DYSTOCIA
(Abnormal labor)
October, 2023
JI PADERANGA, ERALD M.
Outline
1. Presentation of the case - History and PE
2. Admitting working impression
3. Course in the ward
4. Final Diagnosis
5. Discussion about DYSTOCIA
General Data
This is a case of patient L.C., 31 y.o., G1PO PU 38
6/7 weeks AOG by eUTZ, married, Roman catholic,
from Bais Negros Oriental who consulted for labor
pains
Chief Complaint
Labor pain
History of the Present Illness
● 8 hrs PTA, the patient had an onset of uterine
contractions with pain occurring every 3 minutes. It was
described as as moderate in quality, lasting 40 seconds,
and the pain score (PS) was 6/10.
● 2 hrs PTA, the uterine contractions progressed to strong
in quality. They now last 60-80 seconds and occur every
3 minutes, with a PS of 9/10. This prompted the patient
to seek consultation. An initial examination (IE)
performed by her Obstetrician revealed 2 cm cervical
dilatation with 80-90% effacement. Subsequently,
admission was recommended.
OBGYN History
● LMP: January 2, 2023
● PMP: December 1st week, 2022
● EDC by LMP: October 9, 2023
● AOG by LMP: 39 3/7 weeks
● EDC by early UTZ: October 13, 2023
● AOG by early UTZ: 38 6/7 weeks
OBGYN History
● Menarche: 11 y/o, lasted 4 days,
unrecalled number of pads ● Coitus: 25 y/o
used moderately-soaked, not ● Partners: 3
associated with dysmenorrhea ● Contraceptive: Condoms
● Interval: Regular ● Pap smear: none
● Duration: 5 days ● STIs: none
● Amount: 3 ppd, fully soaked
● Signs/symptoms:
● (-) Dysmenorrhoea, (-) breast
changes/complaints
Prenatal History
● 1st Pregnancy test : February 8, 2023
● 1st Prenatal check-up: February 2nd week
Ultrasound reports:
● Early ultrasound (March 29, 2023)
Impression; SINGLE LIVE INTRAUTERINE PREGNANCY, 11 5/7
WEEKS BY CRL; PLACENTA POSTERIOR, GRADE 0, TOTALLY
COVERING THE OS: NO SUBCHORIONIC HEMORRHAGE; NORMAL
OVARIES
Latest ultrasound ( October 3,
2023)
Impression:
● Intrauterine pregnancy, 37
weeks 4 days by fetal biometry,
live, singleton, cephalic
presentation.
● Adequate amniotic fluid volume.
Placenta posterofundal, high in
location, Grade IL.
● The estimated fetal weight falls
on the 26th percentile for a
39-40 week old fetus.
Prenatal History
● Prenatal visits: > 5 visits
● Prenatal Illnesses:
○ (+) Internal hemorrhoids, Grade III: During 2nd
trimester
○ (-) UTI, (-) GDM, (-) Gestational HPN
● Labs: unremarkable
● Supplements: Obimin( Multivitamins + Minerals + DHA),
Calcium
● Partner:
○ Occupation: Teacher
○ Blood type: “AB” positive
Past Medical History
● Comorbidities:
○ (-) HPN, (-) DM, (-) BA, (-) CA, (-) Thyroid dx, (-)
Bleeding dx
● Maintenance medications: None
● Previous admission/Surgery
○ Admitted due to AGE - unrecalled year
● Blood transfusion history: None
● Blood type: “ A” positive
● Immunization:
○ Sinovac 2 doses, Pfizer booster 1 dose
○ (-) Tetanus toxoid vaccine, (-) Flu vaccine, (-) TDaP
Family History
● Paternal: (+) HPN, (-) DM, (-) Bronchial Asthma
● Maternal: (+) HPN, (+) DM, Mother had history of CS
secondary to bony pelvis problem
Personal & Social History
● Non-smoker, occasional beverage drinker(light),
denies illicit drug use
● Occupation: Teacher ( Senior high school)
● Supplements: Obimin( Multivitamins + Minerals +
DHA), Calcium
Review of Systems
(-) Hyperemesis gravidarum
(-) Vaginal Bleeding
(-) Headache, visual
(-) Body weakness
(-) Fever, cough, sneezing
(-) Weight change
(-) Dysuria
(-) Constipation, Diarrhea
(-) 3 P’s: Polyuria, Polyphagia, Polydipsia
(-) Flank pain
Physical Examination
● General: Awake, alert, coherent, NIRD
● Vital Signs:
○ BP 110/80 mmHg
○ HR 80 bpm
○ RR 20 cpm
○ T 36.3
○ Ht 145cm ; Wt (72kg) 78kg
● Skin: No pallor, no jaundice, warm to touch, with good
turgor and mobility
● HEENT: normocephalic, pink palpebral conjunctivae,
anicteric sclerae, moist lips and oral mucosa, No
tonsillopharyngeal congestion
Physical Examination
● Chest/Lungs: Equal chest expansion, Clear Breath Sounds
● Breast: engorged, no palpable masses/tenderness
● CVS: adynamic, regular rate & rhythm
● GUT: (-) KPS
● EXT: no edema/swelling, CRT <2 sec
● Neuro-Exam: essentially normal
● Abdomen: (+) linea nigra, striae gravidarum, NABS, (-)
abdominal scars, (-) tenderness
- FH: 33cm
- EFW: 3,100g
- FHT: 150s
Leopolds
- L1: breech
- L2
- Left: fetal back
- Right: small parts
- L3: cephalic, not engaged
- L4: cephalic
●
ADMITTING IE Pelvimetry
Diagonal conjugate: >11.5 cm?
