterine Rupture
 Sides – pubic rami
 Pathological Retraction Ring of Bandl
 Apex – inferior posterior surface of the symphysis pubis
 An exaggeration of the normal retraction ring
→ Posterior triangle
 Result of obstructed labor
 Base – interischial tuberous diameter
 Marked stretching and thinning of the lower uterine segment
 No bony sides
signifies impending rupture of the lower uterine segment
 Apex – tip of the last sacral vertebra (not the tip of
 Fistula Formation
the coccyx
 Vesicovaginal, vesicocervical, or rectovaginal fistulas
 Pelvic Floor Injury
CONTRACTED PELVIC OUTLET
 Postpartum Lower Extremity Nerve Injury
 Footdrop – secondary to injury at the level of the lumbosacral root,
lumbosacral plexus, sciatic nerve, or common peroneal nerve-
usually caused by inappropriate leg positioning in stirrups during a
prolonged second stage of labor
 Symptoms resolve within 6 months of delivery in most women.

FETAL EFFECTS
  Caput Succedaneum
 Interischial tuberous diameter of 8 cm or less  Fetal Head Molding
 Often associated with midplane contraction  Associated with:
 PURE outlet contraction is RARE  Nulliparity
 Related to perineal tears  Oxytocin
 Vacuum extraction
 Skull fractures
B. PELVIC FRACTURES
 Trauma from automobile collisions – most common cause
 Fracture pattern, minor malalignment, retained hardware are NOT
absolute indication for Cesarean section
 Review of previous radiograph and x-ray pelvimetry later in
pregnancy

C. PELVIC CAPACITY ESTIMATION

 Clinical estimation
 X-Ray Pelvimetry
 Computed Tomographic scanning (250-1500 mrad)
→ Offers reduced radiation exposure, greater accuracy and
easier performance as compared to conventional X ray
 Magnetic Resonance
→ Advantages: lack of radiation, accurate measurements,
complete fetal imaging ,evaluate soft tissue dystocia

D. FETAL DIMENSIONS
Estimation of Fetal Head Size:
1. Clinical (Mueller Hillis Maneuver)

● Fetal brow and suboccipital

region are grasped through the
abdominal wall with the fingers
and firm pressure is directed
downward in the axis of the
inlet

2. Sonogram – Fetopelvic index

NO SATISFACTORY METHOD FOR PREDICTION OF DISPROPORTION!

Pathologic Obstetrics Dystocia 6 of 14

 PART 2
Abnormalities of Presentation and Position
Mechanism of labor for
I. FACE PRESENTATION right mentoposterior
position with subsequent
 Head is hyperextended, occiput rotation of the mentum
is in contact with the fetal back anteriorly and delivery.
and the chin (mentum) is
presenting
 Fetal face may present with the
chin (mentum) anteriorly or
posteriorly, relative to the
maternal symphysis pubis
 The occiput is the longer end of
the head lever. The chin is directly MANAGEMENT
posterior.
 In the absence of a contracted pelvis, and with effective labor,
 Vaginal delivery is impossible unless the chin rotates
successful vaginal delivery usually will follow (Mentum
anteriorly
 Indication for CS if it is mentum posterior. Anterior)
 Cesarean delivery (Mentum Posterior)
ETIOLOGY  Pelvic inlet contraction
• Prematurity NOTE: Do not attempt to manually rotate to vertex, or rotate
• Marked enlargement of the neck or coils of cord about the neck mentum posterior to anterior or do internal podalic version.
may cause extension
• Anencephalic fetuses
• Contracted pelvis II. BROW PRESENTATION
• Very large fetus  Aka MILITARY POSITION
• Multiparous women  Rarest presentation because it often converts to face or occiput
• Hydramnios presentation
 Fetal head between the orbital ridge and anterior fontanel presents
DIAGNOSIS at the pelvic inlet
• Vaginal Examination - palpation of the distinctive facial features of  Fetal head occupies a position midway between full flexion (occiput)
the mouth and nose, the malar bones, and particularly the orbital ridges and extension (mentum or face)
(differentiate it from breech)  Engagement of fetal head and delivery will not occur unless the head
- How to differentiate? Malar bones and mouth will form a is small or pelvis is unusually large.
triangle, while the ischial tuberosities and the anus will form a  Causes and etiology are the same as of the face presentation
straight line.  Unstable – may convert to occiput or face
- If face presentation, bony prominence felt is triangular in relation  Management is the same as those for a face presentation
with the opening. In breech presentation, the prominence is felt
in line with the opening DIAGNOSIS
- If you insert your finger and felt the baby sucking, it is face  Abdominal palpation - when
presentation… but if you get meconium, it is most likely breech both the occiput and chin can be
• Radiographic Examination - demonstration of the hyperextended palpated easily
head with the facial bones at or below the pelvic inlet  Vaginal examination - palpation
of the frontal sutures, large
MECHANISM OF LABOR anterior fontanel, orbital ridges,
• Face presentations rarely are observed above the pelvic inlet eyes, and root of the nose
• The brow generally presents, converted into a face
presentation after further extension of the head during
descent

