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DYSTOCIA

- is defined as the cessation in the progress of parturition as a result of

abnormalities in the mechanics involved. The causes of dystocia fall into main groups:

1. Subnormal or abnormal uterine forces which are not strong enough to overcome the
natural resistance to the birth of the baby offered by the maternal soft parts& the
bony canal. Weakness of uterine action is called uterine inertia or uterine
dysfunction &the most common cause of dystocia.
2. Faulty presentation or abnormal development of the fetus of such character that it
cannot be extruded by the “visa tergo” (peer from behind)
3. Abnormalities in the size or character of the birth canal which forms into the
descent of the fetus.

GROUP I
Dystocia due to anomalies of the Powers or Anomalies of the Expulsive Forces

A. UTERINE INERTIA OR UTERINE DYSFUNCTION-

At the onset of normal labor, there is first a period of several hours
during which the cervix starts to undergo effacement but dilates only very
slightly. This is called latent phase& is if several hours duration. This
followed after by an acceleration& active phase where the cervix dilates rapidly
& just before it becomes fully dilated to about 10 cms, or more, comes the
decelaration or slowing phase. These phases in the progress of cervical
effacement & dilation takes place during the first stage of labor. If any of the
above phase becomes prolonged, the result is uterine inertia or uterine
dysfunction. Prolongation of these phases is due primarily to weak or faulty
uterine contractions.
Uterine contractions during labor are characterized by gradient of activity,
meaning that contractions emanating from the fundus are greatest & decreases
towards the cervix. The contraction phase being simultaneously in all areas of
the uterus known as coordinated uterine action. Several types of dysfunction:

1. The uterine contractions are weak nut gradient of activity is normal

2. The second is characterized by loss of coordinated uterine action of
which there are two or sub-types:
a. Reversal of the gradient – means contractions from the mid-zone of the
uterus are greater or equal to those from the fundus.
b. Incoordinated uterine action so that group of muscles contract one
after the other, characterized by pains in excess of the severity of
the contractions.

 CAUSES OF UTERINE DYSFUNCTION:

1. Weakness of the uterine wall – disease or repeated pregnancies, more among grand
multiparous mothers.
2. Uterine detention & stretching of uterine wall due to multiple pregnancies &
hydramnios.
3. Emotional instability – fear of pain ; contractions are involuntary & not within
the control of the individual
4. Tumors in the uterine wall, like multiple fibroids – interfere with the
effectiveness of uterine contractions
5. Pelvic contraction & malposition ; excessive rigidity of the cervix
6. Early use of painless drugs
7. Certain types of abnormal presentation;
a. Occipito-posterior position
b. Breech presenation
c. Transverse presentation

 MANAGEMENT OF UTERINE DYSFUNCTION (MIDWIVES)

1. Expectant treatment
2. Postural treatment – the patient walk around the labor room or house often cause
the presenting part to descend further into the pelvic brim & makes firm contact
with the cervix (Feuguson reflex). If BOW is ruptured, this should not be done.
3. Physiological treatment
4. Application of tight abdominal binder among grand-multiparous mothers. The
binder tends to increase the tone of the uterine muscle.

The management of uterine inertia is directed towards the cause as much as possible.
CS should never be done unless strong indication are present – CPD, uterine fibroids,

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intractable inertia where the BOW have ruptured prematurely & danger of infection is
great. Antibiotics are given routinely as a preventive for infection.
B. PRECIPITATE LABOR-labor that ends within three hours

CAUSE: Strong uterine contractions that occur one after another with short interval of
time between contractions. It may also be due to wide pelvis.

IMPORTANCE: May undergo intracranial injuries

Consequences to mother – perineal lacerations which may be multiple or
Extensive

MANAGEMENT:Support the perineum & avoid as much as possible a too rapid exit of the
child. She should not fight back the descent of the fetal head as intracranial injuries
can result from this act.

