Comlplications of labor and

delivery
DYSTOCIA

 DEFINITION & CLASSIFICATION

 Dystocia is defined as difficult labor or
childbirth. It may be associated with
abnormalities involving the maternal pelvis,
the fetus, the uterus and cervix, or a
combination of these factors.
 INCIDENCE
 The rise in the number of cesarean sections
has been largely attributable to an increase in
primary cesareans for dystocia and in the
number of repeat cesarean sections
 The main indications for cesarean section were
dystocia, followed by prior cesarean delivery, breech
presentation, fetal distress, and others, including
maternal request.

 Dystocia is currently the most common indication for

primary cesarean section, and is about three times
more common than either nonreassuring fetal status
or malpresentation.
Abnormalities of the Passage

 Abnormalities of the passage constitute pelvic

dystocia,ie, aberrations of pelvic architecture
and its relationship to the presenting part. Such
abnormalities may be related to size or
configurational alterations of the bony pelvis,
soft tissue abnormalities of the birth canal,
reproductive tract masses or neoplasia, or
aberrant placental location.
Abnormalities of the Passenger

 Abnormalities of the passenger are known as

fetal dystocia, ie, difficulties caused by
abnormalities of the fetus.

 Common fetal abnormalities leading to

dystocia include excessive fetal size,
malpositions, congenital anomalies, and
multiple gestation.
Abnormalities of the Powers
 Abnormalities of the powers constitute uterine dystocia,
uterine activity that is ineffective in eliciting the normal
progress of labor.

 Hypertonic, hypotonic, or discoordinated uterine activity

is characteristic of ineffective uterine action.

 Lack of voluntary expulsive effort during the second

stage may also impede the normal course of delivery.
ABNORMAL PATTERNS OF LABOR

Labor is a dynamic process characterized by uterine

contractions that increase in regularity, intensity, and
duration, causing progressive dilatation and effacement
of the cervix and descent of the fetus through the birth
canal.

The progress of labor is evaluated primarily through

estimates of cervical dilatation and descent of the fetal
presenting part.
(1)prolonged latent phase

(2) protraction disorders (protracted active-

phase dilatation and protracted descent)

(3) arrest disorders

(4) precipitate labor disorders

1. Prolonged Latent Phase

 The latent phase of labor begins with the onset of regular

uterine contractions and extends to the beginning of the
active phase of cervical dilatation.

 The duration of the latent phase averages 6.4 hours in

nulliparas and 4.8 hours in multiparas.

 The latent phase is abnormally prolonged if it lasts more

than 16 hours in nulliparas or 14 hours in multiparas.
 Causes of prolonged latent phase include excessive
sedation or sedation given before the end of the latent phase

 the use of conduction or general anesthesia before labor

enters the active phase

 labor beginning with an unfavorable cervix

 uterine dysfunction characterized by weak, irregular,

uncoordinated, and ineffective uterine contractions

 fetopelvic disproportion
 Treatment options in prolonged latent phase
primarily consist of therapeutic rest regimens
or active management of labor.

 After 6–12 hours of rest with sedation , 85% of

patients spontaneously enter the active phase
of labor, and further progression in dilatation
and effacement may be expected.
 Ten percent of patients will have been in false labor,
and may be allowed to return home to await the
onset of true labor if fetal status is reassuring.
 In the remaining 5% of patients, uterine contractions
remain ineffective in producing dilatation
 in the absence of any contraindication, active
stimulation of labor with oxytocin infusion may be
effective in terminating the latent phase of labor.
2. Protraction Disorders
 Protracted cervical dilatation in the active phase of labor
and protracted descent of the fetus constitute the
protraction disorders.

 Protracted active-phase dilatation is characterized by an

abnormally slow rate of dilatation in the active phase, ie,
less than 1.2 cm/h in nulliparas or less than 1.5 cm/h in
multiparas.

