Dystocia Is a broad term referring to prolonged and difficult labor (any labor that lasts more than 24 hours)

Types of Dystocia 1. Uterine dysfunction: abnormalities of the powers a. Hypotonic uterine dysfunction b. Hypertonic uterine dysfunction c. Inadequate secondary forces 2. Abnormalities with passageway a. Pelvic dystocia Inlet dystocia Midpelvis dystocia Outlet dystocia b. Soft tissues dystocia Placenta previa that partially or complete obstructions the birth canal Presence of tumors that obstruct the birth canal 3. Fetal dystocia: abnormalities of the passenger a. Malposition persistent d. Brow occiput posterior position e. Shoulder b. Breech presentation f. Multiple presentation c. Face Abnormal Labor Patterns Is defined as exceeding 20 hours in nulliparas and more than 14 hours in multiparous Diagnosis of abnormal labor i. Imaging studies: Xray pelvimetry and computerized tomography ii. Clinical pelvimetry: Causes: 1. Entering labor with poor cervical condition characterized by unripe, rigid and firm cervix 2. Excessive sedation administered during the course of the latent phase 3. Conduction analgesia Management: 1. Therapeutic rest: using strong sedatives 2. Active intervention: oxytocin stimulation if without CPD and uterine contractions are still inadequate upon awakening Uterine Dysfunction May be caused by any or a combination of the following conditions: pelvic contraction, fetal malposition, over distension, and excessive rigidity of the cervix. 2 common types of uterine dysfunction 1. Hypotonic Uterine contractions: are characterized by weak and inadequate contractions which are insufficient to dilate the cervix. Contractions are not painful because of their poor intensity. Causes: Over distension of the uterus - multiple pregnancy, hydramnios Malpresentation and malposition Pelvic bone contraction Unripe or rigid cervix Congenital abnormalities of the uterus Unknown causes Complications: 1) Maternal and fetal infections because cervix is dilated for a long time 2) Post partum hemorrhage because of prolong labor making the uterus too exhausted to contract effectively 3) Fetal distress and death 4) Maternal exhaustion Management: i. Reevaluate pelvic size

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iii. iv. 2.

Vaginal delivery: Amniotomy if membranes are not yet ruptured Augmentation of oxytocin administration If contracted pelvis is present, caesarian section is the method of delivery Provide supportive nursing care

Hypertonic Uterine contractions: are usually encountered in the latent phase of labor. It is characterized by contractions that are too frequent but uncoordinated, the uterus does not relax completely in between contractions and tend to be more painful Management i. Evaluation of pelvic size ii. Maintenance of fluid and electrolytes balance by infusion of IV fluids iii. Therapeutic rest: morphine and Phenobarbital iv. Keep bladder empty to provide more space for the passage of fetus v. Encourage side lying position to maximize blood flow to the placental fetus vi. Watch for danger signals: fetal distress, passage of meconium stained amniotic fluid Uterine rupture: or the tearing of the muscles of the uterus occurs when the uterus can no longer withstand the strain placed upon it. Causes: Rupture of scar from previous CS Prolong labor, obstructed labor, malposition and malpresentation Over distention of the uterus Injudicious use of oxytocin, forceps and vacuum extraction, internal version Precipitate labor and delivery Manual removal of the placenta External trauma sharp or blunt Gestational trophoblastic neoplasia Signs and symptoms i. Impending uterine rupture is often manifested by a pathologic retraction ring in obstructed labor ii. During the peak of contraction, the woman complains of a sudden sharp tearing pain which, relief is felt as the uterus loses the capacity or if still does, the contractions are too weak to cause much discomfort Types of Uterine rupture 1) Complete Rupture: when the uterus ruptures, the woman experiences a sudden excruciating pain at the peak of a contraction, and then contractions stop altogether. Two swellings will be visible in the abdomen: the uterus and the extra uterine fetus. Internal hemorrhage soon follows and vaginal bleeding may or may not occur. Separation of the placenta from the uterus cuts off blood supply to the fetus resulting in fetal hypoxia and death. 2) Incomplete Rupture: symptoms are localized tenderness and persistent pain over the abdomen. Contractions may still continue or stop but no progress in cervical dilatation will be observed. Vaginal bleeding may or may not be present. Signs of maternal shock and fetal distress are observed because of internal bleeding. Management: a) Blood transfusion and administration of IVF to correct shock b) Administer mask oxygen to the woman at 8L/m c) Expect emergency laparotomy to deliver the baby d) Provide emotional support. Inform woman of what is happening, the procedures being done, answer questions as realistically as possible, do not give false reassurances. e) Post OP care (same as care after hysterectomy) Explain need to avoid driving for 3-6 weeks Explain need to avoid jogging, sexual intercourse, dancing and lifting heavy objects for 6-8 weeks Inversion of the Uterus Is a serious complication of the third stage wherein the uterus is partly or completely turned inside out. Causes

