1. DYSTOCIA: PASSENGER

2. Review
Fetal Lie
Longitudinal
Transverse

3. Review
Fetal Presentation
Cephalic
Breech
Compound
Shoulder

4. Review
Fetal Presentation
Cephalic
Breech
Compound
Shoulder

5. Review
Fetal Presentation
Cephalic
Breech
Compound
Shoulder

6. Review
Fetal Presentation
Cephalic
Breech
Compound
Shoulder

7. OA
ROA
LOA
ROT
LOT
ROP
LOP OP

8. Diagnosis: by vaginal exam
Cephalic Presentation
AP Diameter
(cm)
Head
Feel for…
Vertex/ Occiput
SOB 9.5
Full flexion
Posterior fontanel
Sinciput
OF 12.5
Partially flexed
Anterior fontanel (bregma)
Brow
OM 13.5
Partially extended
Orbital ridge/ frontal bone
Face
SMB 9.5
Hyperextended
Chin/mentum

9. Diagnosis:
Leopold’s maneuver

10. Cardinal movements
Mechanism of labor
Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion

11. DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS
Malpresentation
Cephalic Presentation
Face
Brow
Persistent OP, OT
Transverse Lie
Compound Presentation
Breech Presentation
Shoulder Dystocia
2. Due to development
Hydrocephalus
Large Fetal Abd
Fetal Macrosomia
Conjoined Twins

12. Face Head is hyperextended Chin (mentum) is presenting
In term-size fetuses,
If Mentum Posterior,
Labor progression usually impeded because fetal brow/ bregma pressed against the maternal symphysis pubis
If Mentum Anterior
Flexion of the head and vaginal delivery are typical
Many MP converts spontaneously to MA

13. Face Diagnosis: Vaginal examination and palpation of
Distinctive facial features of mouth and nose, malar bones, and particularly the orbital ridges
Radiographic demonstration of hyperextended head

14. Face
Etiology
Any factor that favors extension or prevents head flexion
Marked enlargement of the neck or coils of cord about the neck  extension
Anencephalic fetuses
Large fetus; Contracted pelvis
Pendulous abdomen
Permits the back of the fetus to sag forward or laterally
High parity

15. Face Mechanism of labor
Brow presentation  face presentation after further extension of head during descent
Descent, internal rotation, and flexion
And the accessory movements of extension and external rotation
Internal flexion: to bring the chin under the symphysis pubis so that neck can traverse the posterior surface of the symphysis pubis (anterior flexion)
Flexion: (chin and mouth appear at the vulva) head is delivered by flexion

16. Face

17. Face Management Vaginal Delivery (MA) Absence of contracted pelvis
With effective labor
Cesarean delivery (MP)

18. Brow Rarest Midway between full flexion (occiput) and extension(face)
Diagnosis:
Abdominal palpation, vaginal examination
Feel for frontal sutures, large anterior fontanel, orbital ridges, eyes and root of the nose
(neither mouth nor chin is within reach)

19. Brow Etiology Same as for face
Brow presentation is commonly unstable and often converts to a face or occiput presentation

20. Brow Mechanism of labor Prognosis
If very small fetus and large pelvis – easy labor
Large fetus
Engagement is impossible until there is
marked molding that shortens the occipitomental diameter (molding deforms the head) or
Until there is either flexion to an occiput persentation or extension to a face presentation
Prognosis
Depends on ultimate presentation
If brow persists – poor for vaginal delivery unless small or birth canal is huge

21. Persistent Occiput Posterior
Often – spontaneous anterior rotation followed by uncomplicated delivery
Contributing factor for failure:
transverse narrowing of the midpelvis

22. Persistent Occiput Posterior
Labor and delivery need not differ remarkably from OA
Progress may be determind by assessing cervical dilatation and descen tof the head
Possibilities for vaginal delivery
Spontaneous delivery
Forceps delivery with occiput directly posterior
Manual rotation to the anterior position followed by spontaneous forceps delivery
Forceps rotation of the occiput to the anterior position and delivery

