DYSTOCIA

ANDREW ROULDAN B. BUIZON, M.D., FPOGS, FSGOP Assistant Professor De La Salle Universit ! "ealt# S$ien$es Instit%te

DYSTOCIA
Literally means Difficult Labor Characterized by Abnormally SLO !ro"ress of Labor

O#er#ie$ of the lecture

I % &ormal and Abnormal Labor II % Causes of Dystocia III % Com'lications of Dystocia

(actors that affect Labor

!o$er
% (irst sta"e) uterine contractions % Second sta"e) uterine contractions * intra+ abdominal 'ressure

!assen"er
% (etal Attitude, !resentation, !osition % Ability to ada't throu"h !assa"e

!assa"e
% -irth canal
.(or &ormal Labor to ta/e 'lace % &ormal 0!1s

!ro"nosis for 2a"inal Deli#ery

Po&er % force of uterine contractions Passen'er)
% !resentation and !osition % Size of fetal head % Ada'tability of fetal head

Passa'e % size and sha'e of maternal bony 'el#is

Sta'es of La(or
(irst. + re"ular uterine contractions fully

Second.+ full cer#ical dilatation deli#ery baby Third + deli#ery of baby 'lacental deli#ery

(ourth +immediate 'ost'artum .Sta"es concerned $ith Dystocia

(irst Sta"e of Labor

Latent !hase Acti#e !hase
% Acceleration !hase
!redicti#e of outcome of labor

% !hase of 3a4imum slo'e

3easure of efficiency of the machine

% Deceleration !hase
5eflecti#e of feto'el#ic relationshi'

6istory of the !arto"ra'h

(unctional Di#isions of Labor

!re'aratory Di#ision Dilatational Di#ision !el#ic Di#ision

!re'aratory Di#ision
Latent !hase and Acceleration !hase Ma)or event % cer#ical ri'enin"
% Softenin") chan"es in "round substance % 7ffacement) obliteration of cer#ical canal

*ervi$al +ilatation % minimal Fetal +es$ent % minimal to absent Sensiti#e to sedation and conduction anal"esia

!re'aratory Di#ision

(unctional Di#isions of Labor

!re'aratory Di#ision Dilatational Di#ision !el#ic Di#ision

Dilatational Di#ision
!hase of 3a4imum Slo'e Ma)or Event % cer#ical dilatation *ervi$al Dilatation % most ra'id rate Fetal Des$ent % minimal 8naffected by sedation and conduction anal"esia

Dilatational Di#ision

(unctional Di#isions of Labor

!re'aratory Di#ision Dilatational Di#ision !el#ic Di#ision

!el#ic Di#ision
Deceleration !hase to Second Sta"e of labor Ma)or Event % cardinal mo#ements *ervi$al Dilatation % ra'id rate Fetal Des$ent % ma4imal 3inimally affected by se+ation but 9bearin" do$n1 effort lar"ely affected by $on+%$tion anal'esia

!el#ic Di#ision

Cer#ical Dilatation and (etal Descent

The only characteristics of the 'arturient useful in assessin" labor : its 'ro"ression Time #s; Cer#ical Dilatation % si"moid cur#e Time #s; (etal descent % hy'erbolic cur#e

3echanical (orces of Labor

(actors res'onsible for 'ro"ression and com'letion of each sta"e (irst sta"e)
% 8terine 'o$er % Cer#ical resistance % (or$ard 'ressure of the fetal head

Second sta"e)
% 3echanical relationshi' bet$een fetal head and 'el#ic ca'acity

Dia'nosis of La(or
,r%e La(or Re'%larit Fre-%en$ D%ration Intensit Effe$t of &al.in' <*= > ? @ ?A min > ?A seconds increasin" a""ra#ates False La(or <+= no 'attern #ariable no 'attern no effect

Criteria for Dia"nosis of Labor

?; Documented uterine contractions <at Least once in ?A minutes, or B in CA min;= In the form of direct obser#ation or 7lectronically usin" a cardiotoco"ram C; Documented 'ro"ressi#e chan"es in cer#ical dilatation and effacement, as Obser#ed by one obser#er 0; Cer#ical effacement of "reater than DE+FAG B; Cer#ical dilatation of "reater than 0 cm

Dia"nosis of &ormal Labor

LABOR PATTERN Latent P#ase *ervi$al Dilatation Fetal Des$ent NULLIPARA H CA hours > ?;C cm@hr > ? cm@hr MULTIPARA H ?B hours > ?;E cm@hr > C cm@hr

Dia"nosis of Abnormal Labor

LABOR NULLIPARA PATTERN Prolon'ation Disor+er Latent !hase > CA hours Deceleration !hase > 0 hours Protra$tion Disor+er Dilatation H ?;C cm@hr Descent H ? cm@hr Arrest Disor+er &o Dilatation > C hours &o Descent > ? hour MULTIPARA

> ?B hours > ? hour H ?;E cm@hr H C cms@hr > C hours > ? hour

!rolon"ed Latent !hase

It is the only disorder dia"nosable in the !re'aratory Di#ision of Labor Criteria)
% &ulli > CA hrs % 3ulti > ?B hrs

7tiolo"y of !rolon"ed Latent !hase

(alse Labor I EAG of the time 74cessi#e sedation 8nfa#orable cer#i4 <thic/, uneffaced, closed= 8terine @ Labor dysfunction 8n/no$n

3ana"ement of !rolon"ed Latent !hase

Thera'eutic 5est
% if no C@I to delay for J+?A hrs % Stron" sedati#es % 8'on $a/in", FEG I enter acti#e 'hase ?EG I false labor

