Dystocia (Abnormal Labor)

Dr. Irma Lee

Labor

A series of processes and events that begin with the onset of uterine contractions and end with the expulsion of the products of conception (fetus and placenta). It is characterized by a progressive increase in frequency of contractions (faster) duration of contractions (longer) intensity of contractions (more painful)

Friedmans Curve Dilatation Curve 1.Latent phase - up to 3-4 cm dilatation ( approximately 8 hours long) 2. Active phase a. Acceleration phase not always present b. Phase of Maximum Slope (PMS) - occurs at approximately 9 cm dilatation - fetus is considered fully descended as it falls one station below the ischial spines c. Deceleration - always present Fetal Descent 1. Latent phase - no fetal descent occurs - extends beyond dilatational phase of descent curve 2. Active phase - comes much later a. Acceleration b. Phase of maximum descent - occurs at around 9 cm dilatation - corresponds to the deceleration of dilatation - fetus fully descended at +1 (station at the level of ischial spines)

Criteria for the Diagnosis of Labor Documented uterine contractions (at least once in 10 minutes, or 4 in 20 minutes). Documentation can be in the form of direct observation or electronically using a cardiotocogram Documented progressive changes in cervical dilation and effacement, as observed by one observer Cervical effacement of greater then 75-80% Cervical dilatation of greater than 3 cm Factors that Affect Labor Powers - uterine contractions Passages pelvis Passenger - fetus Friedmans Curve

Functional Division of Labor Preparatory Division latent phase Dilatational Division active phase - when CERVICAL DILATATION occurs Pelvic Division concerned with descent aspect of delivery Latent Phase of Labor The point at which the mother perceives regular contractions Diagnostic Steps for the Evaluation of Latent Phase of Labor 1. Define the components of latent-phase labor a. Onset b. Interval c. End 1. Describe the antenatal history of the patient 2. Evaluate the pelvis (passage) 3. Evaluate the fetus (passenger) 4. Evaluate the contractions (powers) 5. Evaluate the labor history

WHO Partograph

Factors affecting length of Latent Phase of Labor Cervical dilatation Station of vertex Parity Maternal age Rupture of membranes during latent phase Three Parts of Active Labor A-B Acceleration: slow rate of change or transition from latent to active B-C Maximum slope of acceleration: rapid rate of change C-D Deceleration: A slowing in active phase until molding, descent, or rotation takes place and second stage begins
D
10 9 8 7 6

-5 -4 -3

B A

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

Partograph The active phase of labor commences at 3 cm dilatation The latent phase of labor should not be longer than 8 hours During the active phase, the rate of cervical dilatation should not be slower than 1 cm/ hour A lag time of 4 hrs between slowing of labor and need for intervention is unlikely to compromise the fetus and mother and avoids unnecessary intervention

5 4 3 2 1 0 1 2 3

10

+5

Protraction < 1 cm / hr cervical dilatation for a minimum of 4 hours

Protraction and Arrest of Cervical Dilatation

End of Active Phase

Protracted activephase dilatation

Nullipara Maximum slope of dilatation of 1.2cm/hr or less Deceleration phase duration of 3 hours or more Cessation of activephase for 2 hours or more

Multipara Maximum slope of 1.5cm/hr or less

10 9 8 7

C
End of latent phase

-5 -4 -3

B
Maximum Slope

-2 -1 0 +1 +2

Prolonged deceleration phase

Deceleration phase of 1 hr or more

6 5 4 3 2 1 0 1 2 3 4

Secondary arrest of dilatation

Latent Phase
5 6 7 8 9 10

+3 +4 +5

Pelvic Stations 3 pelvic stations -3 -2 -1 0 1 2 3 5 pelvic stations -5 -4 -3 -2 -1 0 1 2 3 4 5

PROLONGED LATENT PHASE

10 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 3 6 9 12 15 18 21 24 27

Pelvic Inlet

9 8 7 6

Ischial Spines (engagement)

5 4 3 2

On the perineum (vertex in view w/ cxn)

1 0

Abnormalities of Descent Nullipara Protraction <1cm dilatation change/hr No change in dilatation in an hour Multipara <2cm dilatation change/hr No change in dilatation in 30 minutes