23. Persistent Occiput Posterior
Spontaneous delivery
If the pelvic outlet is roomy and vaginal outlet and perineum are somewhat relaxed from previous vaginal deliveries
Forceps delivery
If vaginal outlet is resistant to stretch and perineum is firm… During each expulsive effort the head is driven aginst the perineum to a much greater degree than when anterior. Generous episiotomy usually needed.
(on careful palpation – if head above the pelvic inlet  prompt cesarean delivery)

24. Persistent Occiput Posterior
3. Manual rotation to anterior
Hand introduced to locate posterior ear – confirms posterior position
Then occiput often spontaneously rotates toward anterior position.
If not, head may be grasped with fingers over one ear and the thumb over the other and rotation of the occiput to the anterior position attempted
4. Forceps rotation
Attempted if head is engaged, cervix fully dilated, and pelvis adequate
Most likely when ineffective expulsive efforts of the mother during 2nd stage of labor

25. Persistent Occiput Transverse
Most likely a transitory one because tends toward OA
Delivery:
If rotation ceases because of poor expulsive forces and pelvic contractions are absent  vaginal delivery
Occiput may be manually rotated anteriorly or posteriorly and forceps delivery performed
If failure of spontaneous rotation is caused by hypotonic uterine contractions without cephalopelvic disproportion, oxytocin may be infused and closely monitored
Difficulties
Platypelloid (AP flattened) pelvis
Android (heart shaped) pelvis

26. Transverse Lie
Long axis of the fetus is perpendicular to that of the mother
Shoulder usually over the pelvic inlet
Diagnosis:
Abdomen unusually wide
Uterine fundus extends to only slightly above the umbilicus
No fetal pole is detected in the fundus and the ballottable head is found in one iliac fossa and breech in the other
When the back is anterior, hard resistance plane extends across the front of the abdomen, if posterior – irregular nodulations felt through the abdominal wall

27. Transverse Lie

28. Transverse Lie Etiology: Abdominal wall relaxation from high parity
Women with 4 or more deliveries have 10x incidence
Relaxation of the abdominal wall with a pendulous abdomen allows the uterus to fall forward, deflecting the long axis of the fetus away
Preterm fetus
Placenta previa
Abnormal uterine anatomy
Excessive amniotic fluid
Contracted pelvis

29. Transverse Lie Mechanism of labor Spontaneous delivery impossible
After rupture of membranes, if labor continues, fetal shoulder is forced into the pelvis  arm prolapses

30. Transverse Lie Mechanism of labor
Uterus contracts vigorously in an unsuccessful attempt to overcome the obstacle.
With time retraction ring rises increasingly higher and becomes more marked.
Neglected transverse lie
If not promptly managed  uterine rupture

31. Transverse Lie Mechanism of labor Morbidity increased because of
frequent association with Placenta previa
Increased likelihood of cord prolapse
Necessity for major operative efforts
Small fetus (less than 800 g) + large pelvis  spontaneous delivery is possible. Head and thorax pass through the pelvic cavity at the same time and fetus which is doubled upon itself is expelled (conduplicato corpore)

32. Transverse Lie Management Cesarean delivery Vertical incision
Because a low transverse incision into the uterus may lead to difficulty in extraction of a fetus entrapped in the body of the uterus above the level of incision since neither feet nor head occupies the lower uterine segment
Attempts at conversion to a longitudinal lie by abdominal manipulation will likely not be successful.
? Attempts at external version

33. Breech Predisposing factors uterine relaxation Great parity
Multiple fetuses
Hydramnios
Oligohydramnios
hydrocephalus,
Anencephaly
Previous breech delivery
Uterine anomalies
Tumors of the pelvis

34. Breech Complications Cord prolapse
Increased perinatal morbidity and mortality
due to difficult delivery
LBW or growth restriction
Fetal anomalies and developmental abnormalities
that occur after newborn period
Uterine anomalies
Multiple fractures
Increased operative intervention

35. Breech Mechanism of labor
Delivery of the breech draws the umbilicus and attached cord
into the pelvis, which compresses the cord.
Once the breech has passed beyond the vaginal introitus,
the abdomen, thorax, arms and head must be delivered
promptly.  delivery of successively less readily
compressible parts

36. Breech With term fetus, some degree of head molding may be essential
thus in ceratin cases:
1. delivery may be delayed many minutes
 hypoxia,acidemia
2. delivery may be forced, causing trauma from compression,
traction, or both
With preterm fetus, at times, buttocks and lower extremities will
pass through the cervix but head cannot escape without
trauma. (Duhrssen incision or cesarean delivery)

37. Breech Fetal outcome - Higher perinatal mortality Term fetus:
risk of fracture of the humerus and clavicle,
fracture of the femur during breech extractions,
paralysis of the arm following pressure on brachial plexus
spoon shaped depressions or fractures of the skull,
Term fetus:
causes of death – head entrapment, cerebral injury,
Intracranial hemorrhage, cord asphyxia
Maternal outcome – higher morbidity

38. Breech
Management
Vaginal delivery by essentially skilled obstetricians
Cesarean delivery commonly done if
Large fetus
contraction or unfavorable pelvic shape (platypelloid, android)
Hyperextended head
Delivery indicated in the absence of spontaneous labor (some use oxytocin)
Uterine dysfunction
Incomplete or footling breech presentation
Viable preterm fetus, mother in active labor
Severe fetal growth restriction
Previous perinatal death or children suffering from birth trauma
Request for sterilization
Lack of experienced operator

39. Breech
Management
Vaginal delivery by essentially skilled obstetricians
External cephalic version
Cesarean delivery commonly done if
Large fetus
contraction or unfavorable pelvic shape (platypelloid, android)
Hyperextended head
Delivery indicated in the absence of spontaneous labor (some use oxytocin)
Uterine dysfunction
Incomplete or footling breech presentation
Viable preterm fetus, mother in active labor
Severe fetal growth restriction
Previous perinatal death or children suffering from birth trauma
Request for sterilization
Lack of experienced operator

40. Compound Presentation
Extremity prolapses alongside the presenting part with both presenting in the pelvis simultaneously

41. Compound Presentation
Etiology:
Conditions that prevent complete occlusion of the pelvis inlet by the fetal head including preterm birth
Prognosis
Perinatal loss increased
Concomitant preterm delivery
Prolapsed cord
Traumatic obstetrical procedures

42. Compound Presentation
Management:
Observed closely to ascertain whether the arm retracts out of the way with descent of the presenting part
If it fails, and appears to prevent descent of the head, prolapsed arm should be pushed gently upward and the head simultaneously downward by fundal pressure
Vaginal delivery

43. Shoulder Dystocia

44. Hydrocephalus
Excessive accumulation of CSF with consequent cranial enlargement
Uncommon with births at term
Associated defects: especially neural tube defects
Fetal head circumference:
Often exceeds 50 cm, may reach 80 (N: 32-38)
Fluid volume
As much as 5 L (N: mL)

45. Hydrocephalus Gross cephalopelvic disproportion is the rule
Dystocia usual consequence

46. Hydrocephalus
Breech – difficult to diagnose radiographically because outline of normal fetal head often appears enlarged to a degree suggestive of hydrocephalus
Difficulties inherent in radiological diagnosis obviated by:
Use of ultrasonography to measure the diameter of the lateral ventricles and thickness of cerebral cortex and to compare size of the head with that of the thorax and abdomen

47. Hydrocephalus Management Cesarean delivery Cephalocentesis (?)
With cephalic presentation
transvaginally
With breech presentation
Breech nad trunk delivered, needle inserted transvaginally just below the anterior vaginal wall (sterile plastic tubing to protect birth canal)
Transabdominal approach

48. Large Fetal Abdomen
Usually result of greatly distended bladder, ascites, or enlargement of kidnes or liver.
Diagnosis: Ultrasound
Management
Reduction transabdominally depending on cause
Fluid in fetal bladder and peritoneum can be emptied, however decompression may not be successful with severe hydrops fetalis. Ascites may be accompanied by severe abdominal edema and liver enlargement and render delivery difficult

49. Macrosomia Prognosis Fetal weigh more than 4000 g Factors Multiparity
Large parents especially mother
Maternal obesity
Maternal diabetes
Postdatism
Previous delivery of infants weighing more than 4kg
Prognosis
Mother and fetus at risk: increased perinatal loss, severely depressed at birth, neurologic complications, high infant mortality before age of 7 years

50. Conjoined Twins

51. thanks
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