 Protracted descent of the fetus is characterized by a rate

of descent under 1 cm/h in nulliparas or under 2 cm/h in
multiparas.
 The second stage of labor, which normally
averages 20 minutes for multiparous women and
50 minutes in nulliparous women, is protracted
when it exceeds 2 hours in nulliparas or 1
hour in multiparas, or 3 and 2 hours
respectively in the presence of conduction
anesthesia.
 The underlying pathogenesis of protracted labor
is probably multifactorial.
 Fetopelvic disproportion is encountered in
about one-third of patients.
 Other factors include minor malpositions such
as occiput posterior, improperly administered
conduction anesthesia, excessive sedation,and
pelvic tumors obstructing the birth canal.
 Treatment of protraction disorders depends on the
presence or absence of fetopelvic disproportion, the
adequacy of uterine contractions, and the fetal status.

 Cesarean section is indicated in the presence of

confirmed fetopelvic disproportion..
 In the absence of fetopelvic disproportion,
conservative management, consisting of
support and close observation, and therapy
with oxytocin augmentation both carry a good
prognosis for vaginal delivery if continued
cervical dilation and effacement occur and
there is no fetal compromise.
 The prognosis for the fetus is closely related
to the quality of delivery.

 Spontaneous vaginal delivery or delivery

achieved with minimal manipulation is the
most crucial factor favoring good fetal
outcome.
3. Arrest Disorders

 The four patterns of arrest in labor may be characterized as

follows:
(1) prolonged deceleration, with deceleration phase lasting more
than 3 hours in nulliparas or more than 1 hour in multiparas,

(2) secondary arrest of dilatation, with no progressive cervical

dilatation in the active phase of labor for 2 hours or more,

(3) arrest of descent, with descent failing to progress for 1 hour or

more,
(4) failure of descent, with descent failing to occur during the
deceleration phase of dilatation and during the second stage.
 About 50% of patients with arrest disorders
demonstrate fetopelvic disproportion. Other
causative factors include various fetal
malpositions , inappropriately administered
anesthesia, or excessive sedation.
 When an arrest disorder is diagnosed, thorough
evaluation of fetopelvic relationships before
initiating treatment is crucial.
 Evaluation should include a careful clinical pelvic
examination for pelvic adequacy and estimation
of fetal weight.

 If fetopelvic disproportion is established in the

context of an arrest disorder, cesarean section is
clearly warranted.
 If fe-topelvic disproportion is not present and
uterine activity is less than optimal, oxytocin
stimulation is generally effective in producing
further progress.
 Arrest disorders generally carry a poor
prognosis for vaginal delivery. If allowed to
continue, arrest disorders are associated with
increased perinatal morbidity.
4. Precipitate Labor Disorders

 Precipitate dilatation occurs if cervical dilation

occurs at a rate of 5 or more centimeters per
hour in a primipara or at 10 cm or more per
hour in a multipara.
 Precipitate descent occurs with descent of the
fetal presenting part of 5 cm or more per hour
in primparas and 10 cm or more per hour in
multiparas.
 Precipitate labor may result from either
extremely strong uterine contractions or low
birth canal resistance.
 Abnormal contractions may be associated with
administration of oxytocin.
 Strong uterine contractions(both in force and
increased basal tone) may also accompany
abruptio placentae
 If oxytocin administration is the cause of abnormal
contractions, it may simply be stopped.

 If excessive uterine activity is associated with fetal heart

rate abnormalities,and this pattern persists despite
discontinuation of oxytocin, ritodrine can be given slowly
by intravenous injection if there are no contraindications.
 Magnesium sulfate has also been recommended to
decrease uterine contractions.
 Physical attempts to retard delivery are absolutely
contraindicated.
 Maternal complications are rare if the cervix
and birth canal are relaxed.
 When the birth canal is rigid and extraordinary
contractions occur, uterine rupture may result.
 Lacerations of the birth canal are common. In
addition, precipitate labor is one of the known
antecedents of maternal amniotic fluid
embolism. Thus enhanced maternal monitoring
for this complication is imperative.
 the uterus that has been hypertonic with labor
tends to be hypotonic postpartum, thereby
predisposing to postpartum hemorrhage.

