Dystocia caused by uterine dysfunction ( anommalies of the powers )

1. Dystocia caused by uterine dysfunction ( anommalies of the powers )

2. Normally: Tripledescending gradientof activity Early labor contractions at 3-5 min, 20-30 mmHg Active labor contractions at 2-4 min, 30-50 mmHg + pushing 100-150 mmHg Resting pressure 5-10/12-14 mmHg Duration 30-60/60-90 seconds Intensity Duration Propagation of the uterine contractions

3. HYPERACTIVE states Incoordinate states hypoactive states

4. hpokinetics I: i.a. p< 25 mmHg F: < 2/10 min UA 50-100 UM inert hypoactive states hypotonia uterine tonus < 10 mmHg ± Associated

5. HYPERKINETICS I: i.a. p> 70 mmHg F: > 6 / 10 min UA > 250 UM HYPERACTIVE states HYPERTONIA basal tonus> 35 mmHg ± Associated

6. Dyskinetics I, F, durate, interval anarchic Incoordinate states Ectopic centers – fibrilation Asincronism Upword propagation of the contractile wave + H: miometrial tetany + h tonia

7. Primitive(labor onset): organic causes, neuro-hormonal defects, Hyp/hyp disfunctions, diabetes, obesity, Hypertiroidy,PIH Secondary(during labor): overdistension of the uterus, intempestive RM, excessive sedation + Epidural analgesia Chorioamniotitis Maternal position Etiology Uterine malformations, H.excitability, obstacles(praevia tumors, narrow pelvis,fetal malpositions/ malformations, big fetus), excess of oxytocin Malformations of the uterus, deviation of the cervix,adherent membranes,disproportions, malpositions of the fetal head, hormonal/nervous dysfunctions

8. Clinical diagnosis • tocometry minimum 15 min • VDE: progressof the presentation, dilatation of the cervix • clinical signs of fetal distress Dilation does not progress, tensed membranes, lack of presentation progress, long durate of labor, fetal distress Intense pain, anxiety, frequent,strong, but ineffective contractions, rigid oedematous cervix, no progress of the presentation, Ht+Hk, prerupture syndrome,fetal distress Abnormal contractions, the cervix fail to dilate, oedema of the cervix

9. Paraclinically • Tocometry/tocography (external by tocodynamimeter, internal transducer) • Phonocardiogram • Fetal ECG • pH of the fetal scalp Continous carefully follow-upduring labor

10. Prognosis Fetal good fetal distress reserved/bad • Maternalgood • Prolonged labor • Tiredness/exausted patient • Intraamniotic infection • Obstetrical manoeuvres • Sudden delivery • Lesions of the soft tissues

11. Prophylaxy correct management of labor correct use of drugs correct amniotomy Promptly diagnose the abnormalities in labor, correction AT THE RIGHT TIME

12. Management hypoactive states Enema, amniotomy, Oxytocin 1 UI/100ml Hartman sol/glucose 10 drops/min, increase every 30 min Csection/forceps/vidextraction HYPERACTIVE Stop oxytocin if in place Tocolitics,amniotomy, spasmolitics (ivp), analgesia, anaesthesia Csection/Embriotomy Incoordinate spasmolitics, oxytocin, amniotomy, Csection

13. Specific forms Hypertonia in Utero-Placental Apoplexy “Hypertonia” in hydramnios Hyperactive lower uterine segment Colicky uterus Constriction ring dystocia (Demelin, Schickele)

14. Dystocia due to pelvic fetal imbalance ( pelvic constriction )

15. Dimensions Shape Pubic arch Pathological bony pelvis • morphological • ethiological • dimensional Classification

16. ring shaped pelvis (flat sacrum) • funnel pelvis • narrow pelvis (all dimensions smaller than normal) • flat pelvis - antero-posterior • flat pelvis - transversal • assimetric Morphological classification

25. Ethiological classification 1. Pathology of the hole bony system dwarfism (endocrine, rachitic, achondroplazic)  narrow pelvis rickets(atrophy,deformities)  narrow and a-pflat pelvis osteomalacia(deformities)  triradiate pelvic brim

