CH 19. DYSTOCIA

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CH 19. DYSTOCIA

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• Face presentation
• Brow presentation
• Transverse lie
• Compound presentation
• Persistent occiput posterior position
• Persistent occiput transverse position
• Shoulder dystocia
• Hydrocephalus as a cause of dystocia
• Fetal abdomen as a cause of dystocia

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Fetal presentation in 68,094 (Parkland hospital)

• Presentation Percent
  Incidence
• Cephalic 96.8
  -
• Breech 2.7
  136
• Trnasverse 0.3
  1335
• Compound 0.1
  11000
• Face 0.05
  12000
• Brow 0.01
  110000

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FACE PRESENTATION

• The head hyperextended
• occiput-contact with
  fetal back
• presenting
  part-chin(mentum)
• -mentum posterior brow is compressed
  against
• the maternal
  symphysis pubis
• -mentum anterior typical
• ?convert spontaneosly
  anterior(?posterior)

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FACE PRESENTATION

• Diagnosis
• vaginal examination palpation
• (mouth, nose, malar bone , orbital ridge)
• ? mistake a breech
• anus-mouth
• ischial tuberosities-malar bone
• radiologic demonstration

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FACE PRESENTATION

• Etiology
• favors extension, prevents head flexion
• ? marked enlargement of the neck
• coils of cord about the neck
• anencephalic fetus
• pelvic contracture
• large infants
• multiparous

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FACE PRESENTATION

• Mechanism
• rarely observed above pelvic inlet
• brow presentation-converted into face
  presentation
• cardinal movement-descent, int. rotation,
  flexion
• accessory movement-extension, ext. rotation
• descent-when resistance is encountered
• occiput-pushed toward the
  back
• chin-decsent

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FACE PRESENTATION

• int. rotation
• chin-under the symphysis pubis
• neck-sustend post. surface of symphysis
  pubis
• if the chin rotates posterorly
• short neck cannot span the anterior
  sulface of
• the sacrum (12cm)
• -gthead delivery is impossible unless the
  shoulder
• enter the pelvis

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FACE PRESENTATION

• after anterior rotation and descent
• -gtchin and mouth appear at the vulva
• -gtthe head is delivered by flexion
• appear in seccession over the ant. margin of
  the
• perineum-nose, eye, brow, occiput
• next, ext. rotation-original side
• shoulders are born as the cephalic
  presentation

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FACE PRESENTATION

• face edema, head molding
• increased the length of theoccipitomental
  diameter

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FACE PRESENTATION

• Management
• successful vagianl delivery
• -gtabsence of a contracted pelvis
• with effective labor
• full-term size-c/sec is frequently indicated
• Not attempt
• convert a face manually into a vertex
• manual or forcep rotation (chin post-gtant)
• internal podalic version and extraction

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BLOW PRESENTATION

• rarest presentataion
• between the orbital ridge and the anterior
  fontanel
• at the pelvic inlet
• midway between full flexion (occiput)
• full extension
  (mentum or face)
• unstable-converts to face or occiput
• Etiology- same as face presentation

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BLOW PRESENTATION

• Diagnosis
• abdominal palpation
• vaginal examination
• -frontal suture, large anterior fontanel,
  orbital ridge
• eyes, and root of the nose
• -neither, mouth chin

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BLOW PRESENTATION

• Mechanism of labor
• very difficult, because engagement is
  impossible
• possible-large pelvis, small fetus
• marked molding
• convert to occiput or face
  presentation
• -gt deforms the head
• caput succedaneum-over the forehead

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BLOW PRESENTATION

• Prognosis
• depends upon the ultimate presentation
• if the brow persists,
• prognosis is poor
• Management
• same as those for a face presentation

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TRANSVERSE LIE

• When the long axis of the fetus is approximately
• perpendicular to that of the mother
• obligue lie, unstable lie
• shoulder-over the pelvic inlet
• head-in one iliac fossa
• breech-in the other iliac fossa

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TRANSVERSE LIE

• shoulder presentation
• -acromion direction-gt Rt. Lt
• back
• -anterior or posterior
• -superior or inferior
• (ex. Rt acrimidorsoanterior)
• Incidence 0.3