 Pulling of umbilical cord or applying pressure on uncontracted uterus Uterine relaxation due to the effects of anesthesia or analgesia Sudden increase in intrabdominal pressure such as when coughing, sneezing or straining Signs and symptoms Fundus is no longer palpable Sudden gush of blood from the vagina Uterus appear in the vulva Management 1. Prevention Never apply pressure on an uncontracted uterus Never pull the cord to hasten placental delivery 2. If the placenta has already separated: the uterus is replaced in the uterine cavity then oxytocin is administered 3. If the placenta is still attached: Woman is placed under anesthesia to cause muscular relaxation and facilitate reinsertion of the uterus into the pelvic cavity. The lower uterine segment is inserted first and fundus last. Then oxytocin is administered Do not attempt to remove the placenta if it still attached to the uterus as this will only enlarge the bleeding area. Remove after the uterus is replaced and contracting The placenta is delivered when uterus is already replaced and contracting 4. Blood transfusion and administration of IVF to combat shock 5. Monitor vital signs Prolapsed Umbilical Cord Occurs when the cord passes out of the uterus ahead of the presenting part Causes - Polyhydramnios - Long cord - Malposition and malpresentation (shouloder and foot presentation) - Prematurity - Placenta previa Signs and Symptoms 1. Cord protrudes from the vagina and palpation of cord in the vaginal canal/cervix during IE 2. Fetal distress Management 1. Prevention placed the woman in bed rest after membranes have ruptured 2. Reduced pressure on the cord by: Place in Knee Chest or trendelenburg position, or place a folded towel under the hips Put on sterile gloves and insert two fingers into the vagina, then push presenting part upward 3. If cord is exposed to air, cover it with a saline moistened sterile compress 4. Never replaced the cord back into the vagina as this will result in cord kinking 5. Administered mask oxygen until delivery is completed 6. Deliver baby as soon as possible Vaginal delivery if cervix is fully dilated without fetal distress Cesarean section if cervix is not yet completely dilated and if fetal distress is present. Pelvic Dystocia Occurs when there is a narrowing in one or more of the important diameters of the pelvis 4 Types of Pelvis 1. Gynecoid 3. Android 2. Anthropoid 4. Platypelloid Although X-ray pelvimetry provides accurate measurements of the pelvic diameters, its use to evaluate pelvic size during pregnancy is seldom employed because of the potential radiation exposure hazards to the fetus. Inlet Contracture

Is defined as anteroposterior diameter less than 10 cm and greatest transverse diameter that is less than 12cm or diagonal conjugate less than 11.5 cm. Inlet contracture is due to several conditions including rickets and flat pelvis. Lack of engagement between 36th and 38th week of pregnancy in primiparas is an important sign of pelvic contraction Mid pelvis Contraction The fetus is able to engage but due to the narrowed diameter of the midpelvis the fetal head is prevented from rotating internally. As a result the head is jammed in the midpelvis causing transverse arrest. On internal examination the following findings will be noted: 1. Prominence of the ischial spines 2. Pelvic sidewalls are convergent 3. Concavity of sacrum is shallow 4. Bi-ischial diameter of outlet is less than 8cm. Outlet Contracture Outlet dystocia occurs when the biischial diameter (distance between ischial tuberosities) is less than 8cm Occiput Posterior Position One of the most common causes of prolonged labor, a malposition of vertex presentation. The labor is prolonged because the fetus must rotate a longer distance to reach the symphisis pubis with the mother experiencing much back pain due to the pressure exerted by the fetal head as it moves against the sacrum Management: 1) Provide comfort measures as labor tends to be longer and involves more back pains: Advice the mother to change position frequently to relieve pain Give back rub Apply sacral pressure during contractions 2) In most instances, the fetus rotates spontaneously to anterior position followed by uncomplicated vaginal delivery 3) If fetus does not rotate, the physician may perform manual rotation or use forceps to rotate presenting part to anterior position. Kielland forceps is the type of forceps for this purpose. Breech Presentation is the most common cause of fetal malpresentation. Early in pregnancy most fetuses are in breech presentation. By thirty eight weeks gestation, for some unknown reasons, most have already assumed vertex presentation. Even dead fetuses have been known to turn from breech to vertex presentation. However, about 3 to 4% of fetuses maintain breech presentation until delivery. 4 types of Breech Presentation 1. Frank breech 2. Complete breech 3. Double 4. Single footling Causes Uterine relaxation due to multiparity Fetal abnormalities hydrocephalus Hydramnios and oligohydramnios Congenital abnormalities of the uterus Contracted pelvis Previous breech delivery Space occupying mass in the uterus that prevents the head from fitting into the lower portion such as placenta previa and fibroids Prematurity Multiple pregnancy Complication 1. Prolapsed of the cord

