Dystocia

describes difficulty during labor.

Etiology
'The Powers' (uterus)

The Passenger' (fetus)

'The Parts' (pelvis).

Uterine factors:

good contractions start at the fundus and move down towards the pelvis.
If uterine activity is unco-ordinated or contractions short or infrequent then labour will
be difficult and prolonged.
Primigravid mothers may be more at risk of dystocia as they have a degree of uterine
unco-ordination which is why their labours tend to be longer.
Oxytocin can enhance and co-ordinate uterine contractions.

Fetal factors:

position or lie (eg, transverse or breech),

macrosomia (birth weight 4.5 kg),
shoulder dystocia (this results from a combination of fetal factors and pelvic
passage factors).

Pelvic passage factors:

a pelvis with a round brim is very favourable in labour; however, some women
have a long and oval brim.
A small pelvic brim should be suspected if, in a primigravida, the fetal head has
not engaged into the pelvis by 37 weeks of gestation.
Other factors that can lead to cephalopelvic disproportion are scoliosis,
kyphosis and rickets.
Shoulder dystocia in part results from a small or abnormal pelvic inlet.
Types of dystocia

1. Cervical dystocia
In cervical dystocia, the cervix fails to dilate during labor.

Failure of cervical dilatation can be due to previous cone biopsy or cauterisation

for cervical dysplasia. Other reasons for failure to dilate include trauma.
Sometimes, if there are unco-ordinated uterine contractions then the failure of
cervical dilation may be secondary to this and this should respond to oxytocin.
If dystocia continues despite this then the infant will need to be delivered by
caesarean section.

2. Shoulder dystocia

Shoulder dystocia was first described in 1730 and is an obstetric
complication of cephalic vaginal deliveries during which the fetal
shoulders do not deliver after the head has emerged from the mothers
introitus. It occurs when one or both shoulders becomes impacted
against the bones of the maternal pelvis, as shown in the image below.

Shoulder dystocia occurs for mechanical reasons` During the fetal

heads cardinal movements of descent, flexion, and internal rotation
within the bony pelvis, the shoulders descend to reach the pelvic inlet.
During the heads subsequent extension, delivery, and external rotation,
prior to final expulsion, the shoulders need to rotate within the bony
pelvis in a winding fashion to arrive in the most accommodating
dimension of the pelvis, its oblique diameter. If either the fetal shoulder
dimensions are too large or the maternal pelvis is too narrow, or both, to
permit shoulder rotation to the oblique pelvic diameter, persistent
anteroposterior orientation of the fetal shoulders may result in the
anterior shoulder being obstructed behind the symphysis pubis impeding
delivery and leading to shoulder dystocia. If the sacral promontory also
 obstructs the posterior shoulder, bilateral (and more difficult) shoulder
dystocia occurs.

Risk factors for shoulder dystocia

History of shoulder dystocia in a prior vaginal delivery

Fetal macrosomia (having a disproportionately large body compared to head)
Diabetes/impaired glucose tolerance (false-positive glucose challenge test)
Excessive weight gain (>35 lb) during pregnancy
Maternal obesity (body mass index >30 kg/m 2)
Asymmetric accelerated fetal growth in nondiabetic patients
Postterm pregnancy
Parity
Induction of labour.
Prolonged labour - first or second stage, or secondary arrest.
Oxytocin - used in induction of labour.
Assisted vaginal delivery - forceps or ventouse

Contraindications:
Fundal pressure should not be used in the management of shoulder dystocia, as it is
counterproductive. Pressure directed from behind the fetus only further impacts the
anterior shoulder, making the shoulder dystocia more difficult to resolve and
increasing the risk of permanent brachial plexus injury
Strong lateral traction (more than 20 lb, which is more than 4 times the traction
typically used in routine delivery) should also be avoided, as increased lateral
traction increases the risk of both transient and permanent brachial plexus
injury. The greater the traction, the greater the severity of brachial plexus injury.
Head rotation beyond 90, is to be avoided because it increases the risk of neck and
brachial plexus injury.