C. PATHOLOGICAL RETRACTION RING – the result of obstructed labor ; also called

Bandle’s ring

CAUSES: any form of obstruction of labor:

1. Transverse presentation
2. Big head in a normal size pelvic inlet
3. A normal size head in contracted pelvic inlet
4. Ovarian tumors lying infront of the head
5. Tumors of the uterine wall at the lower uterine segment (tumor previa)
6. Hydrocephalus
7. Face presentation – posterior variety

DIAGNOSIS:
In cases of obstructed labor, the lower uterine segment thins out & stretches so
that one of the most significant symptom is pain & tenderness over the lower abdomen on
palpation. A transverse groove of the uterine wall is sees and regarded as a sign of
impending rupture of the lower uterine segment.

D. CONSTRICTION RINGS
When the group of muscles goes into “tetanic contraction” & forms a spastic
structure around some part of the fetus. These rings cause a true dystocia, it prevents
the descent of the fetus. The rings are seen only in the upper contractile zone of the
uterus.
In cephalic presentation, the ring usually forms around the neck of the fetus, while
the breech presentation, the ring may occur around the trunk. These rings prevent the
exit of the infant & at times may cause intra-uterine fetal death due to compression of
the cord, cutting off fetal circulation. According to Rudolf, constrictions rings are due
to incoordinated uterine action. In some instances, any vaginal manipulations done when
patient is not yet well under anesthesia may cause certain groups of muscle fiber spasm
of the uterine wall.

DIAGNOSIS:
1. Irregular uterine contractions which are incoordinated
2. When the cervix hangs like a cuff with the presenting part away from it and not in
close contact with the cervix
3. When the fetus slips back into the uterine cavity instead of incoming down into the
pelvic canal

Constriction rings do not change in position & level in the uterine wall, in contrast to
Bandle’s ring. It does not cause thinning of the lower uterine segment & does not cause
any pain or tenderness in the lower abdomen. It is felt as a ridge of muscles hugging the
fetus tightly; along the neck in cases where the presenting part is the head.

TREATMENT:
The patient should be taken to a hospital.
In the absence of frank disproportion between the head & the pelvis & the cervix is
not fully dilated, the patient is sedated by the physician to rest her & given dextrose
IV. Morphine is often used as a sedative. Open drop other may also be used if the rings
are not relieved by the morphine.
In the presence of fetal distress, CS may have to be done to save the baby. A
classical section is often done to cut through the rings. In cases where the baby is dead
inside the uterus, watchful waiting to be the choice of treatment. Sedation is done &
dextrose given liberally. Antibiotics are started & contained even after delivery.

MISSED LABOR

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Patient may start labor at or near term & after sometime, uterine contraction
disappear without delivery of the child. The fetus dies & may retained in uterus for
months, undergoing mummification or even retrefaction.

II. DYSTOCIA AND ABNORMALITIES OF THE FETUS

A. ABNORMALITIES IN LIE, PRESENTATION & POSITION

1. Occiput posterior position
2. Breech presentation
3. Face presentation
4. Brow presentation
5. Transverse presentation
6. Compound presentation

1. OCCIPUT POSTERIOR POSITION

The fetus is lying on its back in the uterine cavity with the fetal head
partly flex. The presenting diameter of the fetal head is the occipito- frontal which
measures 11.0 cms. This diameter is wider than the presenting diameter in the anterior
type of vertex presentation as LOA & ROA, where the presenting diameter of the fetal head
is the sub-occipito bregmatic diameter which measures only 9.5 cm. this is due to
reduction by flexion of the fetal head until the chin touches the chest.

DIAGNOSIS:
An abdominal palpation the main differences in the findings as compared to the
anterior variety of vertex, is in the location of the place of the back & small parts.
The plane of the back in the anterior variety of vertex is either to the abdomen. The
fetal heart tones in the posterior variety of vertex is heard best nearer the flanks of
the mother, while in the anterior variety, the FHT are heard best over the anterior
aspect of the abdomen usually over the plane of the back of the fetus.

MECHANISM OF LABOR:
The mechanism of labor in occiput posterior differs from the anterior posterior only
in the internal rotation of the fetal head. In the anterior position, the internal
rotation covers an area of 45 degrees for the occiput to impinge under the symphysis
pubis. In posterior positions, the internal rotation covers a very much wider arc – 135
degrees. The internal rotation occurs when the head hits or reaches the perineal floor.
It is during internal rotation when dystocia often results.

FACTORS IN OCCIPUT POSTERIOR THAT MAKE IT DYSTOCIA:

 The attitude of the fetal head, which is partly flexed, increases the size of the
presenting diameter so that more resistance in encountered by the fetal head during
descent. As a result there is often a premature rupture of the BOW. The expulsive
powers of the mother may give away later and disappear altogether, resulting in the
production of uterine inertia.
 The degree of internal rotation, which is 135 degrees toward the anterior, often
results in the transverse arrest of the fetal head. Transverse arrest of the fetal
head means the incomplete rotation of the head so that the sagittal suture of the
head is along a line joining the two ischial spines. The ischial spines, if rather
prominent, narrows the diameter between them so that the head fails to clear this
area during the rotation to the anterior.

MANAGEMENT OF OCCIPUT POSTERIOR POSITIONS : watchful waiting

MIDWIFE’S MANAGEMENT:
 Get a good obstetrical history
 In the event premature rupture of the bag occurs, keep the mother in bed & wait
 Should uterine inertia takes place, fruit juices should be given to the mother to
supply her calcium needs. Applying a tight abdominal binder often keeps in
augmenting the expulsive powers, when the pains uterus.
 In cases of primiparous patients, FHT should be counted regularly & its characters
noted. If signs of fetal distress appear, the patient should be taken to the
nearest hospital for delivery.

2. BREECH PRESENTATION
Fronk breech is the most common. One should always remember that some kind of feto-
pelvic anomaly may be present in the event breech presentation is seen in a mother
in labor, be she a primipara or multipara.

DIAGNOSIS:

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The findings in the first & third maneuver of Leopold’s are sufficient for one to
make an accurate diagnosis. The breech is smaller in size to the head. The forth maneuver
is negative.
In breech, the FHT are best heard above the level of the navel.

CAUSES OF BREECH PRESENTATION:

 Contracted pelvis
 Abnormality of the size & shape of the fetal head
 Hydramnios
 Prematurity
 Hereditary & individual tendencies
 Undue laxity of the abdominal wall due to repeated pregnancies.

MECHANISM OF LABOR IN BREECH: (spontaneous breech deliveries)

 Engagement & descent of the breech along one of the oblique diameter
 Internal rotation of the breech so that the anterior hip impinges underneath the
symphysis pubis & the posterior hip lies infront of the rectum (sacrum)
 Delivery of the posterior hip by an upward lateral flexion, followed by the
anterior hip bone on a downward lateral flexion
 External rotation (restitution) of the buttocks. This occurs because of the
engagement & the descent of the trunks & shoulders along the some oblique diameter
occupied the breech earlier.
 As soon as the shoulder reach the perineal floor, internal rotation of the
shoulders takes place so that the anterior shoulder goes beneath the symphysis
pubis. The posterior shoulder is delivered by an upward lateral fexion of the body
followed by anterior shoulder in a downward lateral flexion
 External rotation of the shoulder follow, caused by the engagement & descent of the
after coming head, along the oblique diameter opposite that used by the breech &
shoulder
 As soon as the chin reaches the perineal floor, internal rotation of the head occur
so that the sub-occiput goes under the sumphysis pubis & the chin infront of the
sacrum
 Delivery of the head follows in the attitude of flexion, the chin, lips, nose, tip
of the nose and brow coming out in the order.

POINTS TO REMEMBER IN MECHANISM OF SPONTANEOUS BREECH:

1. There are actually three series of delivery
a. Delivery of the breech
b. Delivery of the trunk & shoulder
c. Delivery of the head
2. Each of this deliveries come in increasing difficulty, as the smallest comes first
& the largest comes out last.
3. Difficulty may be encountered by the fetus, in affecting the delivery of the part
that follows.
4. Spontaneous delivery of the fetus in breech can occur only when the fetus is not
big & all the requisite necessary to easy expulsion of the fetus are present.