2. Birth trauma; fracture of the skull, clavicle, humerus, intracranial hemorrhage, rupture of abdominal organs 3. Prolonged labor because the soft buttocks do not aid in cervical dilatation 4. Intracranial anoxia 5. Fetal death Management: 1. Whenever a breech presentation is diagnosed late in pregnancy, the physician may attempt to rotate the fetus from breech to cephalic presentation by external version 2. Vaginal delivery a. Vaginal delivery may be attempted if: There is no pelvic contraction The fetus is not too large not more than 3600grams There are personal skilled in the delivery of breech Spontaneous labor occurs with progressive cervical dilatation and effacement (add piper forcep to the delivery set up) b. Three general techniques of vaginal breech delivery: Spontaneous breech delivery Partial breech extraction: the infant is delivered spontaneously up to the umbilicus; the rest of the body is extracted Total breech extraction: the entire body of the infant is extracted by the obstetrician c. The different maneuvers: d. Management of the vaginal delivery: Continuous assessment of the progress of labor: contractions, effacement, dilatation, station, presentation. Assessment of fetal condition: ultrasound to determine anomalies such as hydrocephalus, microcephaly and anencephaly Continuous monitoring of fetal condition. Additional nursing and medical personnel skilled in breech delivery and an obstetrical attendant to watch over the patient continuously and the physician should be available anytime The decision regarding the method of delivery should be made as soon as possible after admission to avoid complications 3. If it is not possible to deliver the fetus vaginally and to ensure safer route of delivery, cesarean delivery is employed. Face Presentation Occurs when the head is hyper extended and the chin (mentum) is the presenting part. On internal examination, the examining fingers feel the mouth, nose, molar bones and orbital ridges. Causes Large fetus Contracted pelvis Multiple pregnancy lax uterus due to multiparity Occipitoposterior position because of the tendency of the fetus of extending the head instead of flexing it Management 1) If the chin is in anterior position (LMA or RMA), uterine contractions are strong, the head is small shoulder have already entered the pelvis and there is no pelvic contraction, vaginal delivery is possible but longer than usual. 2) If the chin is in posterior position (RMP,LMP) vaginal delivery may be impossible and dangerous if attempted because it can lead to transverse arrest. Cesarean is the delivery of choice when the chin is posterior. Brow Presentation Is the most uncommon of all presentations. The causes are the same as those of face presentation. Brow presentation is commonly unstable, it usually converts to face or vertex presentation. Babies born vaginally from brow presentation experience extreme facial edema, tell parents that their babies unsightly appearance will disappear in a few days.

