Dystocia

Joserizal Serudji
Bag/SMF OBGIN FK Unand/RS.
M.Djamil Padang
 Dystocia

Ineffective labor, or difficult labor and is characterized by

abnormally slow progress of labor.
Generally, abnormal labor is common whenever there is
disproportion between the presenting part of the fetus and
the birth canal.
The expressions such as cephalopelvic disproportion and
failure to progress often are used to describe ineffective
labors.
The expression cephalopelvic disproportion came into use
prior to the 20th century to describe obstructed labor
resulting from disparity between the dimensions of the fetal
head and maternal pelvis such as to preclude vaginal delivery
Failure to progress in either spontaneous or stimulated labor
has become an increasingly popular description of ineffectual
labor
Consequences of 4 distinct abnormalities that may exist
singly or in combination
Abnormalities of expulsive forces: either uterine forces
insufficiently strong or inappropriately coordinated to
efface and dilate the cervix, uterine dysfunction or
inadequate voluntary muscle effort during the second
stage of labor.
Abnormalities of presentation , position, or development of the
fetus
Abnormalities of maternal bony pelvis , that is, pelvic
contraction
Abnormalities of soft tissue of the reproductive tract that form an
obstacle to fetal descent
 Abnormalities: mechanistically simplified into 3
categories:
Power:uterine contractility and maternal expulsive effort
Passenger: fetus
Passage: pelvis
Labor course divided functionally
on the basis of dilatation and
descent curves into
(1) a preparatory division,
including latent and
acceleration phases;
(2) a dilatational division,
occupying the phase of
maximum slope of dilatation;
and
(3) a pelvic division,
encompassing both
deceleration phase and second
stage concurrent with the phase
of maximum slope of descent.
 FETAL STATION AT ONSET OF ACTIVE LABOR

Descent of the fetal biparietal diameter to the level of the maternal pelvic ischial spines (0
station) is defined as engagem ent
There was a significant association between higher station at the onset of labor and subsequent
dystocia.
Both protraction and arrested labor disorders in women with fetal head stations above +1 cm
and noted that the higher the station at the onset of labor in nulliparas, the more prolonged the
labor (Friedman and Sachtleben, 1976).
Handa and Laros (1993) found that fetal station at the time of arrested labor was also a risk
factor for dystocia.
Roshanfekr and associates (1999) analyzed fetal station in 803 nulliparas women with term
pregnancies in whom active labor had been diagnosed. About 30 percent of these women
presented to the hospital with the fetal head at or below 0 station, and their cesarean delivery
rate was 5 percent compared with that of 14 percent for those with higher fetal stations.
The prognosis for dystocia, however, was not related to incrementally higher fetal head stations
above the pelvic midplane (0 station).
Importantly, 86 percent of nulliparous women without fetal head engagement at diagnosis of
active labor delivered vaginally. Thus, lack of engagement at the onset of labor, although a
statistical risk factor for dystocia, should not be assumed to necessarily predict fetopelvic
disproportion. This caveat is especially true for parous women because the head typically
descends later in labor.
 Mechanism of Dystocia

Uterine overdistention, or obstructed labor, or both.

Trial of labor: effective or ineffective
The progress of 1st stage: influenced by
Uterine contraction
Cervical resistance
Forward pressure exerted by the leading fetal head
The diagnosis of uterine difunction in the latent phase is
difficult retrospective:
The American College of Obstetricians and Gynecologists
(1989) has suggested that, before the diagnosis of
arrest during first -stage labor is made, both of these
criteria should be met:
The latent phase has been completed, with the cervix
dilated 4 cm or more.
A uterine contraction pattern of 200 Montevideo units or
more in a 10-minute period has been present for 2
hours without cervical change.
Rouse and colleagues (1999) have recently challenged the
"2-hour rule" on the grounds that a longer time, that is,
at least 4 hours, is necessary before concluding that the
active phase of labor has failed
 Active phase Disorders

Clinically:
Slower than normal progress: protraction disorder
Complete cessation of progress: arrest disorder
Active phase arrest: no dilatation for 2 hours or more; both
criteria should be met:
The latent phase has been completed, with the cervix dilated 4 cm or
more
A uterine contraction pattern of 200 Montevideio units or more in 10-
minutes period has been present for 2 hour without cervical change
Protraction: less than 1 cm/hour cervical dilatation for a
minimum of 4 hour Abnormalities:
Power:uterine contractility and maternal expulsive effort
Passenger: fetus
Passage: pelvis
 2nd stage Disorders

Disproportion of the fetus and pelvis frequently becomes apparent

during the 2nd stage
Moreover, the second stage incorporates many of the
cardinal movements necessary for the fetus to negotiate the
birth canal. Accordingly, disproportion of the fetus and
pelvis frequently becomes apparent during the second
stage.
Until recently, there have been unquestioned second-stage
rules that limited its duration. The second stage in nulliparas
was limited to 2 hours and extended to 3 hours when
regional analgesia was used. For multiparas, 1 hour was the
limit, extended to 2 hours with regional analgesia
Duration of 2nd stage:
NP: 2 hrs + 1
MP: 1 hrs + 1
 REPORTED CAUSES OF UTERINE DYSFUNCTION.

Epidural Analgesia. Epidural analgesia can slow labor, epidural analgesia

has been associated with lengthening of both first- and second-stage labor as
well as slowing of the rate of fetal descent.
Chorioamnionitis. Because of the association of prolonged labor with
maternal intrapartum infection, some clinicians have suggested that infection
itself plays a role in the development of abnormal uterine activity. On theothr
hand, it is likely that uterine infection is a consequence of dysfunctional,
prolonged labor rather than a cause of dystocia.
Maternal Position During Labor. Advocacy , pembelaan for recumbency,
penyerahan diri or ambulation during labor has swung back and forth over
time.
Proponents of walking during labor report it to shorten labor, decrease rates of
oxytocin augmentation, decrease the need for analgesia, and lower the frequency of
operative vaginal delivery
The uterus contracts more frequently but with less intensity with the mother in the
supine position compared with that of lying on her side.
Conversely, contraction frequency and intensity have been reported to increase with
sitting or standing
Thanks