CH 19.

DYSTOCIA

부산백병원 산부인과
R2 서 영진
 Face presentation
 Brow presentation
 Transverse lie
 Compound presentation
 Persistent occiput posterior position
 Persistent occiput transverse position
 Shoulder dystocia
 Hydrocephalus as a cause of dystocia
 Fetal abdomen as a cause of dystocia
Fetal presentation in 68,094 (Parkland hospital)
Presentation Percent Incidence

Cephalic 96.8 -
Breech 2.7 1:36
Trnasverse 0.3 1:335
Compound 0.1 1:1000
Face 0.05 1:2000
Brow 0.01 1:10000
FACE PRESENTATION
 The head: hyperextended
occiput-contact with fetal back
presenting part-chin(mentum)

-mentum posterior : brow is compressed against

the maternal symphysis pubis

-mentum anterior: typical

→convert spontaneosly anterior(←posterior)
FACE PRESENTATION
 Diagnosis
: vaginal examination & palpation
(mouth, nose, malar bone , orbital ridge)
→ mistake a breech
anus-mouth
ischial tuberosities-malar bone

: radiologic demonstration
FACE PRESENTATION
 Etiology
: favors extension, prevents head flexion

→ marked enlargement of the neck

coils of cord about the neck
anencephalic fetus
pelvic contracture
large infants
multiparous
FACE PRESENTATION
 Mechanism
:rarely observed above pelvic inlet
brow presentation-converted into face presentation

:cardinal movement-descent, int. rotation, flexion

accessory movement-extension, ext. rotation

:descent-when resistance is encountered

‘occiput-pushed toward the back
‘chin-decsent
FACE PRESENTATION
:int. rotation
chin-under the symphysis pubis
neck-sustend post. surface of symphysis pubis

:if the chin rotates posterorly

short neck cannot span the anterior sulface of
the sacrum (12cm)
->head delivery is impossible unless the shoulder
enter the pelvis
FACE PRESENTATION
:after anterior rotation and descent
->chin and mouth appear at the vulva
->the head is delivered by flexion

:appear in seccession over the ant. margin of the

perineum-nose, eye, brow, occiput

:next, ext. rotation-original side

shoulders are born as the cephalic presentation
FACE PRESENTATION
:face edema, head molding
increased the length of theo
ccipitomental diameter
FACE PRESENTATION
 Management
;successful vagianl delivery
->absence of a contracted pelvis
with effective labor
:full-term size-c/sec is frequently indicated

:Not attempt
‘convert a face manually into a vertex
‘manual or forcep rotation (chin: post->ant)
‘internal podalic version and extraction
BLOW PRESENTATION
:rarest presentataion
between the orbital ridge and the anterior fontanel
at the pelvic inlet

:midway between full flexion (occiput)

full extension (mentum or face)
unstable-converts to face or occiput

:Etiology- same as face presentation

BLOW PRESENTATION
 Diagnosis
: abdominal palpation

:vaginal examination
-frontal suture, large anterior fontanel, orbital
ridge
eyes, and root of the nose
-neither, mouth & chin
BLOW PRESENTATION
 Mechanism of labor
:very difficult, because engagement is impossible

:possible-large pelvis, small fetus

marked molding
convert to occiput or face presentation

-> deforms the head

caput succedaneum-over the forehead
BLOW PRESENTATION
 Prognosis
: depends upon the ultimate presentation

: if the brow persists,

prognosis is poor

#Management
:same as those for a face presentation
TRANSVERSE LIE
 When the long axis of the fetus is approximately
perpendicular to that of the mother

:obligue lie, unstable lie

:shoulder-over the pelvic inlet

head-in one iliac fossa
breech-in the other iliac fossa
TRANSVERSE LIE
:shoulder presentation
-acromion direction-> Rt. & Lt
:back
-anterior or posterior
-superior or inferior
(ex. Rt acrimidorsoanterior)

#Incidence: 0.3%
TRANSVERSE LIE
 Etiology
1. Unusual relaxion of the abdominal wall resulting
from high parity
2. Preterm ferus
3. Placenta previa
4. Abnormal uterus
5. Excessive amnionic fluid
6. Contracted pelvis
TRANSVERSE LIE
 Diagnosis
: easily, by inspection
-wide abdomen
Ut fundus extends to only slightly above umbilicus
: palpation
-no fetal pole in the fundus
ballottable head in one iliac fossa
breech in the other
-anterior->back(hard resistance)
posterior-> irregular nodulations small parts
TRANSVERSE LIE
: vaginal examination
-the side of the thorax
-further dilatation: scapula or clavicle
-axilla: shouler direction

-later in labor
->shoulder become tightly wedged in the pelvis
->a hand and arm frequently prolapse
TRANSVERSE LIE
 Course of labor
:spontaneous delivery is impossible with a persistent
transverse lie
<neglected transverse lie>
After ROM, labor continue
:fetal shoulder is forced into the pelvis, the corresponding
arm frequently prolapse
After some descent
:shoulder is arrested in pelvis, with the head is in the one
iliac fossa and breech in the other
TRANSVERSE LIE
As labor continues
:the shoulder is impacted fermly in the upper part of
the pelvis
:contracts vigorously
After a time
:a retraction ring rises increasingly higher

->if not promptly managed

uterine rupture, mother & fetus die
TRANSVERSE LIE
:conduplicato corpore
if small fetus(<800g), large pelvis
in spontaneous delivery
->the head and thorax pass through the pelvic
cavity at the same time
#Prognosis
:maternal, fetal hazard: increased
:even with the best care, morbidity is incereased
->placenta previa, cord prolapse
TRANSVERSE LIE
 Management
:the onset of active labor- c/sec
:conversion to a longitudinal lie (before or early labor)
-with the membrane intact, no indication of c/sec
-at 39 wks
-next several contraction: fix the head in the pelvis
:if c/sec-vertical incision
difficulty in extraction of the fetus
(not foot or head on incision site)
COMPOUND PRESENTATION
 An extremity prolapse alongside the presenting
part , with both presenting in the pelvis

#Incidence: 1 of 700 delivery

#Etiology
prevent complete occlusion of the pelvic inlet
by the fetal head
COMPOUND PRESENTATION
 Prognosis and management
:perinatal loss-preterm delivery, cord prolapde
traumatic obstetrical procedures

:prolapsed part –be left alone, not interfere labor

:close observation-prolapsed part prevent descent

if prevent->arm should be gently pushed upward
head:downward (fudus pressure)
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 Most often, occiput posterior position udergo
spontaneous anterior rotation
:failure of spontaneous rotation
-transverse narrowing of the midpelvis

:labor and delivery need not differ remarkably

from that with the occiput anterior
:in most instances, delivery can usually be
accompliched without great difficulty once the head
reaches the perineum
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 The possibilities for vaginal delivery
1. Await spontaneous delivery
2. Forceps delivery with the occiput directly posterior
3. Forceps rotation of the occiput to the anterior
position and delivery
4. Manual rotation to the anterior position followed by
spontaneous or forceps delivery
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 Spontaneous delivery
:pelvic outlet-roomy
vaginal outlet-somewhat relaxed
:vaginal outlet is resistant, perineum is firm
->late 1st stage or the 2nd stage-prolonged

:forceps delivery is indicated

:generous episiotomy is usually needs
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 Forceps delivery as an occiput posterior
:more traction
larger episiotomy
complete analgesia

:the head may not even be engaged

(BPD may not have passed through the pelvic inlet)
->prompt c/sec is appropriate
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 Manual rotation
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 Forceps rotation
:head is engaged
cervix fully dilated
the pelvis adequate

:skilled operator
ineffective expulsive effort during the 2nd stage
PERSISTENT OCCIPUIT
POSTERIOR POSITION
 Outcome
:labor was prolonged
-parous: 1 hrs
nulliparous 2 hrs
:episiotomy extension was increased
:65% required operative intervention(1994)
:Parkland hospital
-manual rotation->forceps delivery
or forceps delivery
failure: c/sec
PERSISTENT OCCIPUIT
TRANSVERSE POSITION
 In the absence of a pelvic architecture abnormality
:most likely a transitory one
:rotates to the anterior position

#Delivery
-the occiput may be manually rotated anteriorly
or posteriorly and forceps delivery carried out
PERSISTENT OCCIPUIT
TRANSVERSE POSITION
:if failure of spontaneous rotation is caused by
hypotonic uterine dysfunction without CPD.
oxytocin may be infused with close observation

:platypelloid(anteroposteiorly flat)
android(heart-shaped) pelvis
c/sec
SHOULDER DYSTOCIA
 Incidence
:varies depending on the criteria used for diagnosis
:0.9%ture shouder dystocia-0.2% (1987)
:maneuvers were required
so, ceuurent report-0.6~1.4%

#increasing factor(1960-1980)
:increasing birthweight
:shoulder-to-head, chest-to head disproportions
:increased attention
SHOULDER DYSTOCIA
 Use of maneuvers – define shoulder dystocia
:but, use of one or more maneuvers-NO diagnosis
:TIME INTERVAL (head to body)
-normal: 24 seconds
-shoulder dystocia: 79seconds

 exceeding 60 seconds: define shoulder dystocia

SHOULDER DYSTOCIA
 Maternal consequences
:postpartum hemorrhage- atony
lacerations (vag. or Cx.)
:puerperal infection
 Fetal consequences
:significant fetal morbidity and mortality
:transient brachial plexus palsy (m/c)
clavicle Fx, humeral Fx, neonatal death
persistent brachial plexus palsy
SHOULDER DYSTOCIA
:Wood maneuver (direct fetal manipulation)
-not associated with an increased rate of fetal
injury
#Brachial plexus injury
:result from down traction on the brachial plexus
during delivery of the anterior shoulder
:Erb palsy (C 5-6,7) –hanging upper arm
extended elbow
:C 7- T 1:hand (clawhand deformity)
:may occur even prior to labor, recovery-13 months
SHOULDER DYSTOCIA
#Clavicular fracture
:0.4%
:often without any clinical events
:unavoidable
unpredictable
no clinical consequence
SHOULDER DYSTOCIA
 Risk factor
:maternal factor-incresed birthweight
obesity, multiparity, diabetes
postterm pregnancy(>42wks)
:Intrapartum complication
-midforceps delivery, prolonged 1st and 2nd stage
:increased birthweight (common)
but, 50%-<4,000g
2260g-dystocia reported
SHOULDER DYSTOCIA
 Summary
1.cannot be predicted or prevented-no accurate
methods
2.ultrasonic measurements to estimate macrosomia
have limited accuracy
3.planned c/sec due to macrosomia
-not reasonable strategy
4.planned c/sec may be reasonable
-nondiabetes (>5,000g)
-diabetes (4,5000g)
SHOULDER DYSTOCIA
 Management
:shoulder dystocia-cannot be predicted
:well versed in the management principles
:great importance to survival
-reduction in the interval of time from delivery
of the head to body

:gentle traction, assisted by maternal expulsive effort

next, large episiotomy, analgesia, clear the infant’s
mouth and nose
SHOULDER DYSTOCIA
1.Moderate suprapubic pressure
-by an assistant while downward traction
2.McRoverts maneuver
-flexing the legs upon the abdomen
-not increase pelvic diameter
straightening of the sacrum
symphysis pubis-toward the maternal head
decrease the angle of pelvic inclination
SHOULDER DYSTOCIA
SHOULDER DYSTOCIA
3.Woods corkscrew maneuver

-rotating the posterior

shoulder 180 degrees

-anterior shoulder could be

released
SHOULDER DYSTOCIA
4.Delivery of the posterior
shoulder
-post. arm: across the chest
then delivery

-next, shoulder girdle rotation

into one of the oblique
diameters of the pelvis
delevery of ant. shoulder
SHOULDER DYSTOCIA
5.Rubin maneuver
-1st, the fetal shoulder are
rocked from side to side
by applying force to the
abdomen

-if not successful,

push the ant. shoulder
toward
the anterior surface of the
chest
SHOULDER DYSTOCIA
6.Hibbard (1982)
-press the fetal jaw and neck in the direction of
the maternal rectum
-strong fundal pressure
anterior shoulder delivery
-only fundal pressure, absence of other maneuver
:77% complication
fetal prthoprdic and neurologoc damage
SHOULDER DYSTOCIA
7.Zavanelli maneuver
-cephalic replacement into
the pelvis and then c/sec
-return fetal head
flex head
push head back into vagina

-terbutaline: Ut relaxation
-fetal injury
neonatal death
stillbirth, brain damage
SHOULDER DYSTOCIA
8. Fracture of the clavicle
-pressing the anterior clavicle against the ramus of
the pubis
-heal rapidly

-not nearly as serious as a brachial nerve injury

9.Cleidotomy
-cutting of the clavicle
-usually used on the a dead fetus
SHOULDER DYSTOCIA
10. Symphysiotomy
-maternal morbidity increased
-urinary tract injury
SHOULDER DYSTOCIA
 Shoulder dystocia drill
1.call for help
2.generous episiotomy
3.suprapubic pressure
-simple, only one assistant
-while normal downward traction
4.McRoverts maneuver
-two assistants
resolve most case
if fail, next steps may be attempted
SHOULDER DYSTOCIA
5. the woods screw maneuver
6. posterior arm delivery is attempted
7. other technique
-Zavanelli maneuver
-fracture of ant. clavicle, humerus
HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Hydrocephlus is an excessive accumulation of
cerebrospinal fluid with consequent cranial
enlargement
:associated defects are common (neural tube defect)

#head circumference: 32-38cm, fluid: 500-1500ml

hydrocephalus: 50-80cm, fluid: 5l
:1/3-breech, but whatever presentation,
gross CPD and serious dystocia
HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Diagnosis
:sonography
-compare the diameter of the lateral ventricle to
the BPD of the head
-evaluate the thickness of the cerebral cortex
-compare the size of the head to that of the
thorax and abdomen
HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Management
:the size of the hydrocephalic head must be reduced
in vaginal delivery and c/sec

:cephalocentesis
-be limited to fetuses with severe associated
abnormalities
-recommended that all others be delivered
abdominally
HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Technique of cephalocentesis
#cephalic presentation
-Cx :3-4cm dilatation
vetricle may be tapped (8-inch, 17-gauge needle)
#breech presentation
-after breech and trunk delivered
the face toward the martenal back
transvaginally, below the ant. vaginal wall
protect the birth canal
HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
#via martenal abdomen into the fetal head
-bladder: empty
skin: cleansed
the needle: in the midline below the maternal
umbilicus

-before oxytocin stimulation

-more successfully: sono-guided
FETAL ABDOMEN
AS A CAUSE OF DYSTOCIA
 Enlargement of the fetal abdomen
:greatly distended bladder
ascites
enlargement of the kidney or liver
edematous fetal abdomen

:before delivery, decision is made

:but, prognosis is very poor