OB Dystocia Part II and III Diagnosis :

Dr. Trasporto o Abdominal exam, IE, X-ray & UTS

Labor & Delivery
PART II ABNORMALITIES INVOLVING THE PASSENGER o Delivery of successively less readily
compressible fetal parts
o Disparity between size of head and
buttocks (preterm)
o Entrapment of the fetal arm behind the
fetal neck (nuchal arm)
o Pelvic cavity not fully occluded by the
breech prolapsed cord
Complications
o Perinatal morbidity and mortality
o Low birth weight due to preterm birth
/intrauterine growth retardation
o Prolapsed cord
o Placenta previa
o Fetal, neonatal and infant anomalies
o Uterine anomalies and tumors

Morbidity & Mortality

Fetal
o Fractures of humerus and clavicle
o Paralysis of the arms
Maternal Infection
o Uterine rupture & cervical laceration
Abnormal presentation, position, & development of the fetus o Deep perineal tears
o Hemorrhage

RECOMMENDATIONS FOR DELIVERY CS is commonly

used in the following circumstances to deliver all but
the extremely premature fetus:
1. Large fetus
2. Any degree of contraction or unfavorable shape
of the pelvis
3. Hyperextended head
4. No labor but with fetal/maternal indications for
delivery
5. Uterine dysfunction
6. Footling presentation
Breech Presentation 7. Apparently healthy 25-26wks or more with
Incidence mother in active labor or in need of delivery
o 3 to 4 % of singleton deliveries 8. Severe fetal growth restriction
o 14% at 29 to 32 weeks 9. Previous perinatal death or birth trauma
Etiology 10. A request for sterilization
o Small fetal size (Prematurity, multiple
fetus)
o Placenta previa, hydramnios,
oligohydramnios
o Fetal/ uterine anomalies & tumors
o Multiple fetuses
o Pelvic contraction
o Fetal malformation
External cephalic version Mechanism of labor
o Small fetus & large pelvis normal
delivery
o Large fetus engagement is impossible
unless theres a marked head moulding
to shorten occipitomental diameter.
o Conversion to face or occiput
presentation
Management
o If labor is progressing and w/o fetal
distress,
o No need to intervene same principles
as face p.

Transverse Lie/Shoulder Presentation

**Review Leopold Maneuver Incidence - 0.3 %
Etiology - unusual relaxation of abdominal wall
Face Presentation o Grand multiparity
Incidence 0.17 % o Abnormal uterus
Diagnosis o Polyhydramnios
o IE, X-ray
o Preterm fetus
Etiology
o Placenta Previa
o Any factor that favors extension or
prevents head flexion: o Contracted pelvis
Cord coils around the neck Diagnosis - Abdominal exam. & IE
Large infants Course of Labor & Prognosis
Pendulous abdomen o Neglected transverse lie
Anencephaly o Conduplicato corpore
Pelvic contraction
Management
High parity
Mechanism of delivery o Cesarian section
o Rarely above pelvic inlet o External version before or during early
o Descent Int. Rotation Flexion labor
extension ext rotation
Management Compound Presentation
o Vaginal delivery in the absence of a
Incidence - 1 in 700
contracted pelvis and with effective
Etiology
labor
o Conditions that prevent complete
o Cesarian delivery if with a contracted
occlusion of pelvic inlet by fetal head
pelvis
preterm birth
Brow Presentation
Prognosis & Management: Perinatal loss is due
to:
Incidence
o Preterm delivery
o Rarest presentation
o Prolapsed cord
o Unstable Presentation
o Traumatic obstetrical procedures
Etiology
o Any factors that favors extension or
Close observation
o Prolapsed part rises out of the way, if
prevents head flexion
not & if prevents descent, gently push
Diagnosis IE
upward & the head downwards by
fundal pressure
Persistent Occiput Posterior Position Predictability
Incidence Risk factors for shoulder dystocia have no
o 15% early in labor, 5% delivered in this predictive value
position malrotation of previously OA Shoulder dystocia is an unpredictable event
position persistence of OP position
Infants at risk for permanent injury are
Etiology
o Transverse narrowing of midpelvis impossible to predict
Management of Vaginal delivery
o Spontaneous delivery Shoulder Dystocia Drill
o Forceps delivery as occiput posterior 1. Call for help
o Forceps rotation of the occiput to the 2. Generous episiotomy
anterior position & delivery
o Manual rotation to the anterior position
3. Suprapubic pressure
followed by spontaneous or forceps 4. McRoberts maneuver
delivery These maneuvers will resolve most cases
Management of Cesarian section *Turtle's sign - "pag gwa sang ulo naga balik sulod"
If they fail:
Persistent Occiput Transverse Position 1. Woods cork screw maneuver
Incidence - Usually transient 2. Delivery of posterior arm
Etiology
o Common in platypeloid and android
pelvises
Management of Vaginal delivery
o If no spontaneous rotation, manually or
by forceps rotate to anterior or
posterior position
Management of Cesarian section