Amniotomy
% $ill not accelerate latent 'hase

Caesarean section
% &ot usually done unless $ith indications

Dia"nosis of Abnormal Labor

LABOR NULLIPARA PATTERN Prolon'ation Disor+er Latent !hase > CA hours Deceleration !hase > 0 hours Protra$tion Disor+er Dilatation H ?;C cm@hr Descent H ? cm@hr Arrest Disor+er &o Dilatation > C hours &o Descent > ? hour MULTIPARA

> ?B hours > ? hour H ?;E cm@hr H C cms@hr > C hours > ? hour

!rotraction Disorders
!rotracted Acti#e !hase !rotracted Descent 7tiolo"y )
% 3al'osition % 74cessi#e sedation @ conduction anal"esia % Ce'halo'el#ic dis'ro'ortion

3ana"ement)
% Au"ment of labor % CS I CFG ha#e C!D

Dia"nosis of Abnormal Labor

LABOR NULLIPARA PATTERN Prolon'ation Disor+er Latent !hase > CA hours Deceleration !hase > 0 hours Protra$tion Disor+er Dilatation H ?;C cm@hr Descent H ? cm@hr Arrest Disor+er &o Dilatation > C hours &o Descent > ? hour MULTIPARA

> ?B hours > ? hour H ?;E cm@hr H C cms@hr > C hours > ? hour

Arrest Disorders
Criteria before dia"nosin" Arrest disorders)
% Latent 'hase com'leted <C4 > B cms= % Intensity of 8terine contractions > CAA 3#8 4 C h

7tiolo"y)
% Ce'halo'el#ic dis'ro'ortion % 6y'otonic uterine contraction % 3al'osition % 74cessi#e sedation @ anesthesia

3ana"ement)
% CS % Au"ment labor

 C+hour rule for dia"nosis of arrest in acti#e 'hase of labor has recently been challen"ed EBC $omen included $here CS deli#ery $as not 'erformed for labor arrest until there $ere at least B hours of a sustained uterine contraction of >CAAmonti#edeo units or a minimum of J hours o4ytocin au"mentation if the contraction 'attern could not be achie#ed

 !rotocol resulted in hi"h rate of #a"inal deli#ery <KCG= $@ no se#ere ad#erse maternal or fetal outcomes Thus e4tendin" the minimum 'eriod of o4ytocin au"mentation for acti#e arrest from C hours to B hours a''ears effecti#e
ACOL !ractice -ulletin, Com'endium CAAB

3ana"ement of Abnormal Labor

Preferre+ ,reat1ent Prolongation Disorders Latent !hase -ed rest Protraction Disorders Dilatation 74'ectant @ Su''ort Descent Arrest Disorders !rol Decel Au"ment if no C!D Co Arrest of Dil Arrest of Descent CS if * C!D (ailure of descent La(or 0attern E/$e0tional ,reat1ent Au"ment @ CS CS for C!D @ Au"ment 5est if e4hausted CS

Abnormal Labor <-ased on (riedman1s cur#e=

Prolon'e+ De$eleration P#ase Fail%re of Des$ent Protra$te+ Des$ent Arrest of Des$ent

Arrest in *ervi$al Dilatation Protra$te+ A$tive P#ase Prolon'e+ Latent P#ase

DYSTOCIA + Abnormal Labor

Other names) Dysfunctional labor, Ineffecti#e labor, (ailure to 'ro"ress

Worl+&i+e 2 Accounts for B0G of all 'rimary cesarean sections

P#ili00ines + it accounts for 0F;FEG

Textbook of Obstetrics, 2002

5is/ (actors for Dystocia

Associated $@ lon"er Cnd sta"e
+ e'idural anal"esia + occi'ut 'osterior 'osition + lon"er ?st sta"e of labor + nulli'arity + short maternal stature + birth$ei"ht + hi"h station at com'lete cer#ical dilatation
ACOL !ractice -ulletin Com'endium CAAB

DYSTOCIA + Abnormal Labor

Three cate"ories causin" Dystocia) <Abnormalities of 0!s=

POWERS
% 74'ulsi#e 'o$ers)
8terine dysfunction, or inadeMuate #oluntary muscle effort

PASSENGER
% !resentation, !osition, or De#elo'ment of the (etus

PASSAGE
% 3aternal -ony !el#is <!el#ic Contraction= % Soft Tissues of the 5e'roducti#e Tract

&ormal 8terine Contractions

Para1eter Latent P#ase A$tive P#ase to Se$on+ Sta'e C+0 mins BA % JA secs 3oderate + stron"

(reMuency @ Inter#al Duration Intensity

0+E mins 0A % BA secs 3ild to moderate

3ethods to Nuantify 8terine Acti#ity

'al'ation e4ternal tocodynamometry internal uterine 'ressure sensors

&ormal 8terine Contractions

Characterized by a "radient of myometrial acti#ity) "reatest and lastin" lon"est at the fundus <fundal dominance= : diminishin" to$ard the cer#i4

8T75I&7 DYS(8&CTIO&
" 0otoni$ Uterine D sf%n$tion 3ore common &o basal hy'ertonus 8terine contractions ha#e a normal 'ressure "radient 'attern <synchronous= I8! H CE mm6" insufficient to dilate cer#i4

8T75I&7 DYS(8&CTIO&
" 0ertoni$ Uterine D sf%n$tion Also called incoordinate uterine dysfunction 7ither basal tone is ele#ated or 'ressure "radient is distorted by contraction of the midse"ment of the uterus $ith more force than the fundus or by com'lete asynchronism or a combination of both

CA8S7S O( 8T75I&7 DYS(8&CTIO&

7'idural anal"esia Chorioamnionitis 3aternal 'osition durin" labor -irthin" 'osition in Cnd sta"e labor
illiam1s Obstetrics, C?st ed;