• Mechanism of labor consists of the following cardinal movements:

→ Descent - brought about by the same factors as in cephalic
presentations.
→ Internal rotation
- the objective is to bring the chin under the symphysis pubis
- results from the same factors as in vertex presentations. MECHANISM OF LABOR
→ Flexion  very small fetus and a large pelvis - labor is generally easy
→ Accessory movements of extension and external rotation  larger fetus - usually difficult, because engagement is impossible until
- results from the relation of the fetal body to the deflected there is marked molding that shortens the occipitomental diameter
head. or, more commonly, until there is either flexion to an occiput
presentation or extension to a face presentation
 Persistent Brow – vaginal delivery is difficult and management is
same as face

Pathologic Obstetrics Dystocia 7 of 14

 III. TRANSVERSE LIE MECHANISM OF LABOR
 the long axis of the fetus is approximately perpendicular to that of Spontaneous delivery of a fully developed newborn is impossible with a
the mother persistent transverse lie:
 Long axis forms an acute angle – Oblique Lie (unstable)
 referred to as shoulder or acromnion presentation
 the shoulder is usually on the pelvic inlet, with the head lying on one
iliac fossa and the breech in another
 Indication for CS delivery

ETIOLOGY
 Abdominal wall relaxation from high parity
 Preterm fetus
 Placenta previa
 Abnormal uterine anatomy
 Excessive amnionic fluid
 Contracted pelvis

DIAGNOSIS

ABDOMINAL EXAMINATION
 abdomen is unusually wide, whereas the uterine fundus extends to
only slightly above the umbilicus.
 no fetal pole is detected in the fundus, ballottable head is found in
one iliac fossa and the breech in the other
 back up (anterior) - a hard resistance plane extends across the front
of the abdomen CONDUPLICATO CORPORE
- do low segment CS
 back down (posterior)- irregular nodulations representing the small
parts are felt through the abdominal wall.
- do classical CS (vertical incision)

 Neglected shoulder presentation. A thick muscular band forming a

pathological retraction ring has developed just above the thin lower
uterine segment.
 The force generated during a uterine contraction is directed
centripetally at and above the level of the pathological retraction
ring. This serves to stretch further and possibly to rupture the thin
lower segment below the retraction ring. (P.R.R. = pathological
retraction ring)
 If the fetus is small—usually less than 800 g—and the pelvis is large,
Palpation in transverse lie, right acromidorsoanterior position. spontaneous delivery is possible despite persistence of the abnormal
A. First maneuver (Fundal Grip) B. Second maneuver (Fetal Back) lie
C. Third maneuver (Pawlick Grip) D. Fourth maneuver (Pelvic Grip)
MANAGEMENT
 In general, at the onset of active labor in transverse lie is an
VAGINAL EXAMINATION indication for cesarean delivery
 Because neither the feet nor the head of the fetus occupies the lower
 early stages of labor: the side of the thorax or the "gridiron" feel of
uterine segment, a low transverse incision into the uterus may lead to
the ribs
difficulty in extraction of a fetus entrapped in the body of the uterus
 Advanced labor: the scapula and clavicle are palpated
above the level of incision. Therefore, a vertical incision is
recommended especially for dorsoanterior presentation

Pathologic Obstetrics Dystocia 8 of 14

 IV. OBLIQUE LIE
 Also called an unstable lie
 when the long axis forms an acute angle
 usually only transitory, because either a longitudinal or transverse lie
commonly results when labor supervenes