Management
National Institute for Health and Care Excellence (NICE) guidance recommends that
pregnant women with diabetes, who have a normally growing fetus, should be offered
elective delivery by induction of labour, or caesarean section if indicated, between
37th and 38th weeks of gestation. Where the estimated fetal weight is greater than 4.5
kg, in women with pre-existing or gestational diabetes, the risks and benefits of elective
caesarean, induction of labour and vaginal delivery should be explained.
Either elective caesarean or vaginal delivery may be appropriate after previous shoulder
dystocia. The decision should be made jointly by the mother and her carers and should take
into account severity of any previous injuries, maternal choice and predicted fetal size.

For shoulder dystocia

McRoberts' manoeuvre - the patient hyperflexes and abducts her hips so they are against
her abdomen. This flattens the lumbosacral angle and increases the anteroposterior
diameter of the pelvis. Mothers in labour may not have enough energy to do this by
themselves and may need the assistance of others in the room - which is usually the case.
Posterolateral pressure is applied suprapubically with axial traction on the fetal head. This
is the most effective and least invasive procedure and should be performed first (success
rates are up to 90%).
If this fails, an episiotomy may be needed to facilitate the obstetrician trying second-line
manoeuvres:
Rubin's manoeuvre - press on the posterior fetal shoulder, thereby creating more
space to allow the anterior shoulder to be delivered.
Woods' screw manoeuvre - turning the anterior shoulder to the posterior position.
Delivery of the posterior shoulder.
The extra manoeuvre that is most likely to succeed should be used; it is not the
individual manoeuvre that is performed that is associated with any subsequent
morbidity but the severity of the dystocia and the difficulty of the delivery.[4]

Complications

Fetal Maternal

Postpartum haemorrhage
Brachial plexus injury . Greater
Third-degree and fourth-degree
severity of injury is associated with
larger birth weight.. perineal tears
Vaginal lacerations.
Perinatal morbidity and mortality from
Bladder rupture.
hypoxia and acidosis.
Uterine rupture.
Fractured humerus or fractured
Symphyseal separation.
clavicle.
Sacroiliac joint dislocation.
Pneumothorax.
Lateral femoral nerve neuropathy.
 Precipitate Labor
occurs when uterine contractions are so strong that a woman gives birth with only a
few, rapidly occurring contractions.
It is often defined as a labor that is completed in fewer than 3 hours.

risk factors:
an above-average pelvic outlet
a well-aligned pelvis, pubic bone and birth canal
an unusually small baby
a baby positioned extremely well to come out
genetic factors
induced labor (it might cause over-stimulation of contractionscausing the labor to
speed up too much.)
Women who have previously experienced fast labor

Signs and Symptoms:

A sudden onset of intense, closely timed contractions with little opportunity for
recovery between contractions.

An intense pain that feels like one continuous contraction allowing no time for
recovery.

The sensation of pressure including an urge to push that comes on quickly and without
warning. This can also be described as bearing down and feel similar to a bowel
movement. Often times this symptom is not accompanied by contractions as the cervix
dilates very quickly.

NURSING CARE MANAGEMENT OF PRECIPITATE DELIVERY

a. Check for Presence of an Intact Amniotic Sac.

1. If the membranes do not break spontaneously, they should be ruptured just prior
to or with the delivery of the head.

2. Caution must be taken to prevent the membranes from covering the infants
mouth as the first breath is taken, otherwise aspiration of amniotic fluid can
occur.
b. Support the Perineum and Infants Head.

1. Apply support to the perineum with your dominant hand (usually right hand) using a
towel or cloth. When available, turn your hand with your palm facing the fetal head and
fingers pointed downward, and apply firm pressure against the perineum with the
flattened fingers.

2. Apply support to the fetal head with your nondominant hand. Spread your middle three
fingers; place your fingers against the anterior aspect of the head.

3. Increase the pressure of the dominant hand in a downward motion against the perineum
as the fetal head extends. This will assist in sliding the perineum over the fetal face.
If the perineum is not flexible enough to deliver the fetus without lacerations, maintain
firm pressure. This will help to minimize the extent of lacerations.

4. Provide mild downward pressure with the nondominant hand against the fetal head as
the fetal head extends. This will guide the head away from the anterior vulva and
minimize lacerations around the urethra.

5. Take special care to avoid excessive pressure on the fetal head. Never attempt to delay
delivery by applying pressure on the fetal head.

6. Combine efforts of the right and left hand. This will result in a slow, controlled
extension of the fetal head.