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Dystocia Case Presentations

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					      Dystocia
  Case Presentations
       Amy Nakajima, MD, FRCSC
Department of Obstetrics and Gynecology
             May 2011
  Why is dystocia important?
• Prolonged labour is associated with morbidity
  and poorer outcomes:
  – Maternal:
     •   Surgical intervention
     •   Infection
     •   Bleeding
     •   Injury
     •   Thrombosis
  – Fetal:
     • Traumatic injury
           – Shoulder dystocia
           – Instrumental delivery
     • ?long term outcomes (?link with infection)
             Scenario 1
• 27 yo G1T0 P0 A0 L0 at 38 wk 5d GA
• Presents to triage with contractions q10
  minutes for a few hours
• She states that she is in labour
• Is she?
                        Scenario1
• History:
   – Uncomplicated pregnancy:
        • Routine prenatal care
           –   A pos, HIV (-), HBSAg(-), syphilis (-), rubella immune
           –   IPS negative, normal anatomic scan, GDS normal
           –   BP normal at prenatal visits, SFH appropriate
           –   GBS negative
   –   No symptoms suggestive of SROM
   –   No pv bleeding
   –   FM good
   –   No symptoms of hypertension
                  Scenario1
• Physical:
  – Vitals stable, BP 120/70
  – FHR auscultated: 140 bpm
  – Contractions: q10-15min, lasting 10 sec
  – Cervical exam:
     • 2 cm dilated
     • soft, ant, 2 cm long, station -3 at best
              Scenario 1
• Patient is uncomfortable
• Is this labour?
• Do you admit?
  – What factors might affect your decision?:
     Definition of Labour
Regular, frequent uterine contractions
                AND
          Cervical change=
              LABOUR
  First Stage - Latent Phase
• Latent phase:
  – The presence of uterine activity resulting in
    progressive effacement and dilation of the
    cervix proceeding to the active phase
  – Complete when:
     • A nulliparous woman reaches 3-4 cm
     • A parous woman reaches 4-5 cm
  – Cervical length should usually be < 1cm
  – Onset difficult to define!
   First Stage - Active Phase
• The presence of regular, painful
  contractions leading to cervical dilation:
  – after 3-4 cm dilatation in a nulliparous
    woman
  – after 4-5 cm dilatation in a parous woman
              Scenario 1
• Is this labour?
• Do you admit?
                  Scenario 1
• Why not to admit:
  – Dystocia is the leading indication for C/S
  – If the first labour is not managed appropriately to
    optimize chances of a successful vaginal delivery:
     • Increased rates of repeat elective C/S
         – Second most common indication for C/S
     • VBAC has its own associated potential complication
  – 1990 study:
     • 11.5% of women had dystocia diagnosed in latent phase
     • 40% of C/S for dystocia were done in latent phase
Management of Latent Phase
• Try to establish an accurate diagnosis
  of labour
• Avoid admission to L&D until active
  labour is established
• Favour observation, rest and analgesia
• Information/education
  – Prenatal classes
  – How/when to access support
                    Scenario 1
• Associated factors:
  –   Symptoms of ruptured membranes? & GBS (+) ?
  –   Pv bleeding?
  –   Fetal movement (FM)?
  –   Previous obstetrical history:
       • VBAC, grand multip, previous precipitous delivery
  – Pregnancy to date?
       • Complications:
           – Maternal: GDM, hypertension, substance abuse etc
           – Fetal:    SGA/IUGR, oligohydramnios, Rh disease, etc
  – Social factors:
       • Weather/road conditions
       • Distance to hospital
            Scenario 2
• 27 yo G1T0 P0 A0 L0 at 38 wk 5d GA
  whom you had seen in triage this
  morning returns
• Contractions now q 5 min x 90 min
• No symptoms of spontaneous ruptured
  membranes (SROM)
• No pv bleeding
• FM +
                       Scenario 2
• Physical:
  –   Vitals stable, BP 130/76
  –   Fetal heart rate (FHR) auscultated: 150 bpm
  –   Contractions: q5min, lasting 30 sec
  –   Cervical exam:
       •   5 cm dilated
       •   soft, ant, 0.5 cm long, station -3
       •   Membranes intact
       •   Head well applied
• Is she in labour?
• Do you admit her?
              Scenario 2
• Patient is admitted to L&D
• Patient is hoping to have a natural child
  birth (NCB)
• Her partner is present and supportive
• What options can you offer her for pain
  control?
   Non-Pharmacological Pain
           Relief
• Techniques that reduce painful stimuli:
  – Ambulation, position change
• Techniques that activate peripheral sensory
  receptors:
  – Massage, acupuncture/pressure
  – Heat/cold
  – Shower/jacuzzi
• Techniques that enhance descending
  inhibitory pathways:
  – Attention focusing, distraction
      Continuous One-to-One
      Support during Childbirth
Cochrane review of continuous support in
  labour included 15 trials involving over 12 000
  women:
• continuous support is associated with:
  –   Decreased likelihood of having analgesia/epidural
  –   Decreased likelihood of C/S
  –   Decreased likelihood of operative vaginal delivery
  –   Less dissatisfaction
                    Scenario 2
• Over the next 2 hours, the patient tries
  ambulation, shower, jacuzzi, but decided that
  she would like an epidural!
   – FHR +
   – Contractions q 3-4 min, lasting 45 sec
   – Pv exam:
      • 6-7 cm dilated, very thin, station -1
      • Membranes intact
• IV started, fluid preload given
• Anesthesiologist consulted:
   – Epidural placