DYSTOCIA

L.D.
27 y/o

married
Jehovas witness Tandang Sora, Quezon City March 1, 2010

CC: for induction of labor

HPI
Patient is G2P1 (0-0-1-0) at 40 4/7 wks AOG
2 weeks PTA occasional uterine contractions no bloody/watery vaginal discharge good fetal movement
went for prenatal checkup IE: done showed 1 cm cervical dilatation, posterior cervix, 30% effaced, floating, (+)BOW observation and follow up Few hours same symptoms prenatal checkup done showed same IE advised admission for induction of labor

OBSTETRICAL HISTORY
LMP: May 21, 2009 AOG: 40 4/7 EDD: Feb 28, 2009 G2P1 (0-0-1-0)
G1: D&C, 2008, blighted ovum, 8 weeks AOG, TMC G2: present pregnancy

Prenatal check-ups: >10 with OB Screening done: Hepatitis: nonreactive

OGCT: normal

Past Medical History

(-) DM

(-) HPN
(-) Asthma

(-) Allergies
(-) Previous Surgeries

Family History
(-) HPN/DM
(-) Asthma (-) CA

Personal and Social History

Non-smoker
Nonalcoholic beverage drinker Denies use of illicit drugs

ROS
(-) anorexia, weight change, weakness, fever, sweats (-) shortness of breath, cough, hemoptysis (-)chest pain, easy fatigability, dypsnea, palpitations,
tremors

(-)nausea, retching, vomiting, diarrhea, food

intolerance, flatulence, abdominal distension, constipation

(-) anxiety, depression

Physical Examination
Conscious, coherent, ambulatory, not in cardiorespiratory

distress BP 130/80 PR 68 RR 20 T36.8C Ht 53 Wt 66.8 kgs Warm, moist skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclera Symmetrical chest expansion, clear breath sounds, no crackles or wheezes Adynamic precordium,regular rate and rhythm, no murmurs

Physical Examination
Abdomen: FH 34 cm
Leopolds Maneuver: FHT: 140 bpm LM1- breech LM2- fetal back, maternal left LM3- cephalic LM4- not engaged

Pelvic exam: IE: Cervix 2cm, 50% effaced, floating, (+) BOW Clinical pelvimetry: sacral promontory not accessible, slightly
prominent ischial spines, pelvic side walls not convergent, sacrum curve

Pulses full & equal, no cyanosis, no edema

Admitting CTG
Reactive, baseline FHR 140s, many accelerations, no decelerations, no contractions, many fetal movements

Assessment
Pregnancy uterine 40 4/7 weeks AOG, cephalic in beginning labor; G2P0 (0-0-1-0)

Lab exams
CBC Hgb Hct Rbc Wbc Platelets Neutrophils Lymphocytes Monocytes 113 0.34 3.74 11.1 348 79 13 08
URINALYSIS Rbc protein sugar wbc epithelial cast bacteria negative negative negative 3 1 0 44

Patient was admitted to LR (1 PM)

NPO IVF: D5NR 1L x 8 hours HNBB 1amp/IV q4 VS: BP 110-130/70-80, HR 68-88, T 36.5

FHT: 140-160 bpm

IE: 1cm, 50%, station -3, +BOW

10 9 8

-5
-4 -3

10

11

12

13

14

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

4th hour (5pm)

Contractions every 4-5mins, moderate, lasting 50

seconds

VS: stable IE: 2cm, 60%, station -3, (+)BOW

10 9 8

-5
-4 -3

10

11

12

13

14

15

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

6th hour (7pm):

D5NR 1L +10 u oxytocin started at 8 gtts/min Uterine contractions every 4-5mins, moderate to
strong lasting 50 seconds

VS: stable

FHT: 150-160
IE: 3 cm, 60%, station -3, +BOW

10 9 8

-5
-4 -3

10

11

12

13

14

15

16

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

7th hour (8pm)

IE: 4cm, 70% station -3, +BOW D5NR 1L +10 u oxytocin increased at 10 gtts/min VS: stable

Uterine contractions every 3 minutes, moderate to

strong lasting 50 seconds

FHT: 150-160

10 9 8

-5
-4 -3

10

11

12

13

14

15

16

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

8th hour (9pm)

AROM was done: clear amniotic fluid

IE: 4cm, 70% station -3, +BOW

10 9 8

-5
-4 -3

10

11

12

13

14

15

16

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

10th hour (11pm)

Contractions every 2-3 minutes, strong lasting for 60

seconds

FHT : 127-150 bpm IE: 5cm, 70% -3, -BOW

10 9 8

-5
-4 -3

10

11

12

13

14

15

16

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

12th hour (1am)