Shoulder Presentation Occurs when the fetus assumes a transverse or oblique lie. Shoulder presentation is suspected when upon palpation; the fetal head occupies one side of the uterus and the buttocks, the other side. It can also be observed that the shaped of the uterus is more horizontal than vertical. Causes - Lax uterine and abdominal muscles due to multiparity is most common cause - Contracted pelvis - Fibroid and congenital abnormality of the uterus - Preterm fetus, hydrocephalus - Placenta previa - Multiple pregnancy Management i. External version before labor begins can be performed to rotate fetus in a delivery position ii. If version fails, the preferred method of delivery is caesarian section. Sometimes vaginal delivery is possible if the pelvic canal is large. Fetal Macrosomia Refers to oversized infant, typically weight more than 4000grams or 10 pounds. The infant is also called large for gestational age (LGA). Causes Common in male infants Maternal diabetes Hereditary Post term pregnancy Complication i. Shoulder dystocia: the fetus head may deliver, but the shoulder are too large for the pelvic inlet. ii. Trauma to the birth canal such as lacerations of the vagina or of the perineum iii. Brachial plexus injury due to damage to the brachial plexus (nerve injury) iv. Dislocation of the cervical vertebrae as a result of traction to get the infant out. v. Fracture of the clavicle. This is the most common problems and is done during delivery of the shoulders. vi. Cerebral hemorrhage (intracranial). This is due to repeated pounding on the pelvis. Management 1. Feto-pelvic size is determined to find out the best method of delivery is possible. If feto-pelvic disproportion exists (estimated size is deemed too large to pass through the mothers pelvis) - CS is the method of delivery. In cases of maternal DM and obesity, an ultrasound is often ordered to estimate fetal weight before vaginal delivery is allowed. Overall, ultrasound predictions of fetal weight fall within 20% of actual fetal weight in the third trimester. In primigravidas with macrosomic infants, often the physician will proceed with CS without trial labor. In multiparas with adequate pelvic size, trial labor with oxytocin and amniotomy may be conducted first and if it fails or abnormal fetal heart rate patterns occur during the induction, CS is performed. 2. Monitor fetal heart tone and maternal vital signs closely 3. Provide comfort measures to the mother as labor is prolonged and maternal exhaustion may occur. 4. Provide short and direct answers to the parents questions. Keep them informed of the progress of labor and explain treatment and tests as they are conducted. Shoulder Dystocia Shoulder dystocia is said to occur when the fetal bisacromial diameter cannot negotiate the pelvic brim (the obstetric conjugate). It may occur when after when the delivery of the head the anterior shoulder is trapped and arrested behind the symphysis pubis and less commonly, from impaction of the posterior shoulder on the sacral promontory. It happens when the baby is too large or the pelvis is too small. Risk Factors for shoulder Dystocia 1. Maternal Abnormal pelvic anatomy

 Gestational diabetes Post-dates pregnancy Previous shoulder dystocia short stature 2. Fetal: suspected macrosomia Complications of shoulders dystocia I. Maternal Post partum hemorrhage Rectovaginal fistula Sympheseal separation or diathesis, with or without transient femoral neuropathy 3rd or 4th degree episiotomy or tear Uterine rupture II. Fetal Brachial plexus palsy Clavicle fracture Fetal death Fetal hypoxia, with or without permanent neurologic damage Fracture of the humerus Management 1) Turtle Sign: shoulder dystocia becomes obvious when the fetal head emerges and then retracts against the perineum 2) When dystocia is diagnosed, avoid the following actions which can only cause injury to the mother and the infant: Applying excessive pressure to the fetal head or neck Applying fundal pressure 3) The HELPERR mnemonic provides a step by step guide for preliminary management of dytocia before more drastic measures are implemented. H: call for HELP the physician calls for additional personnel and equipments to aid in the delivery E: episiotomy is performed not to enlarge the birth canal but to provide additional room for the physicians hands when internal rotation maneuvers are required. L: Legs (Mc Roberts Maneuver) it is done by flexing the legs of the parturient sharply over the abdomen. This action raises symphisis pubis and causes in a flattening of the sacral promontory. As a result the posterior shoulder of the fetus is pushed over the sacral promontory allowing it to fall into the hollow of the sacrum, and the impacted anterior shoulder slips from the entrapment S:Suprapubic pressure the assistants hand places her/his hand suprapubically over the anterior shoulder and then applies pressure in a compression/relaxation cycle similar to the action when performing CPR. This action can make the shoulder adduct and slip under the symphisis. E: enter Maneuver (internal rotation) R:Remove the posterior arm R:Roll the patient Nursing care A. Shoulder Dystocia can be very frightening to the mother. Provide reassurance by informing the mother of what is being done to facilitate delivery of the infants in short simple sentence. B. Asses for cord prolapsed: the initial danger when the shoulder is stuck under the symphisis is cord compression that can result to hypoxia and acidosis. C. Monitor for nucchal cord, cut and clamp two ends if present. D. Suction the infants oropharynx after delivery of the head E. Monitor FHT and maternal vital signs