TYPES OF BREECH DELIVERIES:

1. Spontaneous breech- fetus occur delivered by maternal expulsive powers of the
mother
2. Partial breech extraction- the fetus buttocks was born spontaneously up to the
level of the umbilicus & then extraction done. This is a desirable method of breech
delivery. Fetal mortality is very low.
3. Total or complete breech extraction- one where extraction was done from the
beginning up to the delivery of the after coming head. This method is seldom done
as the incidence of the fetal mortality is high.

MANAGEMENT OF BREECH
1. Preventive : a careful prenatal examination of the pregnant mother should be done
with the aim in view of connecting on time any malpresentation.
In the event a diagnosis of breech is made after the 28 th week of
gestation external cephalic version should be done to correct the same.
2. Management at the time of labor : taking the patients to the hospital
3. Hospital management :in cases when the BOW is intact, an attempt at external
cephalic version may be done by sedating the patient & placing her under ether
anesthesia.
In primiparous mother, an x-ray pelvimetry to determine the true pelvic
capacity. An estimate of the fetal size should also be done. In the presence of
definite pelvic contraction, delivery should be by CS.
Among multiparous mothers, one of the frequent causes of breech
presentation in undue laxity of the uterine & abdominal walls, if not excessive
amniotic fluid (hydramnios)

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If the bag is intact when seen at the time of labor, an attempt should
be made to do an external cephalic version to correct the presentation. If the
fetus is of average size & definite signs of pelvic contraction is absent, a
vaginal delivery may be anticipated, at most a partial breech extraction is done.
When the physician decides on a vaginal delivery, the piper’s forceps
should be ready to be applied should difficulty encountered in the delivery of the
after coming head.

3. FACE PRESENTATION
The attitude of the fetal head is that of extreme extension so that the
occiput touched the spinal column & the engaging diameter of the fetal head is the
tracheobregmatic (the diameter from the fever of the mouth to the large
fontanelle).

CAUSES OF FACE PRESENTATION

1. Disproportion between the fetal head & the pelvic inlet; the most common fault is
that of contracted pelvic inlet.
2. Multiparity- lack of tone of the abdominal muscular allows the uterus to fall
forwards, thereby resulting in fetal attitude which causes flexion of the fetal
head.
3. Development anomalies of the fetusm such as anecephaly, coils of cord along the
neck, abnormalies of the vertebral spine.

DIAGNOSIS OF FACE PRESENTATION

On this type of cephalic presentation, the cephalic prominence is the
occiput, which is felt on the same side of the plane of the back of the fourth maneuver.
If an internal examination is done, the examining fingers will fail to
appreciate the sagittal suture & the small or large fontanelles. Instead, it will feel
the pointed chin which has a bony feeling & the mouth of the fetus. When the diagnosis of
the face presentation is made, the midwife should take the patient to a hospital

HOSPITAL MANAGEMENT:
 X-ray pelvimetry
 Delivery should be by CS in the presence of definite pelvic contraction.
 In the posterior variety of face, if the pelvimetry shows adequate pelvis & a small
head, the patient should be given enough chance to deliver vaginally. In the event
definite signs of the posterior portion, CS should be best method of delivery.

In the anterior variety of face, forceps delivery is often done by the

obstetrician when the condition necessary to a forceps application are present.

4. BROW PRESENTATION
If the fetal head is only partially extended, the brow occupies a portion of
the head between full flexion occupies & full extension (face) & the root of the nose,
becomes the presenting part that is attempting to engage into the pelvic brim. The
engaging diameter of the fetal head is the mento-occipital diameter which measures about
13.5 cms.

