Presentation is loading. Please wait.

Presentation is loading. Please wait.

Dystocia Part II Passage factor. 2 How is abnormal labor evaluated as for the passage Pelvic factors in abnormal labor may include an unfavorable pelvic.

Similar presentations


Presentation on theme: "Dystocia Part II Passage factor. 2 How is abnormal labor evaluated as for the passage Pelvic factors in abnormal labor may include an unfavorable pelvic."— Presentation transcript:

1 Dystocia Part II Passage factor

2 2 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 ).

3 3

4 4 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. 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.

5 5

6 6 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

7 7 2.Contracted midpelvis (anthropoid pelvis)

8 8 3)Contracted pelvic outlet (funnel shaped pelvis, Android) 3)Contracted pelvic outlet (funnel shaped pelvis, Android)

9 9 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

10 10 Michaelis rhomboid

11 11 History Physical examination Pelvimetry external pelvimetry internal pelvimetry diagonal conjugate 12.5~13cm bi-ischial diameter 10cm incisura ischiadica 5~6cm angle of subpubic arch 90 History Physical examination Pelvimetry external pelvimetry internal pelvimetry diagonal conjugate 12.5~13cm bi-ischial diameter 10cm incisura ischiadica 5~6cm angle of subpubic arch 90 Diagnosis :

12 12 septum scar mass septum scar mass Abnormal of soft birth canal

13 13 Dystocia Part Ⅲ passenger factor

14 14 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.

15 15 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

16 16 Cephalic presentation: Persistent occiput posterior position Persistent occiput transverse position Breech presentation Face presentation Brow presentation Transverse lie Compound presentation Shoulder dystocia Cephalic presentation: Persistent occiput posterior position Persistent occiput transverse position Breech presentation Face presentation Brow presentation Transverse lie Compound presentation Shoulder dystocia Common types of abnormal labor due to fetal factors

17 17 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

18 18 PERSISTENT OCCIPUIT POSTERIOR POSITION 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

19 19

20 20 PERSISTENT OCCIPUIT POSTERIOR POSITION Manual rotation

21 21

22 22 PERSISTENT OCCIPUIT POSTERIOR POSITION 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

23 23 PERSISTENT OCCIPUIT POSTERIOR POSITION 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

24 24 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

25 25 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

26 26 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  c/sec 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  c/sec

27 27 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.

28 28 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.

29 29 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. 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.

30 30 Face presentation

31 31 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)

32 32

33 33 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

34 34 FACE PRESENTATION Etiology favors extension, prevents head flexion → marked enlargement of the neck coils of cord about the neck anencephalic fetus pelvic contracture Management 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 contracture Management vaginal delivery: fetal well-being, normal labor stage C-section

35 35

36 36

37 37 FACE PRESENTATION face edema head molding increased the length of the diameter face edema head molding increased the length of the diameter

38 38 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

39 39 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

40 40 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

41 41

42 42 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

43 43 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

44 44

45 45 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

46 46 TRANSVERSE LIE 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 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

47 47 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

48 48 TRANSVERSE LIE Course of labor spontaneous delivery is impossible with a persistent 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 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

49 49 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!!

50 50

51 51 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

52 52 TRANSVERSE LIE 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) 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)

53 53 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

54 54

55 55 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

56 56 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%

57 57

58 58 SHOULDER DYSTOCIA 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 1 st and 2 nd 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 1 st and 2 nd stage

59 59 Effects of shoulder dystocia on mothers and fetus Maternal consequences postpartum hemorrhage atony lacerations puerperal infection Maternal consequences postpartum hemorrhage atony lacerations puerperal infection

60 60 **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 **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

61 61 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)

62 62 SHOULDER DYSTOCIA 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 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

63 63 SHOULDER DYSTOCIA

64 64 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

65 65 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

66 66 SHOULDER DYSTOCIA 5.Rubin maneuver -1 st, 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 -1 st, 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

67 67 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 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

68 68 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

69 69 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.

70 70 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,

71 71 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.

72 72 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.

73 73 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.”

74 74 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.

75 75 B. Learning objective: Know, in general, how to manage a patient with 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.

76 76 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. 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.

77 77 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.

78 78


Download ppt "Dystocia Part II Passage factor. 2 How is abnormal labor evaluated as for the passage Pelvic factors in abnormal labor may include an unfavorable pelvic."

Similar presentations


Ads by Google