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TRANSVERSE LIE

• Etiology
• 1. Unusual relaxion of the abdominal wall
  resulting
• from high parity
• 2. Preterm ferus
• 3. Placenta previa
• 4. Abnormal uterus
• 5. Excessive amnionic fluid
• 6. Contracted pelvis

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TRANSVERSE LIE

• Diagnosis
• easily, by inspection
• -wide abdomen
• Ut fundus extends to only slightly above
  umbilicus
• palpation
• -no fetal pole in the fundus
• ballottable head in one iliac fossa
• breech in the other
• -anterior-gtback(hard resistance)
• posterior-gt irregular nodulations small
  parts

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TRANSVERSE LIE

• vaginal examination
• -the side of the thorax
• -further dilatation scapula or clavicle
• -axilla shouler direction
• -later in labor
• -gtshoulder become tightly wedged in the
  pelvis
• -gta hand and arm frequently prolapse

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TRANSVERSE LIE

• Course of labor
• spontaneous delivery is impossible with a
  persistent
• transverse lie
• ltneglected transverse liegt
• After ROM, labor continue
• fetal shoulder is forced into the pelvis, the
  corresponding
• arm frequently prolapse
• After some descent
• shoulder is arrested in pelvis, with the head is
  in the one
• iliac fossa and breech in the other

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TRANSVERSE LIE

• As labor continues
• the shoulder is impacted fermly in the upper
  part of
• the pelvis
• contracts vigorously
• After a time
• a retraction ring rises increasingly higher
• -gtif not promptly managed
• uterine rupture, mother fetus die

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TRANSVERSE LIE

• conduplicato corpore
• if small fetus(lt800g), large pelvis
• in spontaneous delivery
• -gtthe head and thorax pass through the
  pelvic
• cavity at the same time
• Prognosis
• maternal, fetal hazard increased
• even with the best care, morbidity is
  incereased
• -gtplacenta previa, cord prolapse

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TRANSVERSE LIE

• Management
• the onset of active labor- c/sec
• conversion to a longitudinal lie (before or
  early labor)
• -with the membrane intact, no indication of
  c/sec
• -at 39 wks
• -next several contraction fix the head in
  the pelvis
• if c/sec-vertical incision
• difficulty in extraction of the
  fetus
• (not foot or head on incision
  site)

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COMPOUND PRESENTATION

• An extremity prolapse alongside the presenting
• part , with both presenting in the pelvis
• Incidence 1 of 700 delivery
• Etiology
• prevent complete occlusion of the pelvic
  inlet
• by the fetal head

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COMPOUND PRESENTATION

• Prognosis and management
• perinatal loss-preterm delivery, cord
  prolapde
• traumatic obstetrical
  procedures
• prolapsed part be left alone, not
  interfere labor
• close observation-prolapsed part prevent
  descent
• if prevent-gtarm should be gently pushed
  upward
• headdownward (fudus
  pressure)

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• Most often, occiput posterior position udergo
• spontaneous anterior rotation
• failure of spontaneous rotation
• -transverse narrowing of the midpelvis
• labor and delivery need not differ
  remarkably
• from that with the occiput anterior
• in most instances, delivery can usually be
• accompliched without great difficulty once
  the head
• reaches the perineum

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• The possibilities for vaginal delivery
• 1. Await spontaneous delivery
• 2. Forceps delivery with the occiput directly
  posterior
• 3. Forceps rotation of the occiput to the
  anterior
• position and delivery
• 4. Manual rotation to the anterior position
  followed by
• spontaneous or forceps delivery

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• Spontaneous delivery
• pelvic outlet-roomy
• vaginal outlet-somewhat relaxed
• vaginal outlet is resistant, perineum is
  firm
• -gtlate 1st stage or the 2nd
  stage-prolonged
• forceps delivery is indicated
• generous episiotomy is usually needs

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• Forceps delivery as an occiput posterior
• more traction
• larger episiotomy
• complete analgesia
• the head may not even be engaged
• (BPD may not have passed through the pelvic
  inlet)
• -gtprompt c/sec is appropriate

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• Manual rotation

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• Forceps rotation
• head is engaged
• cervix fully dilated
• the pelvis adequate
• skilled operator
• ineffective expulsive effort during the 2nd
  stage

