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Dystocia :wilted_flower: (Diagnostic criteria: & Mx :green_salad: …
Dystocia
:wilted_flower:
Definition
:honey_pot:
Difficult labor
Abnormally slow labor progress
Mechanism
:honey_pot:
Fetal head need to pass through...
Thick lower uterine segment (LUS)
Undilated Cx (cervical resistance)
Evaluation for Dystocia
(
3 Ps
) :mount_fuji:
Power
(expulsive force)
:postal_horn:
Uterine contraction
(1st & 2nd stage of labor)
Myometrial activity gradient
Greatest at Fundus (
Fundal dominance
)
Uterine dysfunctions
Hypotonic uterine dysfunction: < 180-200
Montevideo units
(subtracting baseline uterine pressure fr peak of contraction in 10-min window)
Gives oxytocin
Hypertonic uterine dysfunction (
Incoordinate
)
Find causes eg. ROM, other causes
:postal_horn:
Maternal pushing effort
(2nd stage of labor)
Fully dilate Cx ➭ Maternal urge to push
Fetal descent needed Combined force of UC + Abdominal ms (pushing)
Poor maternal pushing effort
Maternal exhaustion
Heavy sedation or Regional analgesia (epidural block)
Passage
(maternal pelvis)
#
:railway_track:
Bony pelvis
Inlet
Superior plane of pelvis
Anterior of inlet = Suprapubic
Posterior of inlet = Promontory of Sacrum
Lateral of inlet = Linea terminalis
Contracted
inlet def:
Diagonal conjugate < 11.5 cm
(Normal around 13.5 cm)
Engagement?
Fetal head pass inlet =
Engagement
So if
No engagement
➭
suspected contracted pelvic inlet
Midplane
Midplane of pelvis: ischial spine lvl
AP: Inferior margin of Surapubic bone thru ischial spine
Transverse: Interspinous diameter
Contracted
midplane def:
Interspinous diameter < 10 cm
Outlet
Outlet of pelvis
Anterior: Arch of pubic bone
Transverse: Interischial tuberous
Posterior: Tip of coccyx
Contracted
outlet def:
Interischial tuberous diameter < 8 cm
,
Pubic arch < 90 degree
:star: Pelvis exam ตามตัว bold
:railway_track:
Soft tissue
eg ขาใหญ่
Passenger
(fetal abnormalities)
:baby::skin-tone-2:
Fetal size
Fetal size threshold to predict CPD ➭ Elusive
ACOG recommended:
EFW
> 4,500 in DM
mom or
> 5,000 in non-DM
mom ➭
C/S
:baby::skin-tone-2:
Abnormal presentation & position
Face presentation
Compound presentation
Asynclitism
(การเอียงของหัว)
Malposition of fetal head within the pelvis
Lateral deflection of sagittal suture
Types: Anterior & Posterior
Diagnostic criteria
: &
Mx
:green_salad:
(Based on
Friedman curve
)
Abnormal progession of labor
1st STAGE OF LABOR
ACTIVE PHASE
Protracted active phase of dilatation
(Nulli < 1.2 cm/hr, Multi < 1.5 cm/hr)
:leaves:
Mx
Evaluate 3P
Oxytocin or C/S
:bomb: Causes:
Hypotonic UC
CPD
Secondary arrest of dilatation (No Cx change)
(Nulli > 2 hr, Multi > 2 hr)
#
#
Protracted descent
(Nulli <1 cm/hr, Multi <2 cm/hr)
:bomb: Causes:
Hypotonic UC
CPD
:leaves:
Mx
Evaluate 3P
Oxytocin or C/S
Arrest of descent
(Nullli > 1hr, Multi > 1 hr)
#
#
LATENT PHASE
Prolonged latent phase
(Nulli > 20 hrs, Multi > 14 hrs)
:bomb:Causes:
False onset of labor
Heavy sedation
CPD
:leaves:
Mx
Expectant
2nd STAGE OF LABOR
Prolonged second stage of labor
(Nulli >2hr, Multi >1hr)
+ epidural block
➭ Nulli > 3hr, Multi > 2hr
:bomb: Causes
Poor Maternal support
CPD
:leaves:
Mx
Evaluate 3P
F/E, V/E or C/S
:arrow_double_up: C/S rate worldwide
:star:
No CPD
before adequate labor
Evidence
for
Adequate
and
Arrested
labor
Arrest
of labor: Dx of
this
shouldn't be made until adequate time has elapsed
Adequate
labor:
Cx dilate > 6 cm with adequate UCs for 4 hrs (eg. > 200 Montevideo units)
No Cx change with inadequate UCs for > 6 hrs
Second-stage
labor: No progress for
> 4 hrs
(nulli + epidural) or
> 3 hrs
(nulli + no epidural)
:warning: No C/S before these time limits in the presence of reassuring maternal and fetal status
Complications
:car:
Maternal
:mother_christmas::skin-tone-2:
Infection
Intrapartum choroamnionitis
Postpartum pelvic infection
Uterine rupture
:custard:
From lower uterine segment stretching
:eight_pointed_black_star:
Pathological retraction ring of Bandi
Pelvic floor injury
Pelvic organ prolasped
Urinary incontinence
Postpartum hemorrhage
Uterine atony (fatigue)
Secondary fr infection
Fetal
:baby::skin-tone-2:
Caput succedneum
(หนังหัวเด็กหลุดตอนดึง)
Subgaleal hemorrhage
Shoulder dystocia
(คลอดไหล่ยาก อาจเจอ Fx Clavicle or Palsy)
More on
Uterine rupture
:custard: or Uterine
dehiscence
Def
:blue_car: Dehiscence: separation of lower uterine scar that doesn’t penetrate serosa and
rarely cause
significant hemorrhage
:police_car: Rupture:
complete seperation
of uterine wall and may led to significant hemorrhage and fetal distress
Incidence
for uterine rupture
(mostly from Sx)
Previous
low segment transverse
C/S 0.2-1%
Prior uterine active segment incision (Classical or T-incision) 4-9%
1/3 of women with Hx of
previous classical C/S
who experience rupture do so before onset of labor
:closed_umbrella:
Risk factors
Prev. uterine Sx
C/S, Myomectomy, Prev. resection of a cornual ectopic pregnancy, or Prev. uterine perforation
Induction of labor with prostaglandin agents in the setting of Hx of a prev. C/S (further :arrow_up: risk of rupture)
Others (Interval version or extraction, Operative delivery and Trauma)
:sunflower:
Diagnosis
33%-70% of cases found
Fetal bradycardia
Severity
(got diff initial presentation)
Catastrophic uterine: mayb
Fetal distress
Mild uterine: Simple rise in fetal station or Change in position for Fetal heart monitor placement
:warning:
fetal parts
mayb more
easily palpable abdominally
:leaves:
S&S
Constant abdominal pain
Shock (Hypotension & Tachycardia)
Uterine contractions cessation
Uterine tenderness
Uterine shape alternation
Vx bleeding
:green_apple:
Management
Emergent laparotomy
: delivery of infant & repair of uterine rupture
(if small thin edge - no bleeding not extended to uterine artery)
Hysterectomy
Intersection of these 2Ps:
CPD