ABNORMAL LABOR
Marc Vision Granada Capunong, MDLevel 1 Resident
CHAPTER 23 Williams Obstetrics 26th Edition PAGES 433 - 445
OBJECTIVES
1. To the basics of dystocia
2. To know the abnormalities of the expulsive forces
3. To know the basics in premature ruptured membranes at term
4. To familiarize ourselves with precipitous labor and delivery
5. To refresh ourselves with fetopelvic disproportion
6. To know the different abnormal presentations, its mechanism, and management
7. To know the complications of dystocia
DYSTOCIA
DYSTOCIA
Difficult labor characterized by abnormally slow labor progress
Three distinct categories:
Abnormalities of power, passenger, and passage
Power : insufficient or inappropriate uterine contractions (uterine
dysfunction), inadequate maternal pushing
Passenger: fetal abnormalities of presentation, position, or anatomy
Passage: structural changes, soft tissue abnormalities
SOME CAUSES OF DYSTOCIA IN TERM VERTEX
SINGLETON
TABLE 23 - 1 PAGE 433
ABNORMALITIES IN THE
EXPULSIVE FORCES
TYPES OF UTERINE DYSFUNCTION
Uterine contractions for dilation of the cervix and fetus expulsion
60 mmHg - normal spontaneous contractions
15 mmHg - lower limit of contraction pressure required to dilate the cervix
Types of uterine dysfunction:
Hypotonic uterine dysfunction - more common; normal basal tone and
gradient, however insufficient pressure
Hypertonic uterine dysfunction or uncoordinated uterine
dysfunction - either basal tone is elevated appreciably or the pressure
gradient is distorted
RISK FACTORS FOR UTERINE DYSFUNCTION
Neuraxial analgesia
Chorioamnionitis
Higher station
Maternal age
Maternal obesity
LABOR DISORDERS
ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA, AND METHODS OF
TABLE 23 - 2 PAGE 435
TREATMENT
OBSTETRIC CARE CONSENSUS COMMITTEE
No cesarean delivery in latent phase
Conventional practice
No CS in protraction disorder
Observe, assess uterine activity, stimulation of contractions
Cervical dilation threshold that serves to herald active labor
Cervical dilation of 6 cm is now the recommended threshold
CS is reserved for women with cervical dilatation of ≥6 cm + ruptured
membrane
fail to progress despite 4 hrs of adequate uterine activity or at least 6 hrs of
oxytocin administration but inadequate contractions
SECOND - STAGE DESCENT DISORDERS
Nulliparas
Limited to 2 hours and extended to 3 hours when regional analgesia is
used
Multiparas
One hour has been the limit, extended to 2 hours with regional analgesia
If prolonged:
Higher rates of chorioamnionitis, anal sphincter injury, operative vaginal
birth, and postpartum hemorrhage
SECOND - STAGE DESCENT DISORDERS
Newer guidelines by Consensus Committee 2019:
Recommend that a nullipara push for at least 3 hours and a multipara
push for at least 2 hours before second-stage labor arrest is diagnosed
MATERNAL PUSHING
Contractions of the uterus + abdominal musculature propels the fetus
downward
Heavy sedation/regional analgesia may reduce the reflex urge to push and
may impair the ability to contract abdominal muscles sufficiently
The urge to push is overridden by the intense pain
PREMATURELY
RUPTURED MEMBRANES
AT TERM
Oxytocin MATERNAL PUSHING
For those with hypotonic contractions or with advanced cervical
dilation
lower potential hyperstimulation risk
Prostaglandin E1 (Misoprostol)
For those with an unfavorable cervix, no or few contraction, and no
significant fetal heart rate decelerations
Prophylactic antibiotics
membranes ruptured longer than 18 hours, for group B streptococcal
infection prophylaxis
PRECIPITOUS
LABOR AND DELIVERY
PRECIPITOUS LABOR AND DELIVERY
Extremely rapid labor and delivery
Result from:
Abnormally low resistance of the soft parts of the birth canal
Abnormally strong uterine and abdominal contractions
Lack of pain with contractions to cue advanced labor
Expulsion of the fetus in <3hours
PRECIPITOUS LABOR AND DELIVERY
Maternal complications:
Uterine rupture
Extensive lacerations of the cervix, vagina, vulva, or perineum
Amniotic fluid embolism
Frequently followed by uterine atony
More common in multiparas who had contractions at intervals less than 2
mins
Linked to cocaine abuse and associated with placental abruption,
meconium, postpartum hemorrhage, and low Apgar scores
PRECIPITOUS LABOR AND DELIVERY
Neonatal complications:
uterine contractions, prevent appropriate uterine blood flow and fetal
oxygenation
Resistance of the birth canal rarely may cause intracranial injury
FETOPELVIC
DISPROPORTION
PELVIC CAPACITY: CONTRACTED INLET
Anteroposterior diameter = Obstetrical
conjugate
Inlet contraction - diagonal conjugate <11.5 cm
Head is arrested in the pelvic inlet, the entire force
exerted by contractions acts directly on the portion
of membranes that contact the dilating cervix =
early spontaneous rupture of the membranes is
more likely
Absent pressure by the head against the cervix and
lower uterine segment = to less effective
contractions = dilation may proceed very slowly or
PELVIC CAPACITY: CONTRACTED MIDPELVIS
More common than inlet contraction
Causes transverse arrest of the fetal head = difficult
midforceps operation or to cesarean delivery
Midpelvis measurements are as follows:
transverse, or interischial spinous, 10.5 cm
anteroposterior, from the lower border of the symphysis
pubis to the junction of S4 and S5, 11.5 cm
posterior sagittal, from the midpoint of the interspinous line
to the same point on the sacrum, 5 cm.
