Dystocia Part II Passage factor. 2 How is abnormal labor evaluated as for the passage Pelvic factors...

transcript

Dystocia Part II Passage factor

How is abnormal labor evaluated as for the passage

Pelvic factors in abnormal labor may include an unfavorable pelvic shape or simply a pelvis that is too small（ external and internal pelvimetry） .

There are four types of the female pelvis described**

Gynecoid: a round shape (most common, at 40 to 50%) with straight sidewalls adequate for vaginal delivery.(female)Android: heart-shaped (30% of all women) with convergent side walls (fetus may have difficulty with descent)(male)Anthropoid: vertically oriented oval shape (20% of all women) with straight sidewalls and somewhat smaller interspinous and/or intertuberous diameters (ok for vaginal delivery)(ape)Platypelloid: horizontal oval (rarest, at 2 to 5%) with poor prognosis for vaginal delivery.

Abnormalities of bony pelvis**

1.Contracted pelvic inlet ( Platypelloid)

simple flat pelvis

rachitic flat pelvis

1.Contracted pelvic inlet ( Platypelloid)

simple flat pelvis

rachitic flat pelvis

2.Contracted midpelvis (anthropoid pelvis)

3)Contracted pelvic outlet

(funnel shaped pelvis , Android)

3)Contracted pelvic outlet

(funnel shaped pelvis , Android)

4.Generally contracted pelvis

5.Disruption of normal female pelvic architecture

osteomalacic pelvis

obliquely contracted pelvis

4.Generally contracted pelvis

5.Disruption of normal female pelvic architecture

osteomalacic pelvis

obliquely contracted pelvis

Michaelis rhomboid

HistoryPhysical examinationPelvimetry external pelvimetry internal pelvimetry diagonal conjugate 12.5~13cm bi-ischial diameter 10cm incisura ischiadica 5~6cm angle of subpubic arch 90

Diagnosis :

septum

Abnormal of soft birth canal

Dystocia

Part passenger factorⅢPart passenger factorⅢ

How is abnormal labor evaluated as for the passenger

Fetal factors that interfere with labor include macrosomia (especially in diabetic mothers) or abnormal fetal lie, presentation, or attitude.

Attitude refers to the posture the fetus adopts late in pregnancy. The normal attitude has the chin flexed in front of the chest, thigh flexed, and arms flexed in front of the chest, creating a tight mass that fits snugly against the uterine cavity.

Fetal factors that interfere with labor include macrosomia (especially in diabetic mothers) or abnormal fetal lie, presentation, or attitude.

Attitude refers to the posture the fetus adopts late in pregnancy. The normal attitude has the chin flexed in front of the chest, thigh flexed, and arms flexed in front of the chest, creating a tight mass that fits snugly against the uterine cavity.

Fetal presentation in 68,094

Presentation Percent Incidence

Cephalic 96.8

Breech 2.7

Transverse 0.3

Compound 0.1

Face 0.05

Brow 0.01

Presentation Percent Incidence

Cephalic 96.8

Breech 2.7

Transverse 0.3

Compound 0.1

Face 0.05

Brow 0.01

Cephalic presentation:

Persistent occiput posterior position Persistent occiput transverse position

Breech presentationFace presentationBrow presentationTransverse lieCompound presentationShoulder dystocia

Cephalic presentation: Persistent occiput posterior position Persistent occiput transverse position

Breech presentationFace presentationBrow presentationTransverse lieCompound presentationShoulder dystocia

Common types of abnormal labor due to fetal factors

PERSISTENT OCCIPUIT POSTERIOR POSITION

Most often, occiput posterior position undergo spontaneous anterior rotation

-transverse narrowing of the midpelvis failure of the rotation: persistent ~

Labor and delivery may not differ remarkably from that with the occiput anterior, in some instances, delivery can usually be accomplished without great difficulty once the head reaches the perineum