V. COMPOUND PRESENTATION
 an extremity prolapses
alongside the
presenting part or with
both presenting in the
pelvis simultaneously

 the left hand is lying in Occiput posterior presentation in early labor compared with
front of the vertex. With presentation at delivery. Ultrasonography was used to determine
further labor, the hand position of the fetal head in early labor.
and arm may retract
from the birth canal and POSSIBILITIES OF VAGINAL DELIVERY
the head may then  Spontaneous delivery
descend normally.  Forceps delivery with the occiput directly posterior
 Manual rotation to the anterior position followed by spontaneous or
 NOT AN INDICATION forceps delivery
FOR CS  Forceps rotation of the occiput to the anterior position and delivery

ETIOLOGY DELIVERY OF POP

 Conditions that prevent complete occlusion of the pelvic inlet by the 1. Spontaneous Vaginal Delivery
fetal head, including preterm birth - Roomy pelvic outlet or relaxed perineum
2. Manual rotation to occiput anterior and spontaneous deliver
PROGNOSIS AND TREATMENT - Resistant vaginal outlet or form perineum
 Perinatal loss is increased as a result of preterm delivery, prolapsed 3. Forceps or Vacuum delivery
cord, and traumatic obstetrical procedures - Ineffective expulsive efforts
 In most cases, the prolapsed part should be left alone, because - Must meet criteria for forceps or vacuum delivery
most often it will not interfere with labor 4. Cesarean section
 Prolapsed arm alongside the head -> ascertain whether the arm - Elongation of fetal head (molding/caput succidaneum)
retracts out of the way with descent of the presenting part - Head not engaged
- If it fails to retract and if it appears to prevent descent of the
head, the prolapsed arm should be pushed gently upward PERSISTENT OCCIPUT TRANSVERSE POSITION
and the head simultaneously downward by fundal pressure • Transitory because the occiput tends to rotate to anterior position
in the absence of a pelvic architecture abnormality or asynclitism
• Spontaneous anterior rotation usually is completed rapidly, thus
VI. PERSISTENT OCCIPUT PRESENTATION allowing the choice of spontaneous delivery or delivery with outlet
 2-10 % of deliveries forceps.
 Transverse narrowing of the midpelvis is undoubtedly a contributing
factor NOTE:
 Usually undergo spontaneous anterior rotation followed by Landmark to determine if it is occiput anterior/posterior:
uncomplicated delivery Sagittal suture

RISK FACTORS DELIVERY

 If rotation ceases because of poor expulsive forces and pelvic
 Epidural analgesic
contractures are absent, vaginal delivery usually can be
 Nulliparity
accomplished with oxytocin infusion.
 Greater fetal weight
 The occiput may be manually rotated anteriorly or posteriorly and
 Prior Occiput posterior position delivery
forceps delivery performed from either the anterior or posterior
 Anthropoid pelvis
position
 Application of Kielland forceps to the fetal head to rotate the occiput
ASSOCIATED MORBIDITIES to the anterior position, and then deliver the head either with the
 Prolonged second stage of labor same forceps or with Simpson or Tucker–McLane forceps
 Increased CS delivery and operative vaginal delivery  Difficult rotation is expected on platypelloid and android
 Increased blood loss (vaginal delivery) (heartshaped) pelvis.
 Higher order vaginal lacerations (3rd and 4th degree lacerations)  Persistent occiput transverse is seen in platypelloid pelvis

Pathologic Obstetrics Dystocia 9 of 14

 VII. SHOULDER DYSTOCIA  Causes straightening of the sacrum relative to the lumbar vertebrae,
 0.6 – 1.4% incidence (ACOG 2012) rotation of the symphysis pubis toward the maternal head, and a
 Head to body delivery time decrease in the angle of pelvic inclination
- Normal birth – 24 seconds  Pelvic rotation cephalad tends to free the impacted anterior shoulder
- Shoulder dystocia - > 60 seconds  Reduces the forces needed to free the fetal shoulder
 Fetal shoulder become wedged behind symphysis pubis and fail to
deliver with downward traction and pushing From AOB:
 Turtle sign – macrosomic baby
 EMERGENCY – because the umbilical cord is compressed within
the birth canal.
 Neonates experiencing shoulder dystocia had significantly greater
shoulder-to-head and chest-to-head disproportions compared with
those of equally macrosomic newborns delivered without dystocia

CONSEQUENCES
MATERNAL CONSEQUENCES
 Postpartum hemorrhage - usually from uterine atony, vaginal and
cervical lacerations