PROTRACTED ACTIVE PHASE OF DILATATION

10 9 8 7 6 5 4 3 2 +3 1 0 1 2 3 4 5 6 7 8 9 10 +4 +5 -5 -4 -3 -2 -1 0 +1 +2

Arrest

Second Stage of Labor Definitions Failed No descent is noted from the time the patient is first examined

Protraction (2nd Stage)

Nullipara: Descent <1 cm,/hr Multipara: Descent <2cm/hr

Arrest (2nd Stage)

No change after descent has begun

10

PROTRACTED DESCENT
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 1 2 3 4 5 6 7 8 9 10 9 8 7

Nullipara: 1 hour Multipara: 30 minutes

Labor Diagnosis Term

Prolonged latent phase

Criteria
Nulliparas >20 hours Multiparas >14 hours

5 4 3 2 1 0

Protracted active-phase dilatation

Nulliparas <1.2cm/hour Multiparas <1.5cmhour

Arrest of dilatation Protracted descent

No progress for 2 hours Nulliparas <1 cm/hour Multiparas <2cm/hour

Arrest in descent

No progress for 1 hour

PROLONGED DECELERATION PHASE

10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

Fetal effects Caput succedaneum Fetal head molding

ARREST IN CERVICAL DILATATION

10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10
ROT ROT ROT

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

Shoulder Dystocia Disproportion between the fetal bisacromial diameter and the AP diameter of the pelvic inlet. Incidence: 0.2 3.0% of all vaginal deliveries Risk of Recurrence:11.9 16.7 % Risk Factors: Antepartum Fetal macrosomia increased in body size relative to head size Advanced maternal age Diabetes Mellitus Maternal Obesity Post-term pregnancy Excessive maternal weight gain Prior shoulder dystocia Platypelloid or convergent pelvis Intrapartum Prolonged second stage of labor without descent Oxytocin use Midpelvic delivery Overzealous external rotation of the fetal head by the operator Deliveries on bed Excessive fundal pressure Diabetes Mellitus 70% Increase overall risk for shoulder dystocia Author Increase in Risk Associated with Diabetic Status Rate ratio 5.2 Odds ratio 4,3; 95% CI 2.2 8.3 Relative risk <4,000g 2.6; 95% CI 1.29-5.34 Relative risk >4,000g 3.6; 95% CI 2.37-4.76 Relative risk 6.5; 95% CI 1.5-27.1

ARREST OF DESCENT
10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

Acker et al 1985 Bahar 1996

Langer et al 1991

Sandmire et al 1988

Birth Weight In relation to Birth Weight and Diabetic Status Birth Weight (g) Women Without Diabetes (%) 0.1 1.1 1.1 10.0 4.1 22.6 BW > 4000 g PPV of 3.3% EFW by UTZ Sensitivity: 22-44% PPV: 30-44% Fetal Abdominal Circumference: > 35 cm (MACROSOMIA) BW > 4500 g PPV 9% Macrosomia index = chest diameter BPD = 1.4 cm (critical for vaginal delivery) Sonographic Predictors for Shoulder Dystocia Women With Diabetes (%) 0.6 3.7 4.9 23.1 20.0 50.0

<4,000

FAILURE OF DESCENT
10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

4,000-4,449 > 4,500

Maternal-Fetal Effects of Dystocia Maternal effects Intrapartum infection Uterine rupture Pathologic retraction ring Fistula formation Pelvic floor injury Postpartum lower extremity nerve injuryss

Chest to head difference Shoulder to head difference Shoulder circumference Abdominal to BPD difference

1.4cm 4.8cm 40.9cm 2.6cm

CT Scan Shoulder measurement >14 cm predicts birth weight >4200 gms 100% sensitivity 87% specificity 78% PPV 100% NPV * Head to body delivery interval 24 secs. * Shoulder Dystocia >60 secs Shoulder Dystocia: Indicators Turtle sign Retraction of the fetal head against maternal perineum No spontaneous external rotation Downward traction does not deliver the anterior shoulder Multiple risk factors Sonographic features

Fractures Claviicular (10%) Humerus (5%) Prolonged head-shoulder interval (10.6 3.0 vs 4.3 0.7, P=0.03) Head-shoulder interval >7mins. 65% sensitivity 74% specificity

BRAIN INJURY Maternal Complications PPH ( Large Baby, Prolong Labor) Genital Tract Lacerations Cervical Tears, Bladder Atony, Uterine Rupture