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PERSISTENT OCCIPUIT POSTERIOR POSITION

• Outcome
• labor was prolonged
• -parous 1 hrs
• nulliparous 2 hrs
• episiotomy extension was increased
• 65 required operative intervention(1994)
• Parkland hospital
• -manual rotation-gtforceps delivery
• or forceps delivery
• ?failure c/sec

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PERSISTENT OCCIPUIT TRANSVERSE POSITION

• In the absence of a pelvic architecture
  abnormality
• most likely a transitory one
• rotates to the anterior position
• Delivery
• -the occiput may be manually rotated
  anteriorly
• or posteriorly and forceps delivery carried
  out

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PERSISTENT OCCIPUIT TRANSVERSE POSITION

• if failure of spontaneous rotation is caused
  by
• hypotonic uterine dysfunction without CPD.
• oxytocin may be infused with close
  observation
• platypelloid(anteroposteiorly flat)
• android(heart-shaped) pelvis
• ?c/sec

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SHOULDER DYSTOCIA

• Incidence
• varies depending on the criteria used for
  diagnosis
• 0.9?ture shouder dystocia-0.2 (1987)
• maneuvers were required
• so, ceuurent report-0.61.4
• increasing factor(1960-1980)
• increasing birthweight
• shoulder-to-head, chest-to head
  disproportions
• increased attention

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SHOULDER DYSTOCIA

• Use of maneuvers define shoulder dystocia
• but, use of one or more maneuvers-NO
  diagnosis
• TIME INTERVAL (head to body)
• -normal 24 seconds
• -shoulder dystocia 79seconds
• ? exceeding 60 seconds define shoulder
  dystocia

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SHOULDER DYSTOCIA

• Maternal consequences
• postpartum hemorrhage- atony
• 
  lacerations (vag. or Cx.)
• puerperal infection
• Fetal consequences
• significant fetal morbidity and mortality
• transient brachial plexus palsy (m/c)
• clavicle Fx, humeral Fx, neonatal death
• persistent brachial plexus palsy
  

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SHOULDER DYSTOCIA

• Wood maneuver (direct fetal manipulation)
• -not associated with an increased rate of
  fetal
• injury
• Brachial plexus injury
• result from down traction on the brachial
  plexus
• during delivery of the anterior shoulder
• Erb palsy (C 5-6,7) hanging upper arm
• extended
  elbow
• C 7- T 1hand (clawhand deformity)
• may occur even prior to labor, recovery-13
  months

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SHOULDER DYSTOCIA

• Clavicular fracture
• 0.4
• often without any clinical events
• unavoidable
• unpredictable
• no clinical consequence

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SHOULDER DYSTOCIA

• Risk factor
• maternal factor-incresed birthweight
• obesity, multiparity,
  diabetes
• postterm
  pregnancy(gt42wks)
• Intrapartum complication
• -midforceps delivery, prolonged 1st and 2nd
  stage
• increased birthweight (common)
• but, 50-lt4,000g
• 2260g-dystocia reported

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SHOULDER DYSTOCIA

• Summary
• 1.cannot be predicted or prevented-no accurate
  
• methods
• 2.ultrasonic measurements to estimate
  macrosomia
• have limited accuracy
• 3.planned c/sec due to macrosomia
• -not reasonable strategy
• 4.planned c/sec may be reasonable
• -nondiabetes (gt5,000g)
• -diabetes (4,5000g)

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SHOULDER DYSTOCIA

• Management
• shoulder dystocia-cannot be predicted
• well versed in the management principles
• great importance to survival
• -reduction in the interval of time from
  delivery
• of the head to body
• gentle traction, assisted by maternal
  expulsive effort
• next, large episiotomy, analgesia, clear the
  infants
• mouth and nose

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SHOULDER DYSTOCIA

• 1.Moderate suprapubic pressure
• -by an assistant while downward traction
• 2.McRoverts maneuver
• -flexing the legs upon the abdomen
• -not increase pelvic diameter
• straightening of the sacrum
• symphysis pubis-toward the maternal head
• ?decrease the angle of pelvic inclination

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SHOULDER DYSTOCIA
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SHOULDER DYSTOCIA