FETAL CONSEQUENCES
 Fetal morbidity and mortality (Neuromusculoskeletal injuries)
 Brachial Plexus Injury
 Clavicular fracture/Humeral fracture/Rib Fracture
 Hypoxia

PREDICTORS FOR SHOULDER DYSTOCIA

1. Increasing fetal weight risk factors:
- Obesity
- Multiparity
- Diabetes Mellitus and Gestational Diabetes Mellitus
- Post term pregnancy
- 75% shoulder dystocia cases -> Birthweight >4000 grams
2. Intrapartum Factors:
- Prolonged second stage
- Operative vaginal delivery or prior shoulder dystocia
WOODS CORKSCREW MANEUVER
The hand is placed behind the
ACOG 2012 CONCLUSION ON STUDIES ABOUT SHOULDER
posterior shoulder of the fetus
DYSTOCIA
and progressively rotating the
1. Most cases of shoulder dystocia cannot be accurately predicted or
posterior shoulder 180
prevented
degrees in a corkscrew
2. Elective induction of labor or elective CS for all women suspected of
fashion, so the impacted
having macrosomic fetus is not appropriate
anterior shoulder could be
3. Planned CS maybe considered for non-diabetics with fetus whose
released
MANAGEMENT
estimated weight is > 5000 grams or for diabetics > 4500 grams
 Large episiotomy
 Adequate analgesic RUBIN’S MANEUVER
 Reduction in the interval of time from delivery of the head to  The fetal shoulders are rocked from side to side by applying force to
 delivery of the body is of great importance to survival the maternal abdomen. “You rock it” daw. Hahahaha!
 An initial gentle attempt at traction, assisted by maternal expulsive  The pelvic hand reaches the most easily accessible fetal shoulder,
efforts, is recommended which is then pushed toward the anterior surface of the chest

THE SECOND RUBIN’S MANEUVER

TECHNIQUES TO FREE THE ANTERIOR SHOULDER A. The shoulder-to-shoulder diameter is shown as
FROM ITS IMPACTED POSITION BENEATH THE the distance between the two small arrows.
SYMPHYSIS PUBIS: B. The more easily accessible fetal shoulder (the
anterior is shown here) is pushed toward the
MODERATE SUPRAPUBIC PRESSURE anterior chest wall of the fetus.
 Can be applied by an assistant while downward traction is applied to Most often, this results in abduction of both
the fetal head. shoulders, reducing the shoulder-to shoulder
 Pressure is applied with the heel of the hand on the anterior shoulder diameter and freeing the impacted anterior
shoulder.
MCROBERT’S MANEUVER
 Very first maneuver to perform
 Consists of removing the legs from the stirrups and sharply flexing
them up onto the abdomen

Pathologic Obstetrics Dystocia 10 of 14

 DELIBERATE FRACTURE OF THE CLAVICLE Appendix and sample questions nasa next part 
 Pressing the anterior clavicle against the ramus of the pubis to free
the shoulder impaction
REFERENCES
 Williams Obstetrics 25th Ed
HIBBARD MANEUVER  Clangaroo, La Luna Nugget AOB, & Bernabe trans
 Pressure is applied to the fetal jaw and neck in the direction of the
 Lea Pacis trans
maternal rectum, with strong fundal pressure applied by an assistant  PPT from the department
as the anterior shoulder is freed  Special thanks to Doc Dione for the guidance 

ZAVANELLI MANEUVER USE AT YOUR OWN RISK.

 Cephalic replacement into the pelvis and then caesarean delivery. KINDLY MESSAGE ME IF THERE ARE CORRECTIONS
OR TYPOGRAPHICAL ERRORS. Open naman po ako ;)
CLEIDOTOMY Thank you and good luck!
 Cutting the clavicle with scissors or other sharp instruments - Ela ;)
 Usually used for a dead fetus

SYMPHYSIOTOMY
“Love them anyway.”
- Luke 23:34
 Surgical procedure in which the cartilage of the pubic symphysis is
divided to widen the pelvis allowing childbirth

SHOULDER DYSTOCIA DRILL

1. Call for help
- Mobilize assistants, an anesthesiologist, and a pediatrician.
Initially, a gentle attempt at traction is made.
- Drain the bladder if it is distended.
2. A generous episiotomy (mediolateral or episioproctotomy) may
afford room posteriorly.
3. Suprapubic pressure is used initially by most practitioners because it
has the advantage of simplicity. Only one assistant is needed to
provide suprapubic pressure while normal downward traction is
applied to the fetal head.
4. The McRoberts maneuver requires two assistants.