CEA inducted
Contractions every 2-3 minutes, strong lasting for 60
seconds

FHT: 127-144 IE: 5cm, 70%, -2, -BOW

10 9 8

-5
-4 -3

10

11

12

13

14

15

16

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

13th hour (2am)

Contractions every 2-3 minutes, strong lasting for 60

seconds

IE: 5cm, 70%, -2, -BOW CTG: baseline 140s, many accelerations, (+) variable
decelerations, contractions every 2-3 mins strong, many fetal movements

10 9 8

-5
-4 -3

10

11

12

13

14

15

16

No. of Hours

Station

Cervical dilatation

7 6 5 4

-2
-1 0 +1 +2 +3 +4 +5

3
2 1

0
cm

Manner of Delivery: Stat Primary Low Transverse Cesarean Section for Arrest of Cervical Dilatation for 3hours

MOTHER
Condition awake Sex APGAR Score BW BL Fluids D5NR+10 u oxytocin None None None MT HC Morbidity Mortality Complications CC AC complication s Postpartum VS stable Uterus EBL contracted <750 mL

BABY
Female 9,9

3255g cm 39 weeks, AGA 34cm 34 cm 31 cm None

ACTIVITY Onset of labor Oxytocin drip Ruptured BOW Full Cervical dilatation Baby delivered Placenta delivered

DATE March 1, 2010 March 1, 2010 March 2, 2010 ----March 2, 2010 Marcj 2, 2010

TIME 1 pm 7pm 9 pm -----2:40 am 2:42am

DYSTOCIA
difficult labor cephalopelvic disproportion/failure to progress

most common current indication for primary

cesarean delivery

DYSTOCIA
Arises from distinct abnormalities:

1. Power- expulsive forces, uterine contractility and

maternal effort

2. Passage- maternal pelvis

3. Passenger- presentation, position, devt of fetus 4. Pain

POWER:
Fundal dominance Lower limit of contraction pressure: 15 mmHg

200 montevideo units

POWER: Abnormalities of the expulsive

forces
2 types of uterine dysfunction: 1. Hypotonic uterine dysfunction: - no basal hypertonus, synchronous pattern but pressure is insufficient 2. Hypertonic uterine dysfunction: -more force in the midsegment than the fundus -incoordinate, complete asynchronism of impulses

CAUSES OF UTERINE DYSFUNCTION:

Epidural anesthesia Chorioamnionitis

Maternal position

Abnormalities of Power:
Active phase disorders Second stage disorders

Active-phase disorders
Protraction disorder- slower than normal

Arrest disorder- complete cessation

Both criteria should be met:

1. Cervix is dilated 4cm or more 2. Uterine contraction pattern of 200 Montevideo units or
more in a 10 minute period for 2 hours without cervical change

LABOR PATTERN Latent Phase Prolonged Latent Phase

PRIMIPARA

MULTIPARA

TREATMENT

EXCEPTIONAL TREATMENT Oxytocin or CS if there is an urgent problem CS delivery for CPD

>20 hours

>14 hours

Bed rest

Protraction Disorders
Active Phase Descent Arrest Disorders <1.2 cm/hr <1.0 cm/hr <1.5 cm/hr <2 cm/hr Expectant and support

Prolonged deceleration phase

Secondary arrest of dilatation Arrest of descent Failure to descend

>3 hrs
>2 hrs >1 hour

>1 hour
>2 hours >1 hour

Oxytocin without CPD CS delivery with CPD

Rest if exhausted CS delivery

Still no descent after deceleration phase or second stage of labor

PROLONGED LATENT PHASE

10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

12

15

18

21

24

27

PROTRACTED ACTIVE PHASE OF DILATATION

10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

10

PROTRACTED DESCENT
10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

10

PROLONGED DECELERATION PHASE

10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

10

ARREST IN CERVICAL DILATATION

10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

10

ARREST OF DESCENT
10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

10

FAILURE OF DESCENT
10 9 8 7 6 -5 -4 -3 -2 -1

5
4 3

0
+1 +2

2
1 0

+3
+4 +5

10

Complications of DYSTOCIA
Maternal complications: intrapartum
chorioamnionitis, postpartum pelvic infections, hemorrhage, uterine rupture, fistula formations, pelvic floor injury, postpartum lower extremity nerve injury

Perinatal complications:
infection, mechanical injuries (caput succedaneum, molding, cephalohematoma, skull fracture)

THANK YOU