* No clinical or theoretical data to support that elective cesarean section will prevent shoulder dystocia and avoid brachial plexus injury ACOG Guidelines Planned CS for suspected macrosomia in the general population is not reasonable Planned CS may be reasonable for diabetic pregnant women with EFW >4200 gms-4500 gms Risk factors alone or in combination lacks accuracy to predict SD Ultrasound to estimate macrosomia has limited accuracy

Cardinal Movements of Labor

Goals in Management Maximize safe delivery Shorten the time from delivery of the head to delivery of the body ACOG Proposed Management Protocol Assistance from anesthesia, pediatrics, and obstetrics Gentle attempt at traction assisted by maternal expulsive efforts Generous episiotomy Suprapubic pressure Dont apply it directly downward Apply it to an angle towards the fetal chest Lateral application from either sides of the maternal abdomen Alternating between sides (rocking pressure)

Pathophysiology Persistent Anterior-Posterior of fetal shoulders at the pelvic brim (fetal macrosomia, precipitous labor). Failure of internal rotation of the bisacromial diameter at the midpelvis. Impaction of posterior fetal shoulder on sacral promontory.

Unilateral shoulder dystocia

Bilateral shoulder dystocia

Complications Associated w/ Shoulder Dystocia Fetal complications Asphyxia Brain Damage. Perinatal Death (20-25%) Brachial plexus injury (17%) C5 - C6 Erbs Palsy C7 - C8 Klumpkes Palsy

McRoberts maneuver Benefits: The maternal sacrum is flattened in relation to the lumbar spine Cephalad rotation of the symphysis pubis leads to: Reduction in pelvic inclination from 26 to 0 Increases the size of posterior outlet May unlock the anterior shoulder Increases the intraabdominal pressure by 97% amplitude of the uterine contraction Easy, simple and effective technique Success rate = 42% If combined with episiotomy and suprapubic pressure=54.2%

Rubins maneuver (reverse of Woods) The pressure is applied to the posterior surface of the most accesible part of fetal shoulder (either the anterior or posterior shoulder) to effect shoulder abduction.

How does Mc Roberts Maneuver works Change the angle by flattening the sacrum in relation to the maternal spine and elevate SP. Enhances intrauterine pressure and amplitude of uterine contractions. Rotation of anterior shoulder Woods corkscrew maneuver Progressive rotations of shoulder girdle in a corkscrew fashion by continuous pressure on anterior surface of the posterior shoulder together with downward thrust of the left hand on the buttocks of the baby. Rotation of the posterior shoulder to anterior through 180 arch clockwise

Cephalic Replacement (ZAVANELLI MANEUVER) Return head to OA and flex and push cephalad, once replaced, hold at station 0 Give 0.25 mg terbutaline SC or general anesthesia prior to maneuver. Time of CS dictated by fetal condition

Controversial Methods Symphysiotomy Posterior arm extraction (Barum Maneuver) To do posterior arm delivery, pressure should be applied on the antecubital fossa in order to flex the fetal forearm and then pull across the chest and face until it is outside the vagina

Cleidotomy- cut clavicle, usually used on dead fetus

Clavicular fracture

Other methods: Cephalic replacement Abdominal rescue

Fundal pressure All fours (Gaskin maneuver) The patient is rolled from her existing position into her hands and knees Benefits: Downward force of gravity Favorable change in pelvic diameters

After Vaginal delivery Exploration of the uterus, vagina and cervix for lacerations Check whether the episiotomy has extended into the rectum Check for the presence of hematomas: cervix, vagina and broad ligament Explore the uterus for rupture Rate and Risk Factors for Recurrent Shoulder dystocia

Pelvic Inlet

Midpelvis Author Vaginal SD Deliveries Subsequent Recurrent SD Risk Factors Vaginal for Deliveries Recurrent SD
Fetal weight Maternal parity

AP Diameter Anatomic/True= 11 cm Obstetric (most critical)= 10 cm Diagonal= 12 cm APMP = 11.5 cm Ischial spine Sidewalls Curvature sacrum 9.5 to 11.5 cm

Transverse Diameter Transverse Diameter of the inlet= 13cm

Pelvic Outlet

Ginsberg 39,681

602(1.5%) 66 (10.9%) 11 (16.7%)

