DYSTOCIA

Dr.Selvaraj,chinnasamy M.D
Difficult of labor / abnormal progress of
labor

Pattern that deviates from that observed

in the majority of women who have
spontaneous vaginal deliveries

- abnormally slow progress of

labor

DYSTOCIA
1. Abnormalities of the expulsive forces
 Insufficient uterine forces (uterine dysfunction)
 Inadequate voluntary muscular effort
2. Abnormalities of presentation, position or
development of the fetus
3. Abnormalities of the maternal bony pelvis –
pelvic contraction
4. Abnormalities of the birth canal -- Soft
tissues of the reproductive tract that form an
obstacle to fetal descent.

4 Distinct Abnormalities:
 3 Categories (3 P’s):

1. Power – uterine contractility &

maternal expulsive
efforts
2. Passenger – the fetus
3. Passage – the pelvis
ABNORMAL
PRESENTATIONS AND
POSITIONS OF FETUS
1.Face presentation
Head is hyperextended so that the occiput
is in contact with the fetal back and chin
(mentum) is presenting
In mentum posterior presentation, labor
progression is usually impeded because
Fetal brow (bregma) is compressed against
the maternal symphysis pubis
 In contrast, flexion of the head & vaginal
delivery are typical w/ mentum anterior
presentations.

 Causes of face presentation:

1. Marked enlargement of the neck or coils of cord
about the neck
2. Anencephalic fetuses
3. Contracted pelvis or large fetus
4. Pendulous abdomen in multiparous women

FACE PRESENTATION
Diagnosis:
1. Vaginal exam
▪ palpation of mouth, nose, malar bones,
orbital ridges
▪ maybe mistaken for breech presentation
mouth – anus
malar prominence – ischial tuberosities

FACE PRESENTATION
FACE PRESENTATION
Management:
1. Successful NSD
▪ adequate pelvis
▪ small fetus
2. Cesarean delivery in pelvic inlet
contraction
Rarest
Portion of the fetal head between the
orbital ridge and the anterior fontanelle
present at the pelvic inlet
Presenting diameter- occipitomental

Causes: same as those for face

presentation

2. Brow Presentation
Diagnosis:
Fetal head is above the symphysis pubis
Vaginal exam:
 frontal sutures  orbital ridges
 anter.Fontanel  eyes  nasal bridge.
 root of the mouth

Commonly unstable, and often converts to face

or occiput; If brow persists dystocia occurs.

Principles of management are much the

BROW
same as PRESENTATION
those for a face presentation
3.TRANSVERSE LIE
▪ long axis of the fetus is perpendicular to the
mother
▪ position:shoulder over the pelvic inlet
head lies in one iliac fossa
breech lies on the other iliac fossa
Oblique lie – long axis of fetus forms an
acute angle
- transitory
- during labor, converts to either
longitudinal lie or T-lie
“Unstable lie”
TRANSVERSE LIE
Diagnosis:
1. Inspection
▪ unusually wide abdomen
▪ fundus extends to only slightly above the umbilicus

2. Palpation
▪ no fetal pole in the fundus
▪ ballotable head in one iliac fossa and breech on the
other
▪ Back - anterior – hard resistance plane extends
across the front of the abdomen
- posterior – irrregular nodulations felt through
abdominal wall
Diagnosis:

3. Vaginal exam:
Early labor - “gridorin” feel of the ribs
Advance labor - scapula and clavicle
Late labor - shoulder tightly wedged in the
pelvic canal
- hand/arm prolapsed into the
vagina and vulva
TRANSVERSE LIE
Etiology:
1. Abdominal wall relaxation
2. High parity
3. Preterm fetus
4. Placenta previa
5. Abnormal uterine anomaly
6. Excessive amniotic fluid
7. Contracted pelvis

TRANSVERSE LIE
Mechanism of Labor:
Term fetus – vaginal delivery is impossible
Possible if:
- fetus <800gms
- adequate pelvis

TRANSVERSE LIE
Neglected T-lie:
labor→rupture of membranes→
shoulder forced into pelvis→
arm prolapses→
uterus contracts vigorously→
retraction ring→ uterine rupture

