Dystocia = Difficult / Abnormal labor

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Dystocia Difficult / Abnormal labor

• Greek'dys' 'difficult, painful, disordered,
  abnormal' 'tokos' meaning 'birth'.

Dr. E Gdansky
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DystociaIncidence

• Overall?Retrospective/Unreported in normal
  vaginal delivery
• Primiparous women 25 have dystocia
• Most common indication for primary CS
• 50 of CSs are related to dystocia

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First Stage of Labor
Duration Primip. 6-18 Multip. 2-10
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DystociaAbnormal patterns of labor
Primipara Multipara
Prolonged latent phase (Normal mean 6.4 h) gt20 h (Normal mean 4.8 h) gt14 h
Protracted dilatation lt1.2 cm/h lt1.5 cm/h
Protracted descent lt1 cm/h lt2 cm/h
Protracted 2nd stage (Normal mean 50 min) gt2 h (1 h) (Normal mean 20 min) gt1 h (1 h)
Arrest of dilatation gt2 h gt2 h
Arrest of descent gt1 h gt1 h
Precipitate labor lt3 h from onset of contractions
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DystociaClassification

• Powers
• Passage
• Passenger

• Contractions
• Expulsive forces
• Maternal pelvis
• The fetus (Malposition/Malpresentation)

A combination of these factors
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Dystocia

• Causes

• Treatment

• Dysfunctional uterine contractions
• Hypotonic uterine contracions
• Malpresentation (Asynclitism, OP, DTA, face,
  braw)
• Cephalo-pelvic disproportion CPD
• Epidural
• Pelvic tumor

• Sedation
• Hydration
• Augmentation of labor(amniotomy, oxytocin)
• Instrumental delivery
• Cesarean section

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Dystocia Abnormalities of the passage
Inlet
Mid-pelvis
Outlet
Current Diagnosis Treatment Obstetrics
Gynecology - 10th Ed. (2007)
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Dystocia Abnormalities of the passage

• Bony pelvis- Gynecoid (50)- Android (33
  white, 15 black)- Anthropoid (50 black, 20
  white)-Platypelloid (lt3)

A-P mid-pelvis
True conjugate
Obstetric
Diagonal
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Dystocia Abnormalities of the passage

• Classification
• Contraction of the pelvic inlet
• Contraction of the mid-pelvis and pelvic outlet
• General contraction of the pelvis
• Pelvic deformities

traumatic fracture, rickets, chondrodystrophic
dwarfism, kyphosis scoliosis,exostosis, bone
neoplasia
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Dystocia Abnormalities of the passage

• Conjugate- diagonal (lt11.5)- obstetric (lt10
  cm)- true
• Transverse diameter (lt12 cm)
• Interspinous diameter (lt8 cm)
• Intertuberous diameter (lt8 cm)

• Pelvimetry
• X-ray
• US
• MRI
• Clinical pelvimetry

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Dystocia Abnormalities of the passage

• Soft tissue (uterine or vaginal congenital
  anomalies, scarring of the birth canal)
• Pelvic mass / neoplasia
• Placental location (low implantation / previa)

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DystociaObstructed labor

• Bandls retraction ring Uterine rupture
• Vescicovaginal rectovaginal fistula
• Pelvic floor injury
• Increased neonatal morbidity mortality

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DystociaAbnormalities of the powers

• Normal contractions- Fundal dominance-
  Intensity gt24 mmHg (40-60 mmHg)- Synchronized-
  Basal pressure 12-15 mmHg- Frequency 3-5/10
  min- Duration 60-90 sec- Rhytm force are
  regular
• Hypotonic (causes excessive sedation, early
  epidural, over-distended uterus)
• Hypertonic(causes abruptio, oxytocin, CPD,
  fetal malpresentation, latent phase of labor)

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Dystocia Abnormalities of the powers

• External/ internal Tocodynamometer
• Montevideo unit gt200 mmHg is sufficient for
  normal progress

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Dystocia Abnormalities of the powers

• Hypotonic ? Amniotomy Oxytocin
  augmentation
• Hypertonic ? Decrease/stop oxytocin Tocolysis
  Sedation in latent phase Oxytocin (?)

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Dystocia Management of Labor

• In any case of CPD (relative or absolute) or
  failure treat abnormal progress ? CS
• Second stage disorder with no evidence of CPD
  can, in certain conditions, be treated with
• Vacuum - Assisted Delivery
• Forceps Delivery

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Dystocia Precipitate labor

• lt3 h from onset of contraction
• Primipara Multipara
• Precipitate dilatation gt5 cm/h 10 cm/h
• CausesExtremely strong contractions low birth
  canal resistanceOxytocin ( associate with
  placental abruption)
• TreatmentStop oxytocinbeta mimetics
  (terbutaline / ritodrine)

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