 Perinatal mortality is increased secondary to

hypoxia,possible intracranial hemorrhage, and
risks associated with unattended delivery.
PATHOGENESIS & TREATMENT

 1 Abnormalities of the Passage

 Causes of abnormalities of passage include
bony abnormalities, soft tissue obstruction of
the birth canal, and abnormal placental
location. Pelvic dystocia, particularly that due
to small bony architecture, is the most
common cause of passage abnormalities.
 The 4 major adult pelvic types: gynecoid,
android, anthropoid, and platypelloid. Pure
forms of these pelvic types are rare; mixed
elements are more often present in each type
of pelvis.
 The gynecoid pelvis is considered the most typically
“female” type and is the most favorable for
uncomplicated vaginal delivery The pelvic inlet has an
oval configuration with a transverse diameter slightly
greater than the anteroposterior diameter.Pelvic side
walls are straight, the ischial spines are not prominent,
the subpubic arch is wide, and the sacrum is concave
 The android, or male, type of pelvis is found in about
33% of white women and about 15% of black women.
The inlet is wedge-shaped with convergent side walls,
the ischial spines are prominent, , the subpubic arch is
narrowed, and the sacrum is inclined anteriorly in its
lower third. The android pelvis is associated with
persistent occiput posterior position and deep transverse
arrest
 The anthropoid pelvis is present in about 85% of black women
and 20% of white women. The inlet is oval, with a anteroposterior
diameter greater than the transverse diameter. Pelvic side walls
are divergent, and the sacrum is inclined posteriorly. This pelvic
type is most often associated with persistent occiput posterior
position.
 The platypelloid pelvis is present in fewer
than 3% of all women. This pelvis is
characterized by a transverse diameter that is
wide with respect to the anteroposterior
diameter. Deep transverse arrest patterns of
labor are with this pelvic type.
 Contractions of the pelvis are generally
classified as contractions of the inlet,
midpelvis, or outlet, or as a combination of
these elements.
 Inlet contraction is suspected if the
anteroposterior diameter of the pelvis is less
than 10 cm
 In prolonged labors complicated by inlet
contraction, considerable molding of the fetal
head, caput succedaneum formation, and
prolonged rupture of the membranes are
common.
 Midpelvic-outlet contraction
 Critical contraction 10cm for the interspinous
diameter, intertuberous diameter 7.5 cm
 Relative contraction 8.5-9.5 cm for the
interspinous diameter, intertuberous diameter 6-
7cm
 Absolute contraction 8 cm for the interspinous
diameter, intertuberous diameter 5.5cm
 Techniques for estimating midpelvic adequacy
include the sum of the posterior sagittal diameter
and interspinous diameter, which should be
greater than 13.5 cm.
 Criteria for assessing pelvic outlet adequacy
include intertuberous diameter greater than 8 cm
and a sum of the intertuberous diameter and the
posterior sagittal diameter greater than 15 cm.
 Poor prognosis for vaginal delivery is typical in
midpelvic outlet obstruction, cesarean section is
therefore the delivery method of choice in this
complication.

 Other anatomic abnormalities of the reproductive

tract may cause dystocia.
 Soft tissue dystocia may be caused by uterine or
vaginal congenital anomalies,scarring of the
birth canal, pelvic masses, or low implantation of
the placenta.
2 Abnormalites of the Passenger