TRANSVERSE LIE
Management:
Before labor – external version done at
39weeks with intact membranes

Onset of labor – Classical cesarean section

TRANSVERSE LIE
▪ extremity prolapses alongside the presenting
part, simultaneously presenting in the pelvis
Causes: conditions that prevent complete
occlusion of the pelvic inlet by the fetal head,
including preterm birth.
Management:
the prolapsed part should
be left alone or pushed
gently upward

4.COMPOUND PRESENTATION
 Persistent Occiput Posterior Position
 Causes: transverse narrowing of the midpelvis
malrotation of occiput anterior
presentation during labor
 Management:
1. Spontaneous delivery
2. Forceps delivery w/ the occiput directly
posterior
3. Manual rotation to the anterior position followed
by spontaneous or forceps delivery
4. Forceps rotation of the occiput to the anterior
position & delivery
5. CS

COMPOUND PRESENTATION
 Persistent Occiput Transverse Position
- most likely a transitory one

 Cause: hypotonic uterine contractions

 Management:
1. Manual rotation anteriorly or posteriorly &
forceps delivery
2. Forceps rotation & delivery

COMPOUND PRESENTATION
5.SHOULDER DYSTOCIA
Refers to entrapment of the fetus within the birth
canal resulting from impaction of either the
anterior shoulder against the pubic bone.

head-to-body delivery time exceeds 60mins

Causes: increased birthweight
increased shoulder-to-head & chest-to-head
disproportions

Maternal Consequence:
Pastpartum hemorrhage
-uterine atony
- Cervical & vaginal lacerations
Fetal Consequences:
1. Transient Erb/Duchenne brachial plexus
palsies – most common injury
C5-C6 : downward traction to anterior
shoulder
: hanging upper arm

C7-T1 : clawhand deformity

SHOULDER DYSTOCIA
Fetal Consequences:
2. clavicular fracture
 unavoidable
 unpredictable
 no clinical consequence
3. humeral fracture
4. neonatal death – most serious

SHOULDER DYSTOCIA
SHOULDER DYSTOCIA
Preconceptual Risk Factors
1. Previous shoulder dystocia
2. Maternal obesity
3. Maternal age
4. Multiparity
5. Abnormal pelvis
Antepartum Risk factors
6. Macrosomia
7. Diabetes
8. Excessive weight gain
9. Post dates
SHOULDER DYSTOCIA
Intrapartum Risk Factors
1. Instrumental Delivery
2. Prolonged second stage of labor
3. Multiple risk factors
Diagnosis

Turtle sign- first sign of dystocia where in

the fetal head after emerging recoils
tightly against the maternal perineum.
Management:
Goal :
- reduction in the interval time from
delivery of the head to delivery of the
body
 large episiotomy and adequate analgesic
 cesarean section if:
>5000gms in diabetics
>4500gms in non diabetics

SHOULDER DYSTOCIA
H- call for help
E- evaluate episiotomy
L- legs flexed and abducted( mcrobert’s
maneuver)
P- suprapubic pressure
E- enter maneuvers( Wood’s screw and Rubin
Maneuver)
R- Remove posterior arm
R- Roll the patient, “all fours position”,
Gaskin’s maneuver

HELPERR mnemonic:
A- Ask for help
L- Lift/hyperflex legs
A- Anterior Shoulder Disimpaction
R- Rotation of the Posterior Shoulder
M- Manual removal of the posterior arm
E- episiotomy
R- roll over onto “all fours”

ALARMER mnemonic:
SHOULDER DYSTOCIA
4 p’s that should be avoided:
1. Pull
2. Push
3. Panic
4. Pivot

1. increase functional size of the bony pelvis

(mcRoberts maneuver)
2. decrease bisacromial diameter of the fetus
(suprapubic pressure)
3. change the relationship of the bisacromial
diameter within the bony pelvis( Wood’s screw)
1.Moderate suprapubic pressure applied by
assistant while downward traction is
applied to the fetal head.