Most often, occiput posterior position undergo spontaneous anterior rotation

-transverse narrowing of the midpelvis failure of the rotation: persistent ~

Labor and delivery may not differ remarkably from that with the occiput anterior, in some instances, delivery can usually be accomplished without great difficulty once the head reaches the perineum

The possibilities for vaginal delivery** 1. Await spontaneous delivery 2. Manual rotation to the anterior position

followed by spontaneous or forceps delivery

3. Forceps delivery with the occiput directly posterior

4. Forceps rotation of the occiput to the anterior position and delivery

The possibilities for vaginal delivery** 1. Await spontaneous delivery 2. Manual rotation to the anterior position

followed by spontaneous or forceps delivery

3. Forceps delivery with the occiput directly posterior

4. Forceps rotation of the occiput to the anterior position and delivery

PERSISTENT OCCIPUIT POSTERIOR POSITIONManual rotationManual rotation

Forceps delivery: more traction larger episiotomy complete analgesia

Forceps rotation : head is engaged cervix fully dilated the pelvis adequate skilled operator ineffective expulsive effort during the 2nd stage

Forceps delivery: more traction larger episiotomy complete analgesia

Forceps rotation : head is engaged cervix fully dilated the pelvis adequate skilled operator ineffective expulsive effort during the 2nd stage

C-section:

the head may not even be engaged

(BPD may not have passed through the pelvic inlet)->prompt c/sec is appropriate

C-section:

the head may not even be engaged

(BPD may not have passed through the pelvic inlet)->prompt c/sec is appropriate

Outcomes of PERSISTENT OCCIPUIT POSTERIOR POSITION*

1.labor was prolonged

-multiparous: 1 hrs

-nulliparous : 2 hrs

2.episiotomy extension was increased

3.65% required operative intervention

1.labor was prolonged

-multiparous: 1 hrs

-nulliparous : 2 hrs

2.episiotomy extension was increased

3.65% required operative intervention

PERSISTENT OCCIPUIT TRANSVERSE POSITION

In the absence of a pelvic architecture abnormality

:most likely a transitory one

:rotates to the anterior position

#Delivery

-the occiput may be manually rotated anteriorly or posteriorly and forceps delivery carried out

In the absence of a pelvic architecture abnormality

:most likely a transitory one

:rotates to the anterior position

#Delivery

-the occiput may be manually rotated anteriorly or posteriorly and forceps delivery carried out

PERSISTENT OCCIPUIT TRANSVERSE POSITION

1. if failure of spontaneous rotation is caused by hypotonic uterine dysfunction without CPD.

oxytocin may be infused with close

observation

2.Platypelloid (anteroposteiorly flat)

android(heart-shaped) pelvis

1. if failure of spontaneous rotation is caused by hypotonic uterine dysfunction without CPD.

oxytocin may be infused with close

observation

2.Platypelloid (anteroposteiorly flat)

android(heart-shaped) pelvis

How can I facilitate a change of fetal position through

changes in maternal position?Changing maternal position frequently in labor allows the fetus to change position, often to one that is more favorable to delivery. Occiput-posterior(OP) is a normal variation of fetal position that may slow labor and is associated with greater pain for the mother, particularly in the back. Maternal positions that open the pelvis give the fetus space to shift into occiput-anterior(OA). Squatting, kneechest, and modified Sim’s are all positions that facilitate rotation of the fetal head out of occiput-transverse or posterior position.

Changing maternal position frequently in labor allows the fetus to change position, often to one that is more favorable to delivery. Occiput-posterior(OP) is a normal variation of fetal position that may slow labor and is associated with greater pain for the mother, particularly in the back. Maternal positions that open the pelvis give the fetus space to shift into occiput-anterior(OA). Squatting, kneechest, and modified Sim’s are all positions that facilitate rotation of the fetal head out of occiput-transverse or posterior position.

What are the types of breech presentation?**

Breech presentation occurs in approximately 2 to 4% of singleton deliveries.

