1、1 ABNORMAL LABOR OR DYSTOCIA Chen DanqingWomens Hospital,School of Medicine,Zhejiang University 2Defintion：Dystocia is defined as difficult labor.It may be associated with various abnormalities that prevent or deviate from the normal course of labor and delivery.It is the consequence of four distinc
2、t abnormalities that may exist singly or combination:the power,passage passenger and the psyche.3Cause of dystociaPower contraction or intra-abdominal pressure Passage bone or soft birth canalPassenger malformationPsyche tension-anxiety4 Abnormal uterine actionThe rhythm,symmetry,polarity and retrac
3、tion of uterine contraction become abnormal.Include：uterine hypocontractility uterine hypercontractility5Abnormalities of the powers Uterine dysfunction coordianted hypocontractility Uterine Uncoordinated Dysfunction coordianted hypercontractility uncoordinated6Etiology of uterine action：Cephalopelv
4、ic disproportion or fetal malposition Psychological factorsAbnormal uterus Endocrinal dysfunctionOthers7Clinical manifestationHypotonic uterine action(coordianted)Have normal rhythm,symmetry and polarity.The intensity is low.including:primary and secondary hypotonic uterine action.8Hypotonic uterine
5、 action(uncoordianted)Loss the normal rhythm,symmetry and polarity.The intensity in the periods of relaxation between contractions become larger.The pregnant women will fell persisting pain.9Effect on maternal and fetusmaternal Fatigue Acidosis Infection Postpartum hemorrhage Cesarean section rate i
6、ncreasing fetus Birth injury distress Prolapse of umbilical cord Stillbirth10Managemant Coordinated dysfunctionVaginal examination to rule out Cephalopelvic disproportion or fetal malposition.Evaluate fetus and maternal complexion.11In the first stage of labor Relax,Take good care Improve the contra
7、ctionRupture the membraneOxytocin stimulation of labor:from low dose.Narcotic agent such as morphine sulfate is given in doses large enough to arrest uterine contractions and provide from 6-12 hours of rest;12In second stage of labor There is no cephalopelvic disproportion-improve the expulsive forc
8、e.Fetal distress-finish the labor in shortest time.Cephalopelvic disproportion-cesarean section.In third stage of labor-prevention of postpartum hemorrhage.13Uncoordinated dysfunction：Sedation is generally effective in converting uncoordinated contraction to normal labor patterns.14Hypertonic dysfun
9、ction(coordinated)Manifestation and diagnosisThe contraction have normal rhythm,symmetry and polarity,but the intensity is too strong.Precipitate delivery:The total stage is less than 3 hours when the rates of cervical dilation is more than 5cm/h,the cervical dilation of 10cm and expulsion of fetus
10、occurs in short time.15Hypertonic of uncoordinated contraction Constriction ring of uterus Characteristic:Local smooth muscle in uterus spasmodicly contract to form circular contraction.The ring is located at juncture between lower uterine segment and corpus uteri.16Tetanic contraction of uterus:Los
11、s of rhythmnThe titanic contraction of uterus persist contracting and dont relax,always appear when oxytocin be misused.17Effect on maternal and fetusPrecipitate deliverySoft birth canal traumaRupture of uterusFetal distressFetal deathstillbirth18Prevention is main doctrine.Use oxytocin,artificial r
12、upture of membrane carefully.Aspiration oxygen,prohibit uterine contractionMagnesium sulfate,pethidine.Fetal distress,pathologic retraction ringCesarean.Management19 Abnormal passage Causes of abnormalities of passage include bony abnormalities(pelvic dystocia),soft tissue obstruction of the birth c