CAUSES: practically the same causes for the face presentation

5. SHOULDER PRESENTATION
The fetal caises the maternal axis at right angles (transverse lie). The
presenting part is the shoulder with the head occupying one of the iliac fossa &
the breech in the opposite iliac fossa. It is also known as acromion presentation.

CAUSES:
 Grand multiparity – due to laxity of the abdominal wall
 Placenta previa causes transverse lie as both conditions prevent engagement
 Pelvic contraction of the fetal head

DIAGNOSIS:
Abdomen will be noted to be wider transversely. An palpation, the following are
findings:
1st maneuver : negative (absent of any fetal parts in the fundus)
2nd maneuver : fetal head on one side, round head, round smooth & freely
ballotable mass
3rd maneuver : negative (lower uterine segment is empty)
4th maneuver : negative (no cephalic prominence in shoulder presentation)

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On vaginal examination, the side of the chest wall of the fetus gives a “ gridiron
sensation” the examining fingers.

COURSE OF LABOR
Spontaneous delivery of a full term infant in shoulder presentations is possible,
especially if the baby is alive. The reason is because expulsion of the infant in
shoulder presentation, can occur only when the head & the trunk are able to enter the
pelvic brim at the same time which is possible. Premature macerated infants may be
delivered spontaneously in a shoulder presentation. The head & thorax pass through the
pelvic cavity at the same time & the baby is expelled. This mechanism is known as
“conduplicatis corpou”. This is also possible in twin births when the babies are
premature.

MANAGEMENT OF SHOULDER PRESENTATION (midwife)

The presence of transverse lie in a primiparous mother should always make the midwife
suspicious of a pelvic contraction. If the mother is sees after 28 th week of gestation,
she may try external cephalic version to be able to convert a shoulder presentation into
a cephalic presentation.
The management among multiparous patients, whether during pregnancy or early in
labor, will also consists of attempts at external version. If the bag is ruptured, it is
possible external version will fail. In such cases, the patient is bet delivered in a
hospital. If the bag is still intact, & version is successful, a tight binder may be
applied to keep a cephalic presentation. Compression of the cord may occur after a
version, & this will be shown by changes in the rate & pains, or signs of fetal distress
appear, the mother must be rushed to the nearest hospital for delivery.

HOSPITAL MANAGEMENT:
 Pelvimetry is done upon admission. If one of the upper extremities is prolapsed,
with the baby alive, & the mother primipara, a CS is in order regardless of
cervical dilatation. If the mother is multigravida, with the cervix fully dilated,
internal podalic version & extraction may be done by forceps, if necessary.
 If the bag is intact external cephalic version is attempted & the mother given
enough time to deliver the baby herself. During this time of waiting the FHB is
watched very closely.
 If the presence of definite pelvic contraction, a CS is the best method of
delivery.
 Blood should be ready be immediate once if necessary.

6. COMPOUND PRESENTATION- means the “prolapse of an extremity along side the

presenting part, both entering the pelvic canal at the same time”. In most cases of
compound presentation, the umbilical cord often prolapse also and accompanies this
condition.

CAUSES OF COMPOUND PRESENTATION: Predisposing causes

 Multiparity, because of a lax abdominal wall
 Pelvic contractions
 Small infants

MANAGEMENT OF COMPOUND PRESENTATION

It should be left alone unless
descent of the presenting part. In
interference with the descent of the
upwards & at the same time push down
fundus of the uterus.
the prolapsed part interfere with the delivery &
the event the whole aim is prolapsed & shows
presenting part, then it will have to be pushed
the presenting part by applying pressure on the

B. ABNORMALITIES OF DEVELOPMENT:
1. Excessive development: giant fetus – a fetus that weighs 4500 gms. Or more.
CAUSES: large size of one or both parents, multiparity, or diabetes on
thepart of the mother. Another factor is over term of more than 280 days ; excessive
over-eating on the part of the mother

COURSE OF LABOR
Dystocia or difficulty in labor will only occur when any degree of pelvic
contraction is present. Among multiparous mother, the dystocia is more due to loss of
tone of the uterine muscle as a result of repeated pregnancies. The contractions are
weak, resulting in dystocia. When the fetal head is excessively enlarged, dystocia will
always develop even if the pelvic measurements are within normal.