Dilation: 4 cm Pelvic sidewalls: convergent
Effacement: 90% Sacrum: Hollow with average
Station: -1 inclination?
BOW: Intact Ischial spines: Prominent
Suprapubic angle: Admits 2
Cervix fingerbreadths?
Consistency: soft
Position: Mid-position
Bishop score= 9
ADMITTING CTG
Baseline FHR: 150s
Variability: Normal
Accelerations: Present
Decelerations: Absent
Interpretation: Normal
Contractions: every 2 minutes, lasting 40- 60 seconds, moderate to strong
in quality
MVU: 350-400
Admission Dx:
● G1P0 PU 38 6/7
weeks AOG by early
ultrasound; cephalic, in
latent phase of labor
Course in
the Ward
HOSPITAL S O A P
DAY 1
10/5/2023
CC: Labor pains
D: Placed on DAT. NPO once
1:54 PM G1PO in active labor
Temp: 36.3C,
LMP- Jan, 7 2023
BP: 110/80 mmHg I: D5LR 1L @ 33 gtts/min
EDC by LMP:
10/14/2023 HR: 80 bpm
AOG by LMP: 36 3/7 RR: 28 cpm G1P0 PU 38 6/7
L:
weeks SpO2: 98% weeks AOG by M:
IE: 4cm, 90%, -1, eUTZ, cephalic,
EDC by late utz: IBOW in latent phase
10/08/23 Presentation: O:
AOG by late utz: 37 of labor > Monitor FHT, BP, UC, q1hr
Cephalic
2/7 weeks > Monitor input and output q
FHT: 150’s shift
UC: q2mins,
40-seconds
duration, moderate
to strong in quality
DAY 1 S O A P
BP: 100/70 mmHg D: NPO
7:05 PM Labor pains IE: 6cm, 90%, -1, IBOW
G1P0 PU 38 6/7 I: D5LR 1L @ 33 gtts/min
FHT: 150’s
UC: q3mins, 40-6- weeks AOG by L:
seconds duration, strong eUTZ, cephalic,
in quality in active phase M:
of labor
O:
8:20 PM Labor pains BP: 100/70 mmHg D: NPO
IE: 7cm, 90%, -1, aRBOW I: D5LR 1L @ 33 gtts/min
L:
FHT: 150’s
M: Pethidine + Promethazine
UC: q3mins, 40-6- 50/25 mg cocktail full dose IV
seconds duration, strong now full dose IV now
in quality O:
DAY 2 S O A P
10/06/2023
BP: 100/70 mmHg D: NPO
Labor pains IE: 7cm, 90%, -1, IBOW
1:30 AM G1P0 PU 38 6/7 I: D5LR 1L @ 33 gtts/min
FHT: 150’s
UC: q3mins, weeks AOG by L:
40-60-seconds duration, eUTZ, cephalic,
strong in quality, in active phase M: Cefuroxime 1.5 g IV,,
of labor; Arrest in Omeprazole 40 mg IV
MVU: 200-250 cervical O: For STAT CS secondary to
dilatation arrest in cervical dilatation
> Secure 1 unit of pRBC,
properly screened and
crossmatched
DAY 2 S O A P
(-) Dyspnea V/S: 100/70 mmHg G1P1 (1001) PU D: NPO
(-) Nausea 75, bpm, 18 cpm, 36.2 delivered term,
3:20 AM (-) Vomiting I: D5LR 1L @ 33 gtts/min +
C, 99% cephalic, to a live 20 U oxytocin at 30 gtts/min
(-) Pruritus
male neonate, AS
Intraoperative findings: 8,9, BW, 3.30 kg, BL L:
….. 49 cm, 39 weeks by
M: Cefuroxime, Omeprazole,
BS, AGA, via Ketorolac, Tramadol,
PLSTCS s/t to arrest Metoclopramide
in cervical dilatation
uncer SAB ( O:
10/06/2023 @ 2:16
am)
Procedure: Primary Low-Transverse Cesarean Section
Time started- 2:06 am Time ended-3: 30 am
Intraoperative findings:
> Gravid Uterus with formed out lower uterine segment
> Clear Amniotic Fluid, Moderate in Amount
> Extracted a live male neonate in cephalic presentation, Apgar Score 8,9,
