Dystocia &

Obstructive Laborby, Fahad Mohsen Al-Otaibi

Supervissor, Ass. Prof. Mohammad Al-Khatim

CPD(disproportions)DefinitionsEtiology ManagementSoft tissues obstructionEtiology ManagementComplicationsRuptured uterus Etiology Management

Dystocia

Definition Etiology Maternal & fetal

complications Management

Objectives

Dystocia - Definition

Means difficult labor and is characterized by abnormally slow or no progress of labor.

Dystocia - Etiology

Persistent Occipitotransverse Position Persistent Occipitoposterior Position

Abnormal fetal position

Macrosomia hydrocephalus Meningocele or meningomyelocele

Abnormal fetal structure

Cephalopelvic DisproportionContracted plvis

Maternal pelvic abnormalities

Duo to epidural anesthesia for pain control Conduction anesthesia

When the head fails to flex and rotate → persists in an occipitotransverse position . causes : Cephalopelvic disproportion , Altered pelvic architecture with a platypelloid or android pelvis & Relaxed pelvic floor, brought about by epidural anesthesia or multiparty . management : If fetal head is at or above the level of the ischial spines or the midpelvis is compromised, when the pelvis is of a platypelloid or android type → Cesarean delivery . normal size pelvis, uterine contractions are inadequate &the fetus is not macrosomic → Oxytocic stimulation of labor or by Manual rotation using the fingers of the examiner's hand or forceps rotation using Kielland forceps .

Persistent Occipitotransverse Position

Manual rotation using the fingers of the examiner's hand or forceps rotation using Kielland forceps

Macrosomia

Definition : fetal weight ≥ 4.0 or 4.5 kg . Risk factors : more in male fetus , previous macrosomic infant , excessive maternal weight gain , multiparty , postterm pregnancies , GDM . Diagnosis : clinically & US . Complications : prolonged pregnancy , cephalopelvic disproportion , obstructed labour , shoulder dystocia , birth injuries &future baby obesity . Management Proper prenatal care to prevent macrosomia and diagnose it before labor .Caesarean delivery .

• an enlargement of the fetal head due to accumulation of excessive cerebro-spinal fluid (C.S.F) within the ventricles.

• 0.5-1.8 per 1000 births .• Causes : Genetic aberration as trisomies ,

infections: as cytomegalovirus, toxoplasmosis and rubella or idiopathic .

• Diagnosis : US , large head with biparietal diameter >12 cm , dilated cerebral lateral ventricles , small face in relation to the head size & the thickness of cerebral cortex .

• Complications : obstructed labor with its sequel as rupture uterus & fetus: neurological manifestations and low growth rate.

Hydrocephalus

• intrauterine ventriculo-amniotic shunt: to drain the CSF from the cerebral ventricles into the amniotic cavity .

• In Cephalic presentation , if the cervix is dilated→ transcervical aspiration by a needle or perforation through a gaping suture or fontanelle is done.

if the cervix is not dilated→ transabdominal aspiration with the aid of ultrasonic visualization , traction on the collapsed head can then applied forceps.

• In Breech presentation: •CSF is drained through: Spinal tapping through spina bifida if

present.• cesarean section to avoid the risk of infection, which can result

from transvaginal or trans-abdominal drainage

Management Hydrocephalus

• ascites in the fetal abdomen or enlargement of fetal organs, such as the bladder or liver, may result in unexpected dystocia after the fetal head is delivered →Ascitic fluid or urine from a bladder removed by transabdominal drainage with a needle before vaginal delivery .Cesarean delivery may be indicated if the fetal abdomen cannot be sufficiently decompressed.

• Postpartum:the living newborn should be referred for shunt operation.

…Management Hydrocephalus

Cephalopelvic Disproportion

• Definition: Maternal bony pelvis is not of sufficient size and of appropriate shape to allow the passage of the fetal head.•Maternal causes : Contractions of one of the planes of the pelvis . •Fetal causes :Excessively large fetal head or abdomen & Abnormal positioned fetus . •Degrees & management

Degree Management

Minor disproportion: The anterior surface of the head is in line with the posterior surface of the symphysis.

Vaginal delivery can be achieved

Moderate disproportion (1st degree disproportion):The anterior surface of the head is in line with the anterior surface of the symphysis.

Vaginal delivery may or may not occur

Marked disproportion (2nd degree disproportion):The head overrides the anterior surface of the symphysis.

c-s.

Contracted pelvis

Definition: Anatomical definition: It is a pelvis in which one or more of its diameters are reduced below the normal by one or more centimeters.Obstetric definition: It is a pelvis in which one or more of its diameters are reduced so that it interferes with the normal mechanism of labor.

Causes

Causes in the pelvis:

Developmental (congenital): Small gynaecoid or

anthropoid pelvis

Small android or

platypelloid pelvis type

Split pelvis: splitted

symphysis pubis.

Metabolic:

Neoplastic: as osteoma

Osteomalacia

Traumatic: as fractures.

Rickets

Causes in the spine

Lumbar kyphosis.

Lumbar scoliosis

Contracted pelvis

History Rickets: a history of delayed walking and dentition. Trauma or diseases: of the pelvis, spines or lower limbs. Bad obstetric history: e.g. prolonged labor ended by: difficult forceps & caesarean section .

Examinations

General examination: Gait: abnormal gait suggesting abnormalities in the pelvis,

spines or lower limbs. Stature: women with less than 150 cm height usually

have contracted pelvis. Spines and lower limbs: may have a disease or lesion. Manifestations of rickets as: square head , pigeon chest

&Bow legs. Abdominal examination: 1-Non engagement of the head: in the last 3-4 weeks in primigravida. 2-Malpresentations: are more common.

Investigations

Pelvimetry : assessment of the pelvic diameters.Imaging : X-ray , CT scan , MRI.

Diagnosis Contracted pelvis

Management

depends mainly on the degree of disproportion

Minor

vaginal delivery

Moderate

trial labor, if failed caesarean

section .

Sever

caesarean section

Contracted pelvis

Complications

Maternal Fetal

During pregnancy: ↑retroverted gravid

uterus.   Malpresentations. Pendulous

abdomen                Nonengagement. Pyelonephritis due

to more compression of the ureter.

During labour: Slow cervical

dilatation and prolonged labour.

Premature rupture of membranes and cord prolapse.

Obstructed labour and rupture uterus.

Injury to pelvic joints or nerves from difficult forceps delivery.

Postpartum hemorrhage.

Intracranial hemorrhage.     

Asphyxia.                Fracture skull. Nerve injuries.                 Intra-amniotic

infection

Contracted pelvis

Obstructed labor

It is the arrest of vaginal delivery of the fetus due to mechanical obstruction . Maternal causes :Bony obstruction:

• Contracted pelvis. • Tumors of pelvic bones.

Soft tissue obstruction: • Uterus: impacted subserous pedunculated fibroid,

constriction ring opposite the neck of the fetus. • Cervix: cervical dystocia.• Vagina: septa, stenosis, tumors.• Ovaries: Impacted ovarian tumors.

Fetal causes : • Malpresentations and malpositions: Persistent occipito transverse position and arrest, Brow, Shoulder, Impacted breech • Large sized fetus (macrosomia). • Congenital anomalies: Hydrocephalus. Fetal ascitis.      Fetal tumors. Twins.

…Obstructed labor

1-history:• prolonged labor, • frequent and strong uterine contractions, • Rupture membranes.

2-Examination

General examination:• It shows signs of maternal distress as: exhaustion, high

temperature (³ 38oC) & rapid pulse .• Signs of dehydration: dry tongue and cracked lips.

Diagnosis Obstructed labor

Abdominal examination: The uterus: hard ,tender & frequent strong uterine contractions with no relaxation. The fetus: fetal parts cannot be felt easily & FHS are absent or show fetal distress due to interference with the utero-placental blood flow.

Vaginal examination:1. Cervix: is fully or partially dilated. 2. The membranes: are ruptured. 3. The presenting part: is high and not engaged or impacted

in the pelvis.

…Diagnosis Obstructed labor

1. Failure of the presenting part to descend2. Partogram will show above 2 parameters

Diagnostic criteriaObstructed labor

Complication 1-Maternal:

• Maternal distress • Rupture uterus. • Necrotic vesico-vaginal fistula. • Infections as chorioamnionitis and puerperal sepsis. • Postpartum hemorrhage due to injuries or uterine atony.

2-Fetal: • Asphyxia.        • Intracranial hemorrhage. • Birth injuries. • Infections.

Obstructed labor

Preventive measures:

Careful observation, proper assessment, early detection and management of the causes of obstruction.

Prophylactic measure:

1-Antibiotic(At risk of tetanus, Clostridium Welchii)

2-ttt of shock(Dehydration, hypovolemic, septic) Curative measures:

Caesarean section is the safest method

ManagementObstructed labor

Definition: Dehiscence:is define as: separation of a lower uterine scar that does not penetrate the serosa and rarely causes significant hemorrhage. Rupture is defined as complete separation of the uterine wall and may lead to significant hemorrhage and fetal distress.

Uterine Dehiscence or Rupture

Incidence • Uterine rupture occurs in 0.2% to 1% of patients with a

previous low-segment transverse cesarean section • 4% to 9% of patients with a prior uterine active segment

incision (classical or T-incision)• One-third of women with a history of previous classical

cesarean section who experience rupture do so before onset of labor

…Uterine Dehiscence or Rupture

• previous uterine surgery• cesarean section, myoectomy, previous resection of a

cornual ectopic pregnancy, or previous uterine perforation

• Induction of labor with prostaglandin agents in the setting of a history of a previous cesarean further increases the risk of rupture

• Other risk factors are internal version or extraction, operative delivery, and trauma

Risk factors

Uterine Dehiscence or Rupture

• Fetal bradycardia is clinically manifested in 33% to 70% of cases

• Fetal distress may be initial presentation in catastrophic uterine rupture

• In milder cases the initial presentation is a simple rise in fetal station or change in position for fetal heart monitor placement.

• fetal parts may be more easily palpable abdominally• Maternal signs and symptoms include constant abdominal

pain , shock ( hypotension and tachycardia), cessation of uterine contractions, uterine tenderness, or a change in uterine shape, vaginal bleeding

Diagnosis Uterine Dehiscence or Rupture

Management

• Emergent laparotomy with delivary of the infant and repair of the uterine rupture if small thin edge no bleeding not extended to uterine artery

• If not hysterectomy .

Uterine Dehiscence or Rupture

Summary

• Dystocia means difficult labor that caused by many conditions e.g. macrosomia & hydrocephalous .• many pelvic problems can lead to persistent occipitotransverse position that can be managed by C-S or stimulation of labor .• macrosomia > 4kg with high relation to GDM .• hydrocephalous can lead to obstructive labor & fetal low growth rate .• Cephalopelvic disproportion is maneged according to its degree either by vaginal delivery or C-S .• contracted pelvis causes either in pelvis or in spine .•Obstructed labor caused by bon,soft tissue obstruction or malpresentations , macrosomia & congenital anomalies .•C-S is the safest method in management of obstructed labor .• Uterine dehiscence (separation of a lower uterine scar without hemorrhage ) but rupture (complete separation of the uterine wall with significant hemorrhage and fetal distress ).• managed by either emergent laparotomy or hysterectomy .

References

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