SHOULDER DYSTOCIA
Techniques for Delivery
2.The McRobert manuever , remove the
legs from the stirrups and sharply flexing
them up onto the abdomen.
▪straightening of sacrum

▪rotation of symphysis pubis

toward the maternal head
▪decrease in the angle of
pelvic inclination

SHOULDER DYSTOCIA
Techniques for Delivery
3. Woods corkscrew maneuver:
prograssively rotating the posterior
shoulder 180degrees in a corkscrew
fashion, until the anterior shoulder could
be released.

SHOULDER DYSTOCIA
Techniques for Delivery
4. Delivery of the posterior shoulder consist
of carefully sweeping the posterior arm of
the fetus across the chest, followed by
delivery of the arm.

SHOULDER DYSTOCIA
Techniques for Delivery
. Rubin:
 The fetal shoulders are rocked
from side to side applying force
to the maternal abdomen.
 The pelvic hand reaches the
most accessible fetal shoulder,
which is then pushed toward
the anterior surface of the
chest.
 This results in abduction of
both shoulders and smaller
shoulder-to-shoulder diameter.
SHOULDER DYSTOCIA
Techniques for Delivery
6. Deliberate fracture of the clavicle by pressing the
anterior clavicle against the ramus of the pubis.
The fracture will heal rapidly as is not nearly as
serious as a brachial nerve injury, asphyxia, or
death.

7. Hibbard recommended that pressure be applied

to the fetal jaw and neck in the direction of the
maternal pelvis, with strong fundal pressure
applied by an assistant as the anterior shoulder is
freed.

SHOULDER DYSTOCIA
Techniques for Delivery
8. Zavanelli maneuver : cephalic
replacement into the pelvis and then
perform cesarean section. Terbutaline
250ug subcutaneously is given to produce
uterine relaxation.
9. Cleidotomy: cuting the clavicle with
scissors and other sharp instruments, and
is usually used for dead fetus.
10. Symphysiotomy: high maternal
morbidity due to urinary tract injury

SHOULDER DYSTOCIA
Techniques for Delivery
Suprapubic maneuver or Mazzanti Maneuver
6.Breech Presentation
Types of
More common breech:
remote from term,
most often turns
into cephalic
presentation before
onset of labor
Breech Presentation

Types Of Breech Presentation

 1. Frank Breech- both legs are flexed at
the hip and extended at the knees.

 2. Complete Breech- both legs are flexed

at the hip and knees.

 3. Footling Breech- when a leg is extended

at the hip and the knee.
Breech Presentation
Etiology:
Hydramnios
Oligohydramnios
Mulitple fetuses
 Multiparity
 hydrocephaly
anencephaly
uterine anomalies
Previous breech
pelvic tumors
placenta previa

Breech Presentation
  What causes the baby’s head to flex
and chin to chest?

 1. Maternal muscle tone

 2. Uterine contractions
 3. Operator’s maneuvers
Complications:
1. Increased perinatal morbidity and
mortality from difficult labor
2. Low birth weight from preterm delivery,
growth restriction, or both
3. Prolapsed cord
4. Placenta previa
5. Fetal, neonatal, infant anomalies
6. Uterine tumors and anomalies

Breech Presentation
Diagnosis:
1. Abdominal exam: Leopold maneuver
LM1- hard bollotable head occupies the fundus
LM2- back on one side of the abdomen and
small parts on the other
LM3- breech movable above the pelvic inlet
(unengaged)
LM4- firm breech beneath the symphysis
(engaged)

FHT: heard loudest above the umbilicus

Breech Presentation
Diagnosis:
2. Vaginal exam:
▪ ischial tuberosities, sacrum, and anus are
palpable, and maybe mistaken for face
presentation
▪ complete/footling breech – feet maybe felt
▪ genitalia maybe palpated once breech has
descended into the pelvic cavity

Breech Presentation
Diagnosis:
3. Imaging techniques:
▪ ultrasound: to identify breech and fetal
anomalies
.

Breech Presentation
Footling breech:
▪ compression of prolapsed cord
▪ cord entanglement around the extremities

Breech Presentation:
Thank you