IF THE ABOVE MANEUVERS FAIL:

5. Delivery of posterior arm
6. Woodscrew
7. Rubin’s maneuver

IF IT FAILS...
8. Cleidotomy
9. Zavanelli
10. Symphysiotomy

“No one maneuver is superior to another releasing an impacted

shoulder or reducing an impacted shoulder or reducing the chance of
injury but McRobert’s maneuver was deemed a reasonable initial
approach.”
- American College of OB-GYN (2012)

COMPLICATIONS FROM DYSTOCIA

MATERNAL PERINATAL
• Uterine rupture • Fetal sepsis
• Pathological retraction • Caput succedaneum
ring • Molding
• Fistula formation • Nerve injury/fractures
• Pelvic floor injury • Cephalohematoma
• Infection
Postpartum hemorrhage

Pathologic Obstetrics Dystocia 11 of 14

 APPENDIX FIRST STAGE OF ACTIVE LABOR

PARTURITION
 Bringing forth of the baby, requires multiple transformations in both
uterine and cervical function
 These phases of parturition include:
1. A prelude to First Phase
2. The preparation for Second Phase
3. The process of Third Phase
4. Recovery from Fourth Phase
*** Phases of parturition should NOT be confused with the clinical stages
of labor, that is, the first, second, and third stages—which comprise the
third phase of parturition

LABOR FRIEDMAN’S LABOR CURVE

- Uterine contractions that bring about demonstrable effacement and - Divides active labor into 3 divisions:
dilatation of the cervix
- Generally, this is described by some women as painful uterine 1. Preparatory Division - Covers the latent phase up to the acceleration
contractions phase
2. Dilatational Division - Covers the phase of maximum slope
True Labor: If there is resultant progressive dilatation of the cervix 3. Pelvic Division - Covers the deceleration phase up to the 2nd stage of
labor

PREPARATORY DIVISION
- Cervix dilates little, only changes in the connective tissue
components of the cervix
- Enable the cervix to loosen up/to ripen up in preparation for the
maximum dilation that will happen during the active phase of labor
- Under the LATENT phase! (up to acceleration of ACTIVE phase)
 Sedation and conduction analgesia are capable of arresting this
division of labor
 May be shortened by:
- Sedation
- Use of continuous epidural analgesia
- Amniotomy*
- Oxytocin*
FRIEDMAN’S CURVE * This occurs only for some; May not be applicable for all labors
- Encompasses the 3 stages of labor
Stage 1: Contractions and cervical dilatation DILATATIONAL DIVISION
Stage 2: Fetal descent and delivery - Dilatation proceeds at its most rapid rate
Stage 3: Delivery of placenta - Unaffected by sedation or conduction analgesia
- The patient can still be sedated with sedation or she can be pain free
PHASES OF LABOR because of the effect of epidural anesthesia during the dilatational
(Iba ang Stages sa Phases) division
- Rate of cervical dilatation will still go on despite the sedation or
conduction analgesia
- Under the phase of maximum slope of the ACTIVE phase!

PELVIC DIVISION
- Commences with the deceleration phase of cervical dilatation, up to
the second stage
- The classic mechanisms of labor that involve the cardinal fetal
movements take place principally during the pelvic division

2 PHASES OF LABOR: LATENT AND ACTIVE PHASE

Phase 1: Quiescence - Prelude to Parturition
Phase 2: Activation - Preparation for Labor
Phase 3: Stimulation - Processes of Labor
Phase 4: Involution - Parturient Recovery

PHASE 3 (STIMULATION) OF PARTURITION: LABOR

STAGES OF ACTIVE LABOR:

STAGE 1 (Clinical Onset of Labor)
- Start of Cervical Dilatation -> 10 cm Cervical Dilatation
STAGE 2 (Fetal Descent)
- 10 cm Cervical Dilatation-> Delivery of Baby
STAGE 3 (Delivery of Placenta & Membranes)
- Delivery of Baby -> Placental Delivery
STAGE 4
- 1 hour following the 3rd stage of labor
- 3 stages lang talaga but if nagask sila if alin ung stage 4, eto
un
Pathologic Obstetrics Dystocia 12 of 14
 LATENT PHASE *MEMORIZE!
- Begin somewhere between 1 and 2 cm cervical dilatation and ends on the I’ll just put this table here again, pangreview 
8th hour of labor when the cervix is between 2.5 to 3 cm
- The point at which the mother perceives regular contractions ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA, AND METHODS OF
- The latent phase for most women ends at between 3 and 5 cm of TREATMENT
dilatation Labor Pattern Nulliparas Multiparas Preferred Exceptional
- This threshold may be clinically useful, for it defines cervical dilatation Treatment Treatment
limits beyond which active labor can be expected Prolongation Disorder
Prolonged > 20 hrs > 14 hrs Bed rest Oxytocin or
- Prolonged Latent Phase latent phase cesarean
- Latent phase exceeding 20 hours in the nullipara delivery for
- 14 hours in the multipara urgent
problems
ACTIVE PHASE Protraction Disorders
- Begins when the cervix is at least 3 cm dilated Protracted < 1.2 cm/hr < 1.5 cm/hr Expectant Cesarean
- Each of these phases of the active phase last for an average of 2 hours each active-phase and delivery for CPD
dilatation support (cephalo
Protracted < 1.0 cm/hr < 2 cm/hr pelvic
3 Phases of Active Phase disproportion)
descent
1. Acceleration Phase - From 3 to 4 cm
2. Phase of Maximum Slope - From 4 to 9 cm (where dilatation is at its
fastest) Arrest Disorders
3. Deceleration Phase - From 9 to 10 cm Prolonged > 3 hrs > 1 hrs Oxytocin Rest if
deceleration without exhausted
- This is the start of the Pelvic Division
phase CPD
- There is some slowing down here because at this point, cardinal
Secondary > 2 hrs > 2 hrs
movements of labor will take place
arrest of
dilatation
- Cervical dilatation of 3 to 5 cm or more, in the presence of uterine Arrest of >1 hr > 1 hr Cesarean Cesarean
contractions, can be taken to reliably represent the threshold for descent delivery delivery
active labor Failure of >1 hr, > 1 hr with CPD
descent with no
- According to Rosen, et al: When the cervix is 5 cm dilated already, this descent in
means that the patient is in active labor and at this point you can deceleration
already do active management. phase or
second stage
DURATION OF STAGES OF LABOR
NULLIPARA MULTIPARA CERVICAL ASSESSMENT
FIRST STAGE 1. Cervical Dilation
Latent Phase < 20 hours < 14 hours - Estimating the average diameter of the cervical opening
Active Phase 1.2 cm/hr 1.5 cm/hr expressed in cms
SECOND STAGE 50 minutes 20 minutes - 10 cms: Fully dilated
THIRD STAGE 15-30 minutes 15-30 minutes 2. Cervical Effacement
- Expressed in terms of length of cervical canal compared to
The ischial spines will be the landmark in determining the station of the uneffaced cervix
presenting part. - If reduced by ½ : 50% effaced
- If thin as the adjacent lower uterine segment: Completely or
-At the level of the ischial spine:Station 0
100% effaced
3. Cervical Position
Rule of Fifths:
- Relationship of cervical as to fetal head categorized as posterior,
1 cm higher : -1 (up to -5)
midposition or anterior
1 cm lower :+1 (up to +5)
4. Station
- When lowermost portion of presenting part is at level of ischial
DESCENT
spines designated as zero station
- First requisite for birth of the newborn - The American College of Obstetricians and Gynecologists
- In nulliparas, engagement may take place before the onset of labor, classified stations dividing the pelvic above and below the spines
and further descent may not follow until the onset of the second stage into fifths
- In multiparous women, descent usually begins with engagement - Divisions represent cms above and below the spines into fifths
- Station +5 corresponds to fetal head visible at the introitus
Descent is brought about by one or more of four forces: - To avoid confusion between “thirds” and “fifths” system, use it
1. Pressure of the amnionic fluid as a denominator and station as numerator, for ex. +5/5 - -5/5 - -
2. Direct pressure of the fundus upon the breech with contractions 3/3
3. Bearing down efforts of maternal abdominal muscles - If the head is unusually molded, or if there is an extensive
caput formation, or both, engagement might not have taken
4. Extension and straightening of the fetal body
place even though the head appears to be at 0 station
5. Presenting Part
- Nature and position should be positively determined

Pathologic Obstetrics Dystocia 13 of 14

 SECOND STAGE OF ACTIVE LABOR CASE 1:
 This stage begins when cervical dilatation is complete and ends Diagnosis: Prolonged Latent Phase
with fetal delivery Management: Bed Rest, Sedation
 The median duration is approximately 50 minutes for nulliparas
and about 20 minutes for multiparas, but it is highly variable CASE 2:
(MEMORIZE TABLE) Diagnosis: Protracted Active Phase
Management: Oxytocin
SIGNS AND SYMPTOMS OF 2ND STAGE OF LABOR
- Contractions become more frequent CASE 2 (cont):
- Around less than 1 minute interval and lasts for around 60-90 Diagnosis: Arrest of Cervical Dilatation
seconds Management: Cesarean Section
- Patient will have urges to defecate
- Increase in the amount of bloody show CASE 3:
Diagnosis: Prolonged Deceleration Phase
* Confirm by doing internal examination Management: Oxytocin
Diagnosis: Failure of Descent
Management: Cesarean Section
IDENTIFICATION OF 2ND STAGE
- Full cervical dilatation
CASE 4:
- Bearing down efforts lasting 1 ½ minutes
Diagnosis: Arrest of Descent
- Descent of presenting part with urge to defecate
Management: Cesarean Delivery
MAY BE PROLONGED DUE TO :
1. Large fetus
2. With conduction analgesia REFERENCES
3. Intense sedation  Williams Obstetrics 25th Ed
 Clangaroo, La Luna Nugget AOB, & Bernabe trans
 Prolonged 2nd Stage:  Lea Pacis trans
- Nullipara: > 2 hours  PPT from the department
- Multipara: > 1 hour  Special thanks to Doc Dione for the guidance 
*Di ko na nilagay ung 3rd stage ng labor 
USE AT YOUR OWN RISK.
KINDLY MESSAGE ME IF THERE ARE CORRECTIONS
SAMPLE CASES OR TYPOGRAPHICAL ERRORS. Open naman po ako ;)
Case 1 Thank you and good luck!
G1P0 PU 39 weeks admitted on the 8th hour of [Link] occurred - Ela ;)
every 3-4 minutes moderate intensity. Cervix 1 cm dilated 1.5 cms long
intact bag of waters cephalic station -2
Repeat IE done after 5 hrs,cervix 2 cms dilated ,1cm long,cepahalic
station -2.
“Love them anyway.”
- Luke 23:34
After 5 hrs repeat IE done revealed same findings. Contractions were
occurring 2-3 min. moderate to strong.
Repeat IE done after 3hrs and revealed 3cms cervical dilatation,0.5 cms
long,cephalic station -1. PLOT the findings and what is the diagnosis?

Case 2:
G1P0 38 weeks admitted on the 10th hr of labor. Cervix 4 cms dilated, 0.5
cms long, BOW intact, cephalic station -1. Uterine contractions at 150
montevideo units.
After 2 hours,cervix 5 cms dilated,0.5 cms long.
What is the diagnosis at this time? How will you manage this patient?

Case 2 Continuation: Amniotomy was done revealing clear amniotic fluid.

Oxytocin augmentation was given.
After 1 hr, cervix dilated to 7 cms,0.5 cms long, cephalic station 0.
Uterine contractions at 250 montevideo units.
After 3hrs cervix remained at 7 cms cervical dilatation cephalic, station 0
with caput and molding.
What is the diagnosis? How will you manage the patient?

Case 3:
G1P0 PU 40 weeks admitted on the 11th hr of [Link] 8 cms
dilated,fully effaced ,ruptured membranes cephalic station -[Link]
were good at 200 montevideo units.
After 2 hrs repeat IE revealed a 9 cms cervix,fully effaced,cephalic station -2.
Further observation done after 2 hrs and revealed same findings.
What is the diagnosis? How will you manage this patient?

Case 4:
G1P0 PU 40 weeks admitted on the 10th hr of labor with adequate uterine
contractions. Cervix 6 cms dilated,0.5 cms long cephalic station-1.
Amniotomy done which showed clear AF. Patient was sedated due to pain.
12th hr- 8cms dilated cephalic station 0
13th hr-fully dilated,cephalic station+1
15th hr-fully dilated ,cephalic,occiput posterior,station +1
What is the diagnosis? How will you manage?
Pathologic Obstetrics Dystocia 14 of 14