Frank breech: thighs flexed, legs extended Complete breech: thighs and legs flexed Incomplete breech: one or both hips are not

flexed, such that one or both feet are hanging downward.

Breech presentation occurs in approximately 2 to 4% of singleton deliveries.

Frank breech: thighs flexed, legs extended Complete breech: thighs and legs flexed Incomplete breech: one or both hips are not

flexed, such that one or both feet are hanging downward.

Management of breech presentation

Vaginal delivery is possible in breech presentation in experienced obstetricians.Prerequisites for a trial of vaginal delivery include an adequate maternal pelvis, reassuring fetal heart rate, normal progression of labor, and an average-size fetus.C-section may be preferred or necessary for the breech infant.External cephalic version: the fetus is rotated in the abdomen by the obstetrician prior to the onset of labor.

Face presentation

FACE PRESENTATION

The head: hyperextended

occiput-contact with fetal back

presenting part-chin (mentum)

-mentum posterior : brow is compressed against the maternal symphysis pubis

-mentum anterior: typical→convert spontaneosly anterior(←posterior)

The head: hyperextended

occiput-contact with fetal back

presenting part-chin (mentum)

-mentum posterior : brow is compressed against the maternal symphysis pubis

-mentum anterior: typical→convert spontaneosly anterior(←posterior)

FACE PRESENTATION

Diagnosis

1. vaginal examination & palpation

(mouth, nose, malar bone , orbital ridge)

→ mistake a breech

anus-mouth

ischial tuberosities-malar bone

2. B-ultrasound

Diagnosis

1. vaginal examination & palpation

(mouth, nose, malar bone , orbital ridge)

→ mistake a breech

anus-mouth

ischial tuberosities-malar bone

2. B-ultrasound

FACE PRESENTATIONEtiology favors extension, prevents head flexion → marked enlargement of the neck coils of cord about the neck anencephalic fetus pelvic contractureManagement vaginal delivery: fetal well-being, normal labor stage C-section

Etiology favors extension, prevents head flexion → marked enlargement of the neck coils of cord about the neck anencephalic fetus pelvic contractureManagement vaginal delivery: fetal well-being, normal labor stage C-section

FACE PRESENTATION

face edema

head molding

increased the length of the diameter

face edema

head molding

increased the length of the diameter

BROW PRESENTATION

1.rarest presentataion

between the orbital ridge and the anterior fontanel at the pelvic inlet

2.midway between full flexion (occiput)

full extension (mentum or face)

unstable-converts to face or occiput

1.rarest presentataion

between the orbital ridge and the anterior fontanel at the pelvic inlet

2.midway between full flexion (occiput)

full extension (mentum or face)

unstable-converts to face or occiput

BROW PRESENTATION

Diagnosis

1. abdominal palpation

2.vaginal examination

-frontal suture, large anterior fontanel, orbital ridge, eyes, and root of the nose

-neither, mouth & chin

Diagnosis

1. abdominal palpation

2.vaginal examination

-frontal suture, large anterior fontanel, orbital ridge, eyes, and root of the nose

-neither, mouth & chin

BROW PRESENTATION

Mechanism of labor 1.very difficult, because engagement is

impossible

2.possible-large pelvis, small fetus convert to occiput or face presentation

Mechanism of labor 1.very difficult, because engagement is

impossible

2.possible-large pelvis, small fetus convert to occiput or face presentation

BROW PRESENTATION

Prognosis

1. depends upon the ultimate presentation

2. if the brow persists, prognosis is poor

#Management

same as those for a face presentation

Prognosis

1. depends upon the ultimate presentation

2. if the brow persists, prognosis is poor

#Management

same as those for a face presentation

TRANSVERSE LIE

When the long axis of the fetus is approximately perpendicular to that of the mother

oblique lie, unstable lie

shoulder-over the pelvic inlet

head-in one iliac fossa

breech-in the other iliac fossa

When the long axis of the fetus is approximately perpendicular to that of the mother

oblique lie, unstable lie

shoulder-over the pelvic inlet

head-in one iliac fossa

breech-in the other iliac fossa

TRANSVERSE LIE

Etiology

1. Unusual relaxation of the abdominal wall resulting from high parity

2. Preterm fetus

3. Placenta previa

4. Abnormal uterus

5. Excessive amnionic fluid

6. Contracted pelvis

Etiology

1. Unusual relaxation of the abdominal wall resulting from high parity

2. Preterm fetus

3. Placenta previa

4. Abnormal uterus

5. Excessive amnionic fluid

6. Contracted pelvis

TRANSVERSE LIEDiagnosis

1. inspection

-wide abdomen

-fundus extends to only slightly above

umbilicus

2. palpation

-no fetal pole in the fundus

head in one iliac fossa

breech in the other

Diagnosis

1. inspection

-wide abdomen

-fundus extends to only slightly above

umbilicus

2. palpation

-no fetal pole in the fundus

head in one iliac fossa

breech in the other

TRANSVERSE LIE

3. vaginal examination

-the side of the thorax

-further dilatation: scapula or clavicle

axilla: shoulder direction

-later in labor

->shoulder become tightly wedged in the pelvis

->a hand and arm frequently prolapse

3. vaginal examination

-the side of the thorax

-further dilatation: scapula or clavicle

axilla: shoulder direction

-later in labor

->shoulder become tightly wedged in the pelvis

->a hand and arm frequently prolapse

TRANSVERSE LIECourse of labor

spontaneous delivery is impossible with a persistent transverse lie

<neglected transverse lie**> After ROM, labor continue fetal shoulder is forced into the pelvis, the

corresponding arm frequently prolapse After some descent shoulder is arrested in pelvis, with the head is

in the one iliac fossa and breech in the other

Course of labor spontaneous delivery is impossible with a

persistent transverse lie <neglected transverse lie**> After ROM, labor continue fetal shoulder is forced into the pelvis, the

corresponding arm frequently prolapse After some descent shoulder is arrested in pelvis, with the head is

in the one iliac fossa and breech in the other

TRANSVERSE LIE As labor continues

the shoulder is impacted firmly in the upper part of the pelvis

After a time

a retraction ring rises increasingly higher

->if not promptly managed

uterine rupture, mother & fetus die!!

As labor continues

the shoulder is impacted firmly in the upper part of the pelvis

After a time

a retraction ring rises increasingly higher

->if not promptly managed

uterine rupture, mother & fetus die!!

TRANSVERSE LIE if small fetus(<800g), large pelvis

in spontaneous delivery

->the head and thorax pass through the pelvic cavity at the same time

#Prognosis

1. maternal, fetal hazard

2. even with the best care, morbidity is

incereased

if small fetus(<800g), large pelvis

in spontaneous delivery

->the head and thorax pass through the pelvic cavity at the same time

#Prognosis

1. maternal, fetal hazard

2. even with the best care, morbidity is

incereased

TRANSVERSE LIEManagement

1.before or early labor: conversion to a longitudinal lie (-with

the membrane intact, no indication of c/sec 2.onset of active labor- c/sec if c/sec-vertical incision difficulty in extraction of the fetus (not foot or head on incision site)

Management 1.before or early labor: conversion to a longitudinal lie (-with

the membrane intact, no indication of c/sec 2.onset of active labor- c/sec if c/sec-vertical incision difficulty in extraction of the fetus (not foot or head on incision site)

COMPOUND PRESENTATION

An extremity prolapse alongside the presenting part , with both presenting in the pelvis

# Incidence: 1 of 700 delivery

An extremity prolapse alongside the presenting part , with both presenting in the pelvis

# Incidence: 1 of 700 delivery

What’s the meaning of SHOULDER DYSTOCIA**

TIME INTERVAL (head to body)

-normal: 24 seconds

-shoulder dystocia: exceeding 60 seconds:

define shoulder dystocia

TIME INTERVAL (head to body)