Arch of pubis Lewis 37,465 747(2%) 101(13.5%) 17(13.8%)

Pre-pregnancy weight Weight at delivery Time of second stage of labor Fetal weight that of index pregnancy Fetal weight that of index pregnancy

Biischial/interischial= 10 cm Not prominent divergent More curved Biiscial tuberosity/intertuberous= >8 cm (mans fist) Wide (>90)

Mueller Hillis Maneuver Hands on cervix, while pushing uterine fundus down To know extent of descent Station 0: engaged Station -2: 2 cm above ischial spine Staion +2: 2cm below ischial spine Station -5: head floating above symphysis pubis Deceleration phase of 1st stage of labor Engagement: occurs later in multigravid Descent Flexion Internal rotation External rotation Note: Primigravid: usu descent first before active cxn Multigravid: cxn first before descent Asses Fetal size If mom is Diabetic or obese, a possibility of Fetal macrosomia -> risk shoulder dystocia Breech- can be delivered vaginaly

Smith

34,800

203(0.58%) 42 (20.6%) 5 (11.9%)

Conclusion No reliable and accurate predictors for SD Ultrasound for estimation of macrosomia has limited accuracy Planned CS for EFW >4200-4500 gms Early suspicion and logical sequence of maneuvers to lessen brachial plexus injury No Maneuver that is superior to release impacted shoulder Periodic review of maneuvers Summary Early recognition Initial adequate efficient treatment (mental drill) Stop the patient from pushing Stop fundal pressure Call for help Experienced OB Pediatrician Anesthesiologist Paramedics If there is nuchal cord, reduce Do the following: Anesthesia Empty the bladder Generous episiotomy Mac Roberts Suprapubic pressure Success rate 58%

Footling: Caesarian Section unless baby is small Single Double

Cervical dilatation Descent Stage 1 Stage 2 Stage 3

Primigravida 1.2 cm/hr 1 cm/hr 8 hrs 30 mins 20 mins

Multigravida 1.5 cm/hr 2 cm/hr 5 hrs 15 mins 5 mins

ADDITIONAL Notes from our Discussion 3 Factors Affecting Labor 1. Power uterine cxn for cervix to dilate 2. Passage- pelvic inlet and outlet 3. Passenger- size and presentation of fetus Blood Supply: uterine artery (uterus, Cervix) : ovarian artery: (ovary, distal FT) Diagonal Conjugate - only one measured clinically - measured from the lower border of symphysis pubis to the midpoint of the sacral promontory - if < 11.5: shortened/inadequate

Post term pregnancy (42 weeks) Induced Labor Bishops Score - Effective if > 6 Dilatation Effacement Position Consistency of uterus Gravida Augmented Labor Uterotonic Oxytocin IV (10 U in 1L NSS) 1st stage of labor: beginning dilatation-full dilatation (10cm) Latent Phase Cervix <3-4cm Uterine cxn may be present Affected by sedation (EPIDURAL) Active Phase: > 3-4cm Acceleration phase Outcome of labor Not alwas present Phase of maximum slope Rapid dilatation Efficiency of uterus

Rapid descent of fetus- 7-8 cm start descent fetal head May dilate to @ 9 cm Fetus considered descended if falls 1 cm below ischial spine (occiput anterior) Deceleration phase Fetopelvic relationship Always present (10 cm) Primi: 1 hr Multi: 30 mins Note: Prolonged latent phase Primi: > 20 hours Multi: >14 hrs Arrest for dilatation Most common No change in 2 hrs Usual cause: contracted pelvis

Hypotonic Less pressure Goes back to baseline Both are ineffective -> never lead vaginal delivery Cant dilate cervix Both can be given Oxytocin: to make cxn regular

Note:

Functional Division Preparatory: latent and acceleration phase Dilatational phase: phase of max slope Pelvic phase: deceleration phase to 1st hour after full dilatation : concern w/ descent aspect of delivery : head on perineal wall Prolonged labor: > 20 hours Irregular cxn: send Px home PROM: admit px Labor