BW 3.30 kg, BL 49 cm, 39 weeks by Ballard Score, AGA, with one tight
cord coil in the neck
> Placenta posterior extracted complete, umbilical cord with 3 vessels
> Bilateral fallopian tubes and ovaries, grossly normal
> EBL: 200 mL
DAY 2 S O A P
(-) Flatus, BM V/S: 100/70 mmHg G1P1 (1001) PU D: Soft diet
(-) Dyspnea 75, bpm, 18 cpm, 36.2 delivered term,
7:00 PM (-) Nausea I: D5LR 1L at 44 gtts/min +
C, 99% cephalic, to a live 20 U oxytocin
(-) Vomiting
(-) Pruritus
male neonate, AS
C/L: Clear breath 8,9, BW, 3.30 kg, BL L:
sounds 49 cm, 39 weeks by
M: Cefuroxime, Omeprazole,
Abdomen: flabby, soft, BS, AGA, via Ketorolac, Tramadol,
NABS PLSTCS s/t to arrest Metoclopramide
in cervical dilatation
O:
Contracted Uterus, under SAB (
Minimal Lochia 10/06/2023 @ 2:16
am); in stable
Urine output: 10 cc/hr condition
(10/7/2023)
(-) Flatus, BM V/S: 100/70 mmHg G1P1 (1001) PU D: DAT
(-) Dyspnea 80, bpm, 18 cpm, 36.2 delivered term,
6: 53 AM (-) Nausea I: D5LR 1L at 44 gtts/min +
C, 99% cephalic, to a live 20 U oxytocin
(-) Vomiting
(-) Pruritus
male neonate, AS
8,9, BW, 3.30 kg, BL M: Cefuroxime, Celecoxib >
(-) Dysuria
shifted to PO, Tramadol +
Abdomen: flabby, soft, 49 cm, 39 weeks by
Paracetamol
NABS BS, AGA, via
PLSTCS s/t to arrest O:
Contracted Uterus, in cervical dilatation > Resume prenatal
meds:MV + iron, Calcium +
Minimal Lochia under SAB (
Vitamin D3
10/06/2023 @ 2:16 > Start Natalac
Adequate Urine output: am); in stable
40 cc/hr condition; S/P day 1
FBC was removed
(10/7/2023)
(+) Flatus V/S: 100/70 mmHg G1P1 (1001) PU D: DAT
*During lunch 75, bpm, 18 cpm, 36.2 delivered term,
5: 30 PM time I: IVF was discontinued
C, 99% cephalic, to a live
male neonate, AS L:
8,9, BW, 3.30 kg, BL
M: Cefuroxime, Celecoxib,
Abdomen: flabby, soft, 49 cm, 39 weeks by
NABS, non-tender BS, AGA, via O:
PLSTCS s/t to arrest > Food supplements: MV +
Uterus well contracted in cervical dilatation iron, Calcium + Vitamin D3,
under SAB ( Natalac
> Encourage breastfeeding
10/06/2023 @ 2:16 and ambulation
am); in stable
condition; S/P day 1
(10/8/2023)
(+) Bowel G: Awake, alert, G1P1 (1001) PU D: DAT; High fiber diet
movement oriented, NIRD delivered term,
6:00 AM (+) Latching I:
cephalic, to a live
(+)
Ambulating V/S: 36.2 C, 93 bpm, 18 male neonate, AS L:
com, 110/80 mmHg, 99 8,9, BW, 3.30 kg, BL
M: Cefuroxime, Celecoxib
% 49 cm, 39 weeks by
BS, AGA, via O:
(-) Dyspnea Abdomen: flabby, soft, PLSTCS 45 ams/t to > Food supplements: MV +
(-) Nausea NABS, non-tender arrest in cervical iron, Calcium + Vitamin D3,
(-) Vomiting dilatation under SAB Natalac
(-) Pruritus > Increase oral fluid intake
Uterus well contracted ( 10/06/2023 @ 2:16
am); in stable
Urine output: adequate condition; S/P day 2
(10/9/2023)
G: Awake, alert, G1P1 (1001) PU D: DAT; High fiber diet
No subjective oriented, NIRD delivered term,
11:45 am complaints I:
cephalic, to a live
V/S: 36.2 C, 93 bpm, 18 male neonate, AS L:
com, 110/80 mmHg, 99 8,9, BW, 3.30 kg, BL
M: Take home meds:
% 49 cm, 39 weeks by
>Cefuroxime to complete for
BS, AGA, via 10 days,
Abdomen: flabby, soft, PLSTCS s/t to arrest >Celecoxib PRN for pain,
NABS, non-tender in cervical dilatation >Food supplements: MV +
under SAB ( iron, Calcium + Vitamin D x 3
months
Uterus well contracted 10/06/2023 @ 2:16 > Natalac x 1 week
am); in stable
Urine output: Adequate condition; S/P day 2 O: MGH
> Dressing done
FINAL DIAGNOSIS
G1P1 (1001) PU delivered term,
cephalic, to a live male neonate,
AS 8,9, BW, 3.30 kg, BL 49 cm,
39 weeks by BS, AGA, via
PLSTCS secondary to arrest in
cervical dilatation under SAB (
10/06/2023 @ 2:16 am); in
stable condition
DYSTOCIA
(ABNORMAL LABOR)
Outline of Discussion
1. Review of Normal Labor
2. Mechanism of Dystocia
3. Complications of Dystocia
4. Diagnosis of Abnormal Labor
5. Abnormal labor, Diagnostic criteria, and Treatment
6. Passage “ Pelvis of Mother” - Overview of Pelvic
Contraction
REVIEW OF NORMAL LABOR
Mechanism of Dystocia
● Also called dysfunctional labor, ineffective labor, failure to progress (dilatation
& descent)
● Clinicians must rely on a trial of labor to determine if labor can be successful in
affecting vaginal delivery
● Abnormal labor alerts the physician to consider other methods for a successful
delivery
● MECHANISMS OF DYSTOCIA: Abnormal progress of labor (spontaneous,
induced, or augmented) related to the 3 P's:
1. Uterine factors (power) ,
2. Fetal factors (passenger)
3. Bony pelvis (passage)
Mechanism of Dystocia
General Mechanism of Dystocia
● Most common etiology of dystocia is cephalopelvic disproportion
(CPD)
● Cephalopelvic disproportion: fetal head that is large on a small pelvis
or abnormal fetal head position on a normal or small sized pelvis
● Fetopelvic disproportion: disparity of the size of the fetus for a small
pelvis
● Hypocontractile uterine activity is the most common risk factor for
protraction and/or arrest disorders in the first stage of labor
General Mechanism of Dystocia
Complications of Dystocia
MATERNAL PERINATAL
● Infection ● Fetal sepsis
● Postpartum hemorrhage ● Caput succedaneum and
● Uterine tears with molding
hysterectomy ● Mechanical trauma injury
● Uterine rupture such as nerve injury,
● Pathological Bandl fractures, and
retraction cephalhematoma
● Fistula formation
● Pelvic floor injury
● Lower extermity nerve injury
Diagnosis of Abnormal labor
Diagnosis of Abnormal labor
Abnormal labor, Diagnostic criteria, and
Treatment
“Passageway” ( Pelvis of Mother)
• Fetopelvic disproportion arises from diminished pelvic
capacity, excessive fetal size, or both
• Any contraction of the pelvic diameter that diminishes the
pelvic capacity can create dystocia during labor
“Passageway” ( Pelvis of Mother)
“Passageway” ( Pelvis of Mother)
Overview of Pelvic Contraction
Thank you
Doctors! 😁