-normal: 24 seconds

-shoulder dystocia: exceeding 60 seconds:

define shoulder dystocia

SHOULDER DYSTOCIA

Incidence

varies depending on the criteria used for diagnosis

current report-0.6~1.4%

Incidence

varies depending on the criteria used for diagnosis

current report-0.6~1.4%

SHOULDER DYSTOCIARisk factor

1.maternal factor-incresed birth weight (but, 50%-<4,000g 2260g-dystocia reported) obesity, multiparity, diabetes, postterm pregnancy 2. Intrapartum complication -midforceps delivery - prolonged 1st and 2nd stage

Risk factor 1.maternal factor-incresed birth weight (but, 50%-<4,000g 2260g-dystocia reported) obesity, multiparity, diabetes, postterm pregnancy 2. Intrapartum complication -midforceps delivery - prolonged 1st and 2nd stage

Effects of shoulder dystocia on mothers and fetus

Maternal consequences

postpartum hemorrhage

lacerations

puerperal infection

Maternal consequences

postpartum hemorrhage

lacerations

puerperal infection

**Fetal consequences 1.significant fetal morbidity and mortality 2.transient brachial plexus palsy 3.clavicle fracture or humeral fracture 4.neonatal death 5.persistent brachial plexus palsy

SHOULDER DYSTOCIA

1.cannot be predicted or prevented-no accurate methods

2.ultrasonic measurements to estimate macrosomia have limited accuracy

3.planned c/sec due to macrosomia

-not reasonable strategy

4.planned c/sec may be reasonable

-nondiabetes (>5,000g)

-diabetes (4,500g)

1.cannot be predicted or prevented-no accurate methods

2.ultrasonic measurements to estimate macrosomia have limited accuracy

3.planned c/sec due to macrosomia

-not reasonable strategy

4.planned c/sec may be reasonable

-nondiabetes (>5,000g)

-diabetes (4,500g)

SHOULDER DYSTOCIA1.Moderate suprapubic pressure

-by an assistant while downward traction

2.McRoverts maneuver

-flexing the legs upon the abdomen

-not increase pelvic diameter

straightening of the sacrum

symphysis pubis-toward the maternal head decrease the angle of pelvic inclination

1.Moderate suprapubic pressure

-by an assistant while downward traction

2.McRoverts maneuver

-flexing the legs upon the abdomen

-not increase pelvic diameter

straightening of the sacrum

symphysis pubis-toward the maternal head decrease the angle of pelvic inclination

SHOULDER DYSTOCIA

3.Woods corkscrew maneuver

-rotating the posterior

shoulder 180 degrees

-anterior shoulder could be released

3.Woods corkscrew maneuver

-rotating the posterior

shoulder 180 degrees

-anterior shoulder could be released

SHOULDER DYSTOCIA

4.Delivery of the posterior shoulder

-post. arm: across the chest then delivery

-next, shoulder girdle rotation into one of the oblique diameters of the pelvis

delevery of ant. shoulder

4.Delivery of the posterior shoulder

-post. arm: across the chest then delivery

-next, shoulder girdle rotation into one of the oblique diameters of the pelvis

delevery of ant. shoulder

SHOULDER DYSTOCIA5.Rubin maneuver

-1st, the fetal shoulder are rocked from side to side by applying force to the abdomen

-if not successful, push the ant. shoulder toward the anterior surface of the chest

5.Rubin maneuver

-1st, the fetal shoulder are rocked from side to side by applying force to the abdomen

-if not successful, push the ant. shoulder toward the anterior surface of the chest

SHOULDER DYSTOCIA

Shoulder dystocia drill HELPERR 1.call for help 2.generous episiotomy 3.suprapubic pressure -simple, only one assistant -while normal downward traction 4.McRoverts maneuver -two assistants

SHOULDER DYSTOCIA

5. the woods screw maneuver

6. posterior arm delivery is attempted

7. other technique

-Zavanelli maneuver

-fracture of ant. clavicle, humerus

5. the woods screw maneuver

6. posterior arm delivery is attempted

7. other technique

-Zavanelli maneuver

-fracture of ant. clavicle, humerus

What is meant by the term operative vaginal delivery?

