Dystocia Teng Yincheng M.D., Ph.D., Professor Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine Teng Yincheng M.D., Ph.D., Professor Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine

2 Definition Dystocia literally means difficult labor and it is characterized by abnormally slow progress of labor It is the consequence of four distinct abnormalities that may exist singly or combination Dystocia literally means difficult labor and it is characterized by abnormally slow progress of labor It is the consequence of four distinct abnormalities that may exist singly or combination

3  Abnormal of the powers(uterine contractility and maternal expulsive effort)  Abnormalities of passenger(the fetus)  Abnormalities of the passage(the birth canal)  Abnormal of the powers(uterine contractility and maternal expulsive effort)  Abnormalities of passenger(the fetus)  Abnormalities of the passage(the birth canal) Categories of dystocia

4 Abnormalities of the powers Uterine dysfunction hypotonic primary uterine inertia secondary Uterine hypertonic Dysfunction uterine hypercontractility Uterine dysfunction hypotonic primary uterine inertia secondary Uterine hypertonic Dysfunction uterine hypercontractility

5 Abnormalities of the powers -----uterine inertia 1.Etiology of uterine inertia  Cephalopelvic disproportion or Fetal malposition  Abnormal of uterine muscle  Imbalance of endocrine system  Administration of analgesia  psychical-factors  Others fatigue 1.Etiology of uterine inertia  Cephalopelvic disproportion or Fetal malposition  Abnormal of uterine muscle  Imbalance of endocrine system  Administration of analgesia  psychical-factors  Others fatigue

6 Abnormalities of the powers -----uterine inertia

7 2.Clinical findings Failure to progress  Lack of progressive cervical dilatation Prolonged latent phase ( >16h) Prolonged active phase ( >8h ; <1.2cm/h or <1.5cm/h) Protracted active phase (stop dilatation >2h) Prolonged second phase(>2h )  Lack of fetal decent Prolonged descent (<1cm/h; <1.5cm/h) Protracted descent (stop decent >1h) Prolonged labor (>24h) 2.Clinical findings Failure to progress  Lack of progressive cervical dilatation Prolonged latent phase ( >16h) Prolonged active phase ( >8h ; <1.2cm/h or <1.5cm/h) Protracted active phase (stop dilatation >2h) Prolonged second phase(>2h )  Lack of fetal decent Prolonged descent (<1cm/h; <1.5cm/h) Protracted descent (stop decent >1h) Prolonged labor (>24h)

8 Abnormalities of the powers -----uterine inertia 3.diagnosis Palpation: strength duration frequency Tocodynamometer Vaginal examination 3.diagnosis Palpation: strength duration frequency Tocodynamometer Vaginal examination

9

10

11

12 Abnormalities of the powers -----uterine inertia 4.Effect on maternal and fetus maternal fatigue acidosis infection postpartum hemorrhage cesarean section rate fetus birth injury distress prolapse of umbilical cord stillbirth 4.Effect on maternal and fetus maternal fatigue acidosis infection postpartum hemorrhage cesarean section rate fetus birth injury distress prolapse of umbilical cord stillbirth

13 Abnormalities of the powers -----uterine inertia 5.management hypotonic 1) general management 心理护理 饮食护理 镇静 2) physical methods 导尿 灌肠 人工破膜 针刺穴位 5.management hypotonic 1) general management 心理护理 饮食护理 镇静 2) physical methods 导尿 灌肠 人工破膜 针刺穴位

14

15 Abnormalities of the powers -----uterine inertia 3) Drugs oxytocin 2.5U + 5%GS 500ml 5mU/ml 8 滴／分开始 地西泮 10mg iv 3) Drugs oxytocin 2.5U + 5%GS 500ml 5mU/ml 8 滴／分开始 地西泮 10mg iv

16 Abnormalities of the powers -----uterine inertia Hypertonic Sedative CS Hypertonic Sedative CS

17 Abnormalities of the powers hypercontractility 1.Clinical findings and diagnosis Precipitate delivery Constriction ring of uterus Tetanic contraction of uterus 1.Clinical findings and diagnosis Precipitate delivery Constriction ring of uterus Tetanic contraction of uterus

18 Abnormalities of the powers hypercontractility 2.Effect on maternal and fetus  Precipitate delivery  soft birth canal trauma  Rupture of uterus  Fetal distress  Fetal death  stillbirth 2.Effect on maternal and fetus  Precipitate delivery  soft birth canal trauma  Rupture of uterus  Fetal distress  Fetal death  stillbirth

19 Abnormalities of the powers hypercontractility 3.management  Prophylaxis  Tocolytic therapies  Forcep  operation 3.management  Prophylaxis  Tocolytic therapies  Forcep  operation

Dystocia Part II

21 Abnormalities of birth canal 1.Bony pelvic 1)Contracted pelvic inlet simple flat pelvis rachitic flat pelvis 1.Bony pelvic 1)Contracted pelvic inlet simple flat pelvis rachitic flat pelvis

22 2)Contracted midpelvis (anthropoid pelvis)

23 3)Contracted pelvic outlet (funnel shaped pelvis) 3)Contracted pelvic outlet (funnel shaped pelvis)

24 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

25 Clinical signs of contracted pelvis 1)Contracted pelvic inlet 2)Contracted midpelvis 3)Contracted pelvic outlet Clinical signs of contracted pelvis 1)Contracted pelvic inlet 2)Contracted midpelvis 3)Contracted pelvic outlet

26 Diagnosis : 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 : 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

27

28 Effects on maternal and fetus Management 2. Abnormal of soft birth canal Effects on maternal and fetus Management 2. Abnormal of soft birth canal

29 Abnormalities of the passenger A. malposition and malpresentation a. vertex malposition persistent occiput posterior persistent occiput transverse 5% sincipital presentation 1.08% anterior asynclitism posterior asynclitism 0.5%~0.81% b. brow presentation 0.03%~0.1% c. face presentation 0.08%~0.27% d. breech presentation 3%~4% e. abnormal fetal lie transverse or oblique lie 0.25% A. malposition and malpresentation a. vertex malposition persistent occiput posterior persistent occiput transverse 5% sincipital presentation 1.08% anterior asynclitism posterior asynclitism 0.5%~0.81% b. brow presentation 0.03%~0.1% c. face presentation 0.08%~0.27% d. breech presentation 3%~4% e. abnormal fetal lie transverse or oblique lie 0.25%

30

31

32

33

34 Breech presentation  complete(mixed) breech presentation  frank breech presentation  incomplete breech presentation knee or footling presentation Breech presentation  complete(mixed) breech presentation  frank breech presentation  incomplete breech presentation knee or footling presentation

35 Extraction of breech

36

37

38 B. Fetal macrosomia large for gestational age(LGA) ≥4000g shou lder dystosia B. Fetal macrosomia large for gestational age(LGA) ≥4000g shou lder dystosia

39

40 C. Fetal malformation

41 Operative delivery 1)forceps operations 2)Vacuum extractor 1)forceps operations 2)Vacuum extractor

42 2)Vacuum extractor

43 3)Cesarean section

44

45 Main point of dystocia managemnet

46 思考题 : 1.The definition and classification of dystosia 2.How to deal with uterine inertia during the first stage of labor ? 思考题 : 1.The definition and classification of dystosia 2.How to deal with uterine inertia during the first stage of labor ?

47 THANKS FOR YOUR ATTENTION Teng Yincheng M.D., Ph.D., Professor M.D., Ph.D., Professor Dep. of Obstet. & Gynecol. Renji Hospital Affiliated to SJTU School of Medicine