CH 19. DYSTOCIA

부산백병원 산부인과R2 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 1:36Trnasverse 0.3 1:335 Compound 0.1 1:1000Face 0.05 1:2000Brow 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 theocci

pitomental 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 traction2.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 DYSTOCIA3.Woods corkscrew

maneuver -rotating the posterior shoulder 180 degrees

-anterior shoulder could be released

SHOULDER DYSTOCIA4.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 DYSTOCIA5.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 DYSTOCIA7.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 injury9.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