Problems with the Passage

Abnormal size or shape of the pelvis

Cephalopelvic disproportion
Shoulder dystocia

 Abnormal size or shape of the pelvis

• Factor that dystocia can occur is the contraction or narrowing of the passageway of the birth canal.
• This can happen at the inlet, at the midpelvis, or at the outlet,

A long,
narrow,
oval-shaped
inlet

The narrowing causes:

• Cephalo-Pelvic Disproportion -- a disproportion between the size of the fetal head and the pelvic diameters.
 will results in failure to progress in labor
Inlet contraction
 is the narrowing of the anteroposterior diameter to less than 11 cm, or the
transverse diameter to 12 cm or less
 Primigravida – fetal head engage bet. 36-38 weeks of pregnancy
 if engagement occurs before labor proof that pelvic inlet is adequate.
 general rule “what goes in, comes out”
 a head that engages – it fits into the pelvic brim and able to pass thru the
midpelvis and outlet.
 if engagement does not occur in primi  fetal abnormality (larger –than-
usual head) or pelvic abnormality (smaller-than-usual pelvis.)
 as a rule, engagement doesnot occur in multigravida until labor begins.
 CPD – fetus does not engage and remains floating, malposition may occur  may complicate the
situation

Management:
 Primigravida – should have pelvic measurements taken and recorded before 24 weeks of pregnancy
 based on measurement s, birth decision can be made.

Outlet CONTRACTION
 is the narrowing of the transverse diameter at the outlet to less than
11 cm. distance between the ischial tuberosities.
 measurement can make during a prenatal visit – can be anticipated
before labor begins.
A narrow
sacrosciatic notch
Management:
 Trial labor
– if the woman has a borderline (just adequate)inlet measurement and the fetal lie and position are
good.
 the physician allow woman a “trial” labor to determine labor
can progress normally.
 External Cephalic Version
 is the turning of a fetus from breech to a cephalic position before birth.
 tocolytic drug may be given to help relax the uterus
  Forceps births
 unable to push with contractions in the pelvic division of labor
 cessation of descent in the 2nd stage of labor
 fetus is in an abnormal position
 fetus is in distress

Criteria before forceps are applied:

 membranes must be ruptured.
 CPD must not be present.
 the cervix must be fully dilated.
 woman’s bladder must be empty.

 Vacuum Extraction
 a fetus, if positioned far enough down the birth canal.

• Shoulder Dystocia
Delayed or difficult birth of the shoulders that may occur as they impacted above the
maternal symphysis pubis.
after head is born, it retracts against the perineum, much like a turtle’s head drawing into
it’s shell (“turtle sign”)

Shoulder dystocia is an urgent situation  because umbilical cord can compressed

between the fetal body and maternal pelvis

Methods to relieve impacted fetal shoulders:

1. McRobert’s maneuver – woman flexes her thights sharply against her abdomen
which straightens the pelvic curve

2. Suprapubic pressure – by pressing the fetal anterior

shoulder downward to displace it from
above the mother’s symphysis.
fundal pressure should not be used because it
will push the anterior shoulder even more firmly
against the mother’s symphysis