MANAGEMENT

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Get a good obstetrical history, size of the babies in her previous deliveries.
Determine through a fasting urine examination the presence of sugar. X-ray pelvimetry &
cephalometry.

2. MALFORMATIONS OF THE FETUS

a. Double monsters (conjoined twins)
(1) Incomplete double formations at the upper or lower half of the baby.
(dipagus)
(2) Twins which areunited together at the upper or lower end of the body
(craniopagus, ischiophagus, or pryopagus)
(3) United by the trunk (thoracopagus, dicephalus)

b. Anencephalus or Hemicephalus :
This is monster with an imperfectly developed head but with a large trunk. A
large portion of the skull & the brain is lacking. The dystocia develops because of
the head but more of the large shoulders & trunk, delivery of which is difficult.
Because of the small brain, there is often an excess of amniotic fluid. The
incidence of face presentation is frequently observed. By force of gravity, there
is also an increase in the incidence of breech & shoulder presentation. When the
presentation is by breech, delivery is often easy. The reason behind this is that
breech is better dilator of the cervix than the imperfectly deleveloped head.

3. Hydrocephalus
Excessive accumulation of the cerebro-spinal fluid in the ventricles of
thebrain, resulting in an enlargement of the cranium. The enlargement of the
circumference of the head is about 50 cm or 80 cms. Because of the excessive
enlargement of the head, it cannot adopt to the pelvic brim, resulting in breech
presentation. If recognized only, delivery is through CS. The x-ray can best verify
the suspicion of hydrocephalus.
In neglected cases, the danger is a rupture of the uterus at the lower uterine
segment.

GUIDE IN DIAGNOSIS OF HYDROCEPHALUS:

 “head remains high, despite a normal pelvis”
 “a floating head-that feels broad”

The delivery can be affected only by craniotomy to be able to drain the cerebrospinal
fluid & diminish the size of the head.

4. Enlargement of the body of the fetus

This is usually the result of ascites, distended urinary bladder, or of tumors of
the kidneys or liver.

CAUSES:
(1) General dropsy- seen in cases or eruthroblastosia fetalic. A child suffering
from chondrodeptrophia fetalis becomes edematous as to cause of dystocia.
(2) Defective development of the urinary tract may result in distention of the
abdomen due to retention of urine.
(3) Congenital cystic kidneys result in diffusion of urine into the body
cavities, resulting in distention of the abdomen.
Delivery is only possible by puncturing the abdominal wall of the fetus to permit
its exit.

5. Prolapse of the cord :

A condition where a loop of cord protrude through the cervix, into the
vagina & often emerge through the vulva.

CAUSES:
Any condition which interferes with an accurate adaptation of the presenting part to
the pelvic brim, may predispare to a prolapse of the cord, such as :
(a) Shoulder presentation
(b) Footling type of breech presentation
(c) Contraction of the pelvic inlet
(d) Excessive development of the fetus
(e) Hydramnios
(f) Anencephalic fetuses

Prolapse of the cord is much more common among multiparous patients. It is the fetus that
suffers & it is often the cause of stillbirths because of compression on the presenting
parts on the cord against the pelvic brim. Compression on the cord result in interference
with the fetal circulation, resulting in fetal anoxia & death.

DIAGNOSIS:
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Often times the cord, or a cord of loop of cord is sees out of the vaginal opening.
If not out of the vulva, a loop of cord may be felt by the examining fingers on vaginal
examination.

PREVENTION:
(1) Keep the patient in bed, whenever rupture of the BOW had already occurred.
(2) Never rupture the membranes artificially if the head is not engaged into the
pelvic brim
(3) Correction of all abnormal presentations through an external version
whenever possible during prenatal care or while ear;y in labor provided the bag is
intact.