Shoulder Dystocia Risk Factors Obesity DM Excessive weight gain Multiparity Postdatism Previous delivery of LGA Fetal Macrosomia (LGA: > 4500g) *External Rotation: bisacromial diameter of shoulder: parallel to AP diameter of symphysis pubis Indications Turtle sign - Cephalad retraction - Due to obstruction of shoulder because of wide bisacromial diameter/ anterior shoulder is above the sacral promontory (normally, it should go under the sacral promontory) - Should expel the baby in 60 sec If not may lead to hypoxia -> ASPHYXIA AND CEREBRAL PALSY

Frequency of cxn ( faster) Intensity of cxn (more painful) Duration of cxn (longer) Interval Peak= frequency

Cardiotopographic graph/ Labor admission test 1. Measure frequency 2. Classify if: a. Mild: indent abdominal wall b. Moderate c. Strong: skin abdominal wall cant be indented 3. Intensity (peak-baseline): Montevideo units in 10 min Should not be <180 for it to be effective Criteria for true labor 1. Uterine cxn At least 1 in 10 mins or 4 in 20 mins 2. Progressive change in cervical dilatation & effacement 3. Cervical effacement 75-80% 4. Cervical dilatation >3 cm Normal length cervix: 1 inch (2.54 cm) Fully effaced: paper thin Ripe cervix: midline in position, dilatable WHO partograph 1cm.hr dilatation 4 hours difference from alert line to action line Latent time of 4 hrs b/w slowing of labor & need for intervention is unlikely to compromise the fetus and mom ( avoids unnecessary intervention) Active phase commences at 3cm Latent phase shud not be longer than 8 hours During active phase, rate dilatation should not be slower than 1 cm/hr Uterine Cxns Hypertonic Sustaine cxn Period of relaxation very short Above the baseline Best to sedate px: to decrease anxiety 10 mg Nalbuphine HCL IV 100mg Meperidine IM

Other Complications: Brachial plexus injury Clavicular fracture Humerus fracture Increase fetal morbidity and mortality Mom Uterine rupture: prolonged labor, LGA Uterine atony: PPH : prolonged labor, LGA Birth canal injuries: especially if low forceps extraction Fistula formation: b/w 2 viscus Rectovaginal: assoc w/ operations/maneuvers in vagina Vesicovaginal Urethrovaginal Before doing procedure, empty bladder Repair: 6 weeks post delivery esp. vesicovaginal Can give antimicrobial tx Prognosis related to Fetal Macrosomia Increased perinatal loss Infants severely depressed at birth Neurological complications High infant mortality befor age 7 Note:

Contracted pelvis: absolute indication CS Elective surgery: unethical, bec of increase risk for mom & baby

Maneuvers 1. Mc Roberts Least traumatic to the mom esp if done w/ clavicular fracture CALL FOR HELP FIRST First procedure to increase outlet diameter (questionable) Flex thigh mom upto abdomen Feet on stirrups straightens the spine (lift symphysis pubis) : increase outlet diameter Rubins Push scapula baby towards chest (anterior rotation) Anterior shoulder counterclockwise Thrust on armpit -> grasp humerus -> swing it anteriorly

2.

3.

4.

5.

6. 7. 8.

9.

Woods corkscrew Push shoulder by pushing anterior surface of the posterior shoulder (posterior rotation) and dislodge posterior shoulder anteriorly clockwise direction Zavanelli Super hard Flex the shoulder Push the baby inside again ( doing internal rotation) Reposition the baby After repositioning: do CS Complication: chance to rupture Puerperal infection Gaskin Mom upside down kneeling, palms on floor twist baby towards his/her anterior surface Symphysiotomy put xylocaine, then cut symphysis pubis Duhrseen Cut the cervix to make it big Chavis Shoulder horn instrument w/ concave blade w/ long handle, is slipped b/w symphsis pubis and impacted anterior shoulder Hibbard Pressure applied at infants jaw and neck in the direction of the moms rectum, w/ strong fundal pressure applied by an assistant as the anterior shoulder is freed Complication: if fundal pressure applied at a wrong time -> fetal orthopaedic and neurologic damage

Epidural anesthesia best anesthesia in labor to alleviate pain to assist us in doing procedures for shoulder dystocia Bupivacaine

Transcribe by: Cecil Ong Notes from: Cecil Ong Lea Oiga Mae Olivares Argelyn Ong Emy Onishi
Cecil Ong Emy Onishi Mitzel Mata Fred Monteverde Regina Luz Lala Nieto Mae Olivares SEC C 2009 !