• 3.Woods corkscrew maneuver
• -rotating the posterior
• shoulder 180 degrees
• -anterior shoulder could be
• released

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SHOULDER DYSTOCIA

• 4.Delivery of the posterior
• shoulder
• -post. arm across the chest
• then delivery
• -next, shoulder girdle rotation
• into one of the oblique
• diameters of the pelvis
• ?delevery of ant. shoulder

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SHOULDER DYSTOCIA

• 5.Rubin maneuver
• -1st, the fetal shoulder are
• rocked from side to side
• by applying force to the
• abdomen
• -if not successful,
• push the ant. shoulder toward
• the anterior surface of the
• chest

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SHOULDER DYSTOCIA

• 6.Hibbard (1982)
• -press the fetal jaw and neck in the direction
  of
• the maternal rectum
• -strong fundal pressure
• ?anterior shoulder delivery
• -only fundal pressure, absence of other
  maneuver
• 77 complication
• fetal prthoprdic and neurologoc damage

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SHOULDER DYSTOCIA

• 7.Zavanelli maneuver
• -cephalic replacement into
• the pelvis and then c/sec
• -return fetal head
• flex head
• push head back into vagina
• -terbutaline Ut relaxation
• -fetal injury
• neonatal death
• stillbirth, brain damage

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SHOULDER DYSTOCIA

• 8. Fracture of the clavicle
• -pressing the anterior clavicle against the
  ramus of
• the pubis
• -heal rapidly
• -not nearly as serious as a brachial nerve
  injury
• 9.Cleidotomy
• -cutting of the clavicle
• -usually used on the a dead fetus

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SHOULDER DYSTOCIA

• 10. Symphysiotomy
• -maternal morbidity increased
• -urinary tract injury

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SHOULDER DYSTOCIA

• Shoulder dystocia drill
• 1.call for help
• 2.generous episiotomy
• 3.suprapubic pressure
• -simple, only one assistant
• -while normal downward traction
• 4.McRoverts maneuver
• -two assistants
• ?resolve most case
• if fail, next steps may be attempted

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SHOULDER DYSTOCIA

• 5. the woods screw maneuver
• 6. posterior arm delivery is attempted
• 7. other technique
• -Zavanelli maneuver
• -fracture of ant. clavicle, humerus

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HYDROCEPHALUS AS A CAUSE OF DYSTOCIA

• Hydrocephlus is an excessive accumulation of
• cerebrospinal fluid with consequent cranial
• enlargement
• associated defects are common (neural tube
  defect)
• head circumference 32-38cm, fluid
  500-1500ml
• hydrocephalus 50-80cm, fluid 5l
• 1/3-breech, but whatever presentation,
• gross CPD and serious dystocia

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HYDROCEPHALUS AS A CAUSE OF DYSTOCIA

• Diagnosis
• sonography
• -compare the diameter of the lateral
  ventricle to
• the BPD of the head
• -evaluate the thickness of the cerebral
  cortex
• -compare the size of the head to that of
  the
• thorax and abdomen

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HYDROCEPHALUS AS A CAUSE OF DYSTOCIA

• Management
• the size of the hydrocephalic head must be
  reduced
• in vaginal delivery and c/sec
• cephalocentesis
• -be limited to fetuses with severe
  associated
• abnormalities
• -recommended that all others be delivered
• abdominally

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HYDROCEPHALUS AS A CAUSE OF DYSTOCIA

• Technique of cephalocentesis
• cephalic presentation
• -Cx 3-4cm dilatation
• vetricle may be tapped (8-inch, 17-gauge
  needle)
• breech presentation
• -after breech and trunk delivered
• the face toward the martenal back
• transvaginally, below the ant. vaginal
  wall
• protect the birth canal

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HYDROCEPHALUS AS A CAUSE OF DYSTOCIA

• via martenal abdomen into the fetal head
• -bladder empty
• skin cleansed
• the needle in the midline below the
  maternal
• umbilicus
• -before oxytocin stimulation
• -more successfully sono-guided

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FETAL ABDOMEN AS A CAUSE OF DYSTOCIA

• Enlargement of the fetal abdomen
• greatly distended bladder
• ascites
• enlargement of the kidney or liver
• edematous fetal abdomen
• before delivery, decision is made
• but, prognosis is very poor