Shoulder Dystocia
Head to body delivery time >60 seconds
Need to employ maneuvers to deliver the
shoulders other than traction
Incidence - 0.9 %
Etiology
o Greater shoulder to head & chest to
head disproportion
Risk factors
o Obesity, multiparity, Diabetes Mellitus,
postmaturity McRoberts Maneuver

Consequencies:
Maternal
o Post partum hemorrhage from uterine
atony & cervical & vaginal lacerations
Fetal
o Fractured clavicle & humerus brachial
plexus injury
 DELIVERY OF THE POSTERIOR SHOULDER

Carefully sweep the posterior arm of the fetus across the

chest follwed by the arm delivey. Shoulder girdle is
rotated into oblique diameter with delivery of the
shoulder.

Management
Other Techniques to free impacted anterior
shoulder:
1. Rubins maneuver
2. Hibbard maneuver
3. Zavanelli maneuver
4. fracture the clavicle
5. Cleidotomy & Symphysiotomy

Progressively rotating the posterior shoulder 180

degrees in a cork screw fashion
 PART III ABNORMALITIES OF THE PASSAGES
Abnormalities of the Bony Pelvis
Any contraction of the pelvic diameters that
diminishes the capacity of the pelvis can create
dystocia during labor.

Rubins maneuver
Fetal shoulders rocked from side to side by
applying force to the maternal abdomen. Contracted Inlet
If not successful: Shortest AP diameter: < 10 cm. ( obsterical plane)
Pelvic hand reaches the most accessible fetal Greatest transverse diameter: < 11.5 cm.
shoulder, is then pushed toward anterior chest Face & shoulder presentation: 3x more frequent
to reduce shoulder to shoulder diameter Cord prolapse: 4-6x more frequent
(adduction) displacement of the anterior EROM more likely
shoulder from behind the symphysis pubis Slow or absent progress in cervical dilatation
Frequently causes transverse arrest of the head
Hibbard
Prognosis & Management
Pressure applied to fetal jaw and neck in the
AP diameter slightly <10cm vaginal delivery
direction of the maternal rectum, with strong
maybe successful
fundal pressure applied by the assistant
AP diameter < 9cm vaginal delivery nearly
hopeless
Zavanelli
Cephalic replacement into the pelvis followed Management
by CS Trial of labor should be carefully managed
Conduction anesthesia & Oxytocin with caution
Cleidotomy Cesarian section for arrest of cervical dilatation
Cutting the clavicle of the fetus
usually in FDU cases Maternal Effects
1. Uterine rupture
Symphysiotomy 2. Fistula formation
Cutting the symphysis punis of the mother
3. Intrapartum infection
Rare
Fetal Effects
1. Caput succedaneum
Fetal Developmental Abnormalities
2. Fetal head moulding
1. Fetal macrosomia
3. Umbilical cord prolapse
2. Hydrocephalus
3. Large fetal abdomen
4. Conjoined twins
Midpelvic Contraction Pelvic fractures
Likely contracted X-ray
Interischial spinous diameter and posterior Rare pelvic contractions
1. Tuberculosis
sagittal diameter: < 13.5 cm
2. Poliomyelitis
Suspect contraction 3. Kyphoscoliosis
Bispinous diameter is < 10cm 4. Rickets
Definitely contracted
Bispinous diameter is < 8cm Soft Tissue Dystocia
Suggestive of contraction Uterine abnormalities, prolapsed uterus,
Prominent ischial spines uterine torsion diffuse balooning of the uterine
Side walls convergent wall
Flat sacrum Cervical stenosis, coaglutination of the cervix
Narrow intertuberous diameter Vaginal septum
Pelvic masses, myomas, ovarian tumor
Prognosis
Frequently a cause of transverse arrest that can
potentially lead to difficult mid forceps
extraction or cesarean delivery

Management
Natural forces should be allowed to push the
]]biparietal diameter beyond the potential
interspinous obstruction forceps extraction
Fundal pressure not done above obstruction
Cesarian section

Contracted Pelvic Outlet

Interischial tuberous diameter - 8cm or less

Prognosis
Usually associated with midpelvic contraction
Midpelvic contracts, outlet also contracts
If alone, not cause severe dystocia but may
predispose to production of perineal tears