29. 2. Diseases of the pelvic bones • congenital • inflammatory • tumors • traumatic Naegele pelvis, Robert, Litzman Assimetric pelvis Obstructed pelvis Smaller pelvis due to fractures or calus

30. Causes in the pelvis • Developmental (congenital): • Small gynaecoid pelvis (generally contracted pelvis). • Small android pelvis. • Small anthropoid pelvis. • Small platypelloid pelvis (simple flat pelvis). • Naegele’s pelvis: absence of one sacral ala. • Robert’s pelvis: absence of both sacral alae. • High assimilation pelvis: The sacrum is composed of 6 vertebrae. • Low assimilation pelvis: The sacrum is composed of 4 vertebrae. • Split pelvis: splitted symphysis pubis. • Metabolic: • Rickets. • Osteomalacia (triradiate pelvic brim). • Traumatic: as fractures. • Neoplastic: as osteoma.

31. Naegele’s pelvis: absence of one sacral ala.

32. Robert’s pelvis: absence of both sacral alae.

38. 3. Spinal diseases Lordosis Kyphosis Scoliosis Spondylolisthesis Flat a-p pelvis Funnel pelvis Deformities

39. Causes in the spine • Lumbar kyphosis. • Lumbar scoliosis. • Spondylolisthesis: The 5th lumbar vertebra with the above vertebral column is pushed forward while the promontory is pushed backwards and the tip of the sacrum is pushed forwards leading to outlet contraction.

41. 4. Diseases of the lower limbs Asymmetric pelvis • coxo-femural arthrosis • coxo-femuraldisplasia • amputation of one limb • congenital • post traumatic/surgery

42. Causes in the lower limbs • Dislocation of one or both femurs. • Atrophy of one or both lower limbs. • N.B. oblique or asymmetric pelvis: one oblique diameter is obviously shorter than the other. This can be found in: • Naegele’s pelvis. • Scoliotic pelvis. • Diseases, fracture or tumours affecting one side.

43. Minor disproportion (borderline contracted pelvis, on the limit of normal) Obstetrical conjugate 10,5 - 9 cm Dimensional classification Mild disproportion (first degree contracted pelvis Obstetrical conjugate9 - 7 cm ! Severe disproportion (second degree contracted pelvis Obstetrical conjugate< 7 cm

44. Diagnosis of contracted pelvis • History • Examination • General • Abdominal • Vaginal digital exam

45. History • Rickets: is expected if there is a history of delayed walking and dentition. • Trauma or diseases: of the pelvis, spines or lower limbs. • Bad obstetric history: e.g. prolonged labour ended by: • difficult forceps, • caesarean section or • still birth. • Examination • General examination: • Gait: abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs. • Stature: women with less than 150 cm height usually have a contracted pelvis. • Spines and lower limbs: may have a disease or lesion.

46. Manifestations of rickets as: • square head, • rosary beads in the costal ridges. • pigeon chest, • Harrison’s sulcus and bow legs. • Dystocia dystrophia syndrome: the woman is short, stocky, subfertile, has android pelvis and masculine hair distribution, with history of delayed menarche. • Abdominal examination: • Nonengagement (up situated head) in the last 3-4 weeks • in primigravida. • Pendulous abdomen: in a primigravida. • Malpresentations: are more common.

47. Pelvimetry antero-post. diameter 20 cm bispinous 24 cm bicrestal 28 cm bitrochanterian 32 cm base of Trillat triangle12 cm diamant of Michaelis 11/10 cm (4 cm sup.+7 inf., 5+5) biischiatic 11 cm External pelvimetry

48. Internal pelvimetry Diagonal conjugate 12 cm - 1,5 cm True conjugate 10,5 cm Interspinous diameter 10 cm Sacral promontory position Subpubic angle

49. Imaging pelvimetry: US, X-ray CT, MRI Prognosis Fetal: RESERVED Maternal: RESERVED