likely contracted when interspinous + posterior sagittal
PELVIC CAPACITY: CONTRACTED OUTLET
Interischial tuberous diameter of 8 cm or less
Outlet contraction without concomitant midplane
contraction is rare
ABNORMAL PRESENTATIONS
ABNORMAL PRESENTATIONS
FACE PRESENTATION
ABNORMAL PRESENTATIONS
ABNORMAL PRESENTATIONS
BROW PRESENTATION
ABNORMAL PRESENTATIONS
ABNORMAL PRESENTATIONS
TRANSVERSE LIE
ABNORMAL PRESENTATIONS
ABNORMAL PRESENTATIONS
UMBILICAL CORD PROLAPSE
BIRTH INJURY HELP CENTER
HTTPS://WWW.BIRTHINJURYHELPCENTER.ORG/BIRTH-
INJURIES/DELIVERY-COMPLICATIONS/UMBILICAL-CORD-
PROLAPSE/
ABNORMAL PRESENTATIONS
ABNORMAL PRESENTATIONS
COMPOUND PRESENTATION
ABNORMAL
PRESENTATION:
MECHANISM OF LABOR
FACE PRESENTATION
Present with the chin (mentum) anteriorly, transversely, or posteriorly
Chin anterior:
Internal rotation of the face brings the chin under the symphysis pubis
After anterior rotation and descent, the chin and mouth appear at the vulva, and the undersurface
of the chin presses against the symphysis
The neck can flex
The nose, eyes, brow, and occiput then appear in succession
The occiput sags backward toward the anus
The chin rotates externally to the side toward which it was originally directed
Shoulders are born as in cephalic presentations
BROW PRESENTATION
Engagement of the fetal head and subsequent delivery cannot take place as
long as the brow presentation persists
Engagement is impossible until marked molding shortens the occipitomental
diameter
Or until the neck either flexes to an occiput presentation or extends to a face
presentation
The caput succedaneum is over the forehead
TRANSVERSE LIE
Spontaneous delivery of a fully developed newborn is
impossible
If labor continues, the fetal shoulder is forced into the pelvis,
and the corresponding arm frequently prolapses
After some descent, the shoulder is arrested by the margins
of the pelvic inlet
Shoulder is impacted firmly in the upper part of the pelvis
With time, a uterine contraction ring rises increasingly
higher and becomes more marked. An extreme form is the ILLUSTRATED VERDICT, INC.
https://www.illustratedverdict.com/template-pregnancy/delivery-b
andls-ring
Bandl ring.
Neglected transverse lie, the uterus will eventually rupture
UMBILICAL CORD PROLAPSE
Prompt manual elevation of the fetal head relieves cord compression
COMPOUND PRESENTATION
Prolapsed part should be left alone
Typically does not impede labor and often retracts out of the way with descent
of the presenting part
ABNORMAL
PRESENTATION:
MANAGEMENT
FACE PRESENTATION
Fetal heart rate monitoring is best done with external devices to avoid face or
eye injury
Cesarean delivery rates are substantially higher than with occiput
presentation
Low or outlet forceps delivery of a mentum anterior face presentation can be
completed
Vacuum extraction has been associated with eye trauma and is not
recommended
BROW PRESENTATION
Management principles mirror those for a face presentation.
TRANSVERSE LIE
Typically requires cesarean delivery
Dorsoanterior or back down position:
Neither the fetal feet nor head occupies the lower uterine segment
Vertical hysterotomy incision
Dorsoposterior or back up position:
One or both feet can be grasped
Low transverse incision
Delivered by breech extraction
UMBILICAL CORD PROLAPSE
For cesarean delivery
Vaginal or operative vaginal birth if it can be completed more rapidly than
emergent cesarean birth
COMPOUND PRESENTATION
If it fails to retract and if it appears to prevent descent of the head, the
prolapsed part can be pushed gently upward and the head simultaneously
downward by fundal pressure
Co-presenting hand, the fetus may reflexively retract the hand if pinched by
the provider
COMPLICATIONS WITH
DYSTOCIA
MATERNAL
Maternal infection PUSHING
Postpartum hemorrhage
Uterine tears
Uterine rupture
Ring of Bandl
Fistula formation
Lower-extremity nerve injury
Caput succedaneum and molding