 Fetal dystocia is abnormal labor caused by

malposition or malpresentation, excessive
size of the fetus, or fetal malformation.
 1.) Vertex malpositions—
 a. Occiput posterior—The occiput posterior
position may be normal in early labor, with
about 10–20% of fetuses in occiput posterior
position at onset of labor.
 In 87% of cases, the head rotates to the
occiput anterior position when it reaches the
pelvic floor.
 If the head does not rotate, persistent
occiput posterior position may result in
dystocia.
 Occiput posterior presentation may result
from a contracted anthropoid or android
pelvis or insufficient uterine action.
 The use of epidural anesthesia and oxytocin
augmentation have been associated with
higher rates of occiput posterior presentation.
 The diagnosis of occiput posterior position is
generally made by manual vaginal
examination of the orientation of the fetal
cephalic sutures.
 Maternal morbidity, including extension of
episiotomies, higher rates of anal sphincter
injury, and other birth canal lacerations,
occurs more frequently in occiput posterior
deliveries.
 b. Occiput transverse—Occiput transverse
is also frequently a transient position.
Persistent occiput transverse is associated
with pelvic dystocia, uterine dystocia, and
platypelloid or android pelvis.
 When the fetal head engages but for various
reasons does not rotate spontaneously in the
midpelvis as in normal labor, midpelvic transverse
arrest is diagnosed.
 Deep transverse arrest occasionally occurs at the

inlet, with molding and caput succedaneum formation

falsely indicating a lower descent. Cesarean section is
required.
c Brow presentation—

 Browpresentations usually are transient fetal

presentations with deflexion of the fetal head.
 During the normal course of labor, conversion to
face or vertex presentation generally occurs.
 If no conversion takes place, dystocia is likely.
 Brow presentation occurs in approximately
0.06% of deliveries.
 The diagnosis is made by vaginal examination.
 Initial management is expectant, as
spontaneous conversion to vertex presentation
occurs in more than one-third of all brow
presentations.
 Oxytocin is not recommended
 liberal use of cesarean section should be made.
d Face presentation—

 Face presentation is associated with grand

multiparity, advanced maternal age, pelvic
masses, pelvic contraction, multiple gestation,
placenta previa, and premature rupture of the
membranes.
 Diagnosis of face presentation is most often
accomplished by vaginal examination. The
prognosis for vaginal delivery is guarded.
Complications generally arise.
2). Abnormal fetal lie—
 In transverse or oblique lie, the long axis of the fetus is
perpendicular to or at an angle to the maternal
longitudinal axis.

 Causative factors include grand multiparity, prematurity,

pelvic contraction, and abnormal placental implantation.

 When the diagnosis is made in the third trimester prior to

labor, external cephalic version enables a number
of these patients to undergo vaginal delivery.

 Abnormal axial lies have a 20 times greater incidence of

cord prolapse than vertex presentations.
3) Compound presentation

 Compound presentations are often diagnosed

during physical examination and investigation
for failure to progress in labor. Most commonly,
a hand is palpated beside the vertex.
 Labor in most of these patients will end in
uncomplicated vaginal delivery, but cesarean
section should be done in the presence of
dystocia or cord prolapse.
4). FETALMACROSOMIA

 Excessive fetal size encompasses those fetuses

that are large for gestational age (LGA) and
those with macrosomia.
 LGA implies a birthweight greater than the 90th
percentile, and macrosomia implies growth
beyond a certain size, usually 4000–4500 g,
regardless of gestational age.
 A better estimated weight may be possible with real-
time ultrasonography and standard measured
parameters, but ultrasound also lacks accuracy,
particularly with increased fetal size.
 While morbidities to infant and mother increase with
increasing size between 4000 and 4500 g
 perinatal mortality for fetuses weighing more than
4500 g is about fivefold higher than in normal term
infants, and incidence of shoulder dystocia is at
least 10% in this group.
5) Shoulder dystocia

 Shoulder dystocia, or difficult delivery of the shoulders

after delivery of the fetal head, is an obstetric
emergency, with high risk of fetal brachial plexus injury,
hypoxia, or asphyxia.

 The incidence of shoulder dystocia is 0.15–1.7% of all

vaginal deliveries.