This implies a vaginal delivery aided by the application to the fetus of a vaccum or obstetrical forceps. Both methods require a fully dilated cervix, ruptured membranes, knowledge of the position of the fetal head, and an appropriate maternal pelvis. Experience is key when performing these maneuvers, as significant trauma may occur to both the mother and baby if done improperly.

When is a cs indicated for abnormal labor**

There are numerous indications for CS. These include but are not limited to failed induction of labor, cephalopelvic disproportion, preeclampsia, classic CS incision (vertically oriented uterine incision), unknown type of cesarean incision, history of uterine rupture, obstructive lesion such as fibroids, non-reassuring fetal heart rate, cord prolapse, breech presentation, multiple gestation, fetal abnormalities, placenta abnormalities,

If a C-section is scheduled, a low transverse uterine incision is made on the uterus, allowing the possibility of VBAC in future deliveries. A classical uterine incision (vertical) is performed on an emergent basis and when the fetus is in a transverse lie to allow greater exposure.

Discussion A 30-year-old primiparous patient at 34 weeks gestation presents to labor and delivery triage complaining of a bloody show and regular uterine contractions for several hours. She has no medical problems and her presentation determined at her last prenatal visit one week ago. Upon sterile speculum examination, you notice the umbilical cord protruding through a visually dilated cervical os of 4cm .

A 30-year-old primiparous patient at 34 weeks gestation presents to labor and delivery triage complaining of a bloody show and regular uterine contractions for several hours. She has no medical problems and her presentation determined at her last prenatal visit one week ago. Upon sterile speculum examination, you notice the umbilical cord protruding through a visually dilated cervical os of 4cm .

A. what is your diagnosis ?

B. How do you manage this case ?

C. what are risk factors for this presentation ?

D. Define “engagement.”

A. what is your diagnosis ?

B. How do you manage this case ?

C. what are risk factors for this presentation ?

D. Define “engagement.”

A. Learning objective: Recognize the presentation of umbilical cord prolapse .Diagnosis in this case is that of an umbilical cord prolapse ,which constitutes an obstetrical emergency.

B. Learning objective: Know, in general, how to manage a patient wit

h umbilical cord prolapse .umbilical cord prolapse is managed in an emergent fashion ,with a patient being taken immediately for a cesarean section .A sterile gloved hand shoud be placed immediately into the uterus to displace the presenting part from the umbilical cord. This will help prevent umbilical cord compression by the presenting part during a uterine contraction and can be help prevent fetal death .The hand placed into the uterus should not be removed until delivery has been completed by a cesarean section .

umbilical cord prolapse is managed in an emergent fashion ,with a patient being taken immediately for a cesarean section .A sterile gloved hand shoud be placed immediately into the uterus to displace the presenting part from the umbilical cord. This will help prevent umbilical cord compression by the presenting part during a uterine contraction and can be help prevent fetal death .The hand placed into the uterus should not be removed until delivery has been completed by a cesarean section .

C. Learning objective:Be aware of the risk factors for umbilical cord prolapse. Risk factors umbilical cord prolapse include breech presentation, prematurity, rupture of membranes (either spontaneous or artificial, with a non-engaged presenting part), and polyhydramnios.

D. Learning objective: Know the definition of engagement. Engagement is defined as the descent of presenting part of the fetus into the pelvic inlet. In the case of vertex presentation, this is defined as the biparietal diameter descending to the level of the pelvic inlet. In the case of a breech presentation, engagement occurs when the intertrochanteric diameter has entered and passed the pelvic inlet.

Dystocia Part II Passage factor. 2 How is abnormal labor evaluated as for the passage Pelvic factors...

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