IMMEDIATE TREATMENT:
(1) Lower the head of the bed (Tendelenburg) when sees during labor or early in
labor. This is to prevent compression of the cord.
(2) Do not try to repose the cord
(3) Transfer at once to the nearest hospital

HOSPITAL MANAGEMENT: Depend on several factors

1. Degree of cervical dilatation
2. Whether the baby is still alive or not
3. Parity of the patient
4. Type of presentation

If the baby is alive with the cervix partly dilated, delivery is through CS. If the
baby is already dead, vaginal delivery is permitted, irrespective of the degree of
cervical dilatation.

MANAGEMENT (Midwife)
(a) If after a reasonable period of “trial labor” vaginal delivery is not in
sight such patients must be taken to a hospital for delivery.
(b) Primiparous mothers less than fine feet in height must be delivered in the
hospital

III. DYSTOCIA DUE TO ANOMALIES OF THE PASSAGES

A. Dystocia due to anomalies of the pelvis:

(1) Contraction of the Pelvic Inlet
The inlet is said to be contracted if the antero-pposterior diameter is 10
cms. Or less (obstetrical conjugate)
Since the AP diameter of the inlet may be measured through the diagonal
conjugate, inlet contraction may also able to be define as shortening of the
diagonal conjugate to a diameter of 11.5 cm or less. The diagonal conjugate
normally measures about 13.5 cm

CAUSES:
The most common cause of contraction of the pelvic inlet is a disease called
Rickets (lack of vitamin D) softening of the pelvic bones.
The sacrum lies at a lower level & is very close to the symphysis pubis,
causing shortening of the AP diameter of the inlet (flat pelvis).
Inlet contraction can also be due to generally poor development of the
individual. Mothers of short stature- short limbo, short trunk & thoracic cage. Simple
flat pelvis – congenital origin.

DIAGNOSIS
(a) Abdominal & rectal – Millea Impression Method :
The head of the fetus is grasped with the finger of one hand, just like the
Pawlick’s grip. The head is then pushed in the detection of the pelvic cavity,
while one finger of the free hand is inside the rectum. If the pelvic inlet is not
short, the head will be felt by the finger in the rectum to enter the pelvic brim &
vaginal delivery is possible. In the event the head does not enter the pelvic
inlet, it is possible there is inlet contraction.
(b) X-ray pelvimetry & Cephalometry : Best method of determining whether there
is inlet contraction or not.
(c) Trial Labor- a period of labor long enough to find out whether vaginal
delivery is possible or not, with safety to the mother & the baby. The time of such
trial labor may vary from 6 to 10 hrs. the FHT must be watched carefully.

(2) Contraction of the midpelvis

The plane of the midpelvis is that area bounded by the anterior margin of
the symphysis pubis in front; the ischial spine at the side ; & the junction of
the 4th & 5th sacral vertebra at the back.
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The normal measurements are:
 Inter-ischial spine = 10.5 cm
 AP diameter = 11.5 cm
 Posterior sagittal (from the midpoint of the interspinous line to the junction of
the 4th & 5th sacral vertebrae = 5.1 cm

When the sum of the inter-ischial spinous & the posterior sagittal diameter
(10.5 cms plus 5.0 cm) is 13.5 cms or below, then a midpelvic contraction is present. A
midpelvic contraction is present when the inter-ischial diameter alone is below 9.5 cm.

DIAGNOSIS:
This is best attained through an X-ray pelvimetry. The mid-pelvic
contraction is present or should be suspected whenever the ischial spines feel to
prominent as felt during an internal examination.

PROGNOSIS- not all cases with actual midpelvic contraction will develop dystocia during
labor. The following factors must be considered:
(1) The size of the baby
(2) The size of the pelvic inlet
(3) The character of the uterine contractions. If ever dystocia develops the
usual type is seen in cases of occiput-posterior, where there is transverse arrest
of the fetal head during internal rotation through as arch 135 degrees. Delivery is
effected through a forceps extraction.

MANAGEMENT:
Such cases of prolonged second stage of labor are better delivered in
hospitals, more so when the mother is primiparous.

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