 After the fetal head delivers, it retracts back on the

maternal perineum.
 The first thing to do is to call for assistance.
Then if gentle posterior and inferior traction of
the fetal head is not successful, the McRobert’s
maneuver may be attempted, which is a rotation
of the symphysis pubis.
 The patient’s legs are sharply flexed against her
abdomen in an attempt to free the anterior
shoulder of the fetus.
 Episiotomy may reduce soft tissue dystocia and
allow the operator to maneuver more easily.

 Delivery of the posterior arm or intentional

fracture of the clavicle may be required to effect
delivery.
 If all else fails and there is a chance for a good
fetal outcome, a symphysiotomy or replacement
of the fetal head into the vagina in the flexed
position may be performed, then an urgent
cesarean section is performed
 .
6). FETALMALFORMATION

 Fetal malformation may cause dystocia, primarily

through fetopelvic disproportion. The most common
malformation is hydrocephalus, with an incidence of
0.05%. Management is determined by the severity
of the disorder and its prognosis.
 Other fetal anomalies that may prevent the normal
progress of labor include enlargement of the fetal
abdomen caused by distended bladder, ascites, or
abdominal neoplasms; or other fetal masses,
including cystosarcoma.
3 Abnormalities of the Powers

 Uterine dystocia denotes any abnormality in

the force or coordination of uterine contractility
that prevents the normal progress of labor.
 Studies of normal uterine activity during labor have
revealed the following characteristics:
(1) the relative intensity of contractions is greater in the
fundus than in the midportion or lower uterine segment
(this is termed fundal dominance);

(2) the average value of the intensity of contractions is

more than 24 mm Hg
 (3) contractions are well synchronized in
different parts of the uterus;
 (4) the basal resting pressure of the uterus is
between 12 and 15 mm Hg;
 (5) the frequency of contractions progresses
from one every 3–5 minutes to one every 2–3
minutes during the active phase
 (6) the duration of effective contraction in
active labor approaches 60 seconds

 (7) the rhythm and force of contractions are

regular.
 .
 The external tocodynamometer is a pressure
sensor placed over the fundal prominence of
the uterus that gives an accurate determination
of the frequency and duration of uterine
contractions.
Uterine dysfunction generally comprises 3
categories:
 hypotonic dysfunction,
 hypertonic dysfunction,
 uncoordinated dysfunction.
 Hypotonic dysfunction is uterine activity
characterized by contraction of the uterus with
insufficient force (< 24 mm Hg), irregular or
infrequent rhythm, or both. Seen most often in
primigravidas in the active phase of labor
 It may be caused by excessive sedation, early
administration of conduction anesthesia, twins,
polyhydramnios, or overdistention of the uterus.
 Hypotonic dysfunction responds well to oxytocin;

 Care must be taken to first rule out

cephalopelvic disproportion and
malpresentation.
 Active management of labor has been shown to
decrease perinatal morbidity and cesarean
section rates.
 Hypertonic uterine contractions and
uncoordinated contraction often occur together
and are characterized by elevated resting tone
of the uterus
 Dys-synchronous contractions with elevated
tone in the lower uterine segment, and frequent
intense uterine contractions.
 Treatment may require tocolysis, decrease or
stop in oxytocin infusion,or cesarean section as
indicated for concomitant malpresentation,
cephalopelvic disproportion, or fetal distress.
 . When these patterns occur in the latent phase
of labor, sedation may be effective in converting
hypertonic contractions to normal labor patterns.
 Hypertonic labor may also cause precipitate
labor disorders, resulting in fetal intracranial
hemorrhage, fetal distress, neonatal injury or
depression, and birth canal lacerations from
rapid delivery.
 Inadequate pushing in the second stage of labor is
common and may be caused by conduction anesthesia,
oversedation, exhaustion, or neurologic dysfunction, or
by psychiatric disorders.

 Mild sedation or a waiting period to permit analgesic or

anesthetic agents to wear off may improve expulsive
efforts,

 Outlet forceps or vacuum delivery may be effected in

selected cases.