13、anal.Pelvic dystocia,particularly that due to small bony architecture,is the most common cause of passage abnormalities.20inletoutletcavityfemalemale21Contracted pelvic inlet platypelloid is comonThe platypelloid pelvis is characterized by a transverse diameter that is wide with respect to the anter
14、oposterior diameter.Simple flat pelvisRachitic flat pelvis22Midpelvis contraction Midpelvis contraction is defined as values less than 10 cm for the interspinous diameter,always occurs in android pelvis and anthropoid pelvis.23Contracted pelvic outlet Pelvic outlet contraction is defined as values l
15、ess than 8cm for the intertuberous diameter and the sum of the intertuberous and posterior sagittal diameter less than 15cm.always occurs in android pelvis.24Generally contracted pelvicEach pelvic plane is 2cm less than normal value or more,which is called generally contracted pelvic and can be seen
16、 in shape more short and small,well-balanced women of type of figure.Pelvic malformationThe pelvic loss the normal shape and symmetry.25Clinical manifestation of Contracted pelvic inlet Abnormal presentation and lie position.Lack of progressive cervical dilatation and fetus descending:prolonged late
17、nt phase and active phase.Premature rupture of membrane and umbilical cord prolapse.26Contracted pelvic inlet 27 Clinical manifestation of Midpelvis contraction Abnormal position Persistent occiput posterior position,or deep transverse arrest Prolonged labor stage Forcep increasing28Contracted pelvi
18、c outlet Clinical manifestation Secondary hypotonic uterine action and protracted second stage of labor.The fetal biparietal diameter cant pass the pelvic outlet.29Management of pelvic bony contraction Considering type of pelvic,power,fetus position and fetal distress.Contracted pelvic inletExternal
19、 conjugate 16.517.5cm,anteroposterior diameter 8.59.5cm.External conjugate 16.0cm,anteroposterior diameter 16h。Prolonged active phase 8hCervical dilation:1.2cm/h，M 1.5cm/h。Clinical finding and diagnosis of abnormal labor67 Protracted active phase The cervical dilation stop for 2 hours in active phas
20、e。Prolonged second stageThe second stage last more than 2 hours for。68Prolonged descent:the rate of fetus descending in deceleration phase and the second stage of labor less than 1.0cm/h()，or 2.0cm/h()。Protracted descent:fetus descending in deceleration phase stop for more than 1h。Prolonged labor:th
21、e total stage last more than 24h。6970Management of vaginal delivery：Evaluation of uterine contraction,fetal size and position,pelvic size,fetopelvic disproportion or not.Prolonged latent stageSedation may cause absence of uterine contraction in false labor.。71Prolonged active stageObserve the progre
22、ss of labor、expulsive force、fetal heart rate、fetal position for 24h,when rule out the fetopelvic disproportion.72Prolonged second stage of laborThe first,perform vaginal examination to rule out fetopelvic disproportion,correct the abnormal fetal position,then can improve the uterine contraction by o
23、xytocine.73Ceasrean section posterior asynelitism、Anterior asynelitism)、Brow presentation;General pelvic contract Fetal macrosomia;Shoulder presentation,Feet presentation;Pathologic contracting ring;74潜伏期潜伏期有延长倾向或已有延长倾向或已经延长经延长强烈镇静剂强烈镇静剂无进展无进展催产素催产素剖宫产术剖宫产术无进展无进展有进展有进展宫颈扩张活跃期宫颈扩张活跃期无进展无进展有进展有进展有进展有进
24、展人工破膜人工破膜潜伏期延长的处理方案潜伏期延长的处理方案排除排除CPD排除胎窘排除胎窘75延缓延缓阻滞阻滞胎儿娩出胎儿娩出无明显无明显CPD人工破膜人工破膜 2小时小时无进展无进展严重胎头严重胎头位置异常位置异常剖宫产术剖宫产术无严重胎头无严重胎头位置异常位置异常催产素催产素无进展无进展剖宫产术剖宫产术有进展有进展明显明显CPD剖宫产术剖宫产术有进展有进展活跃期宫颈扩张延缓及阻滞处理活跃期宫颈扩张延缓及阻滞处理76胎头下降延缓阻滞胎头下降延缓阻滞明显明显CPD剖宫产剖宫产无明显无明显CPD加强宫缩加强宫缩（人工破膜，催产素人工破膜，催产素）儿头最大横径位于或儿头最大横径位于或低于坐骨棘以下低于坐骨棘以下儿头最大横径位于或儿头最大横径位于或低于坐骨棘以上低于坐骨棘以上阴道分娩阴道分娩徒手内旋徒手内旋双顶径降至双顶径降至坐骨棘以下坐骨棘以下阴道分娩阴道分娩失效失效剖宫产剖宫产活跃期胎头下降延缓阻滞及胎头娩出期延长的处理活跃期胎头下降延缓阻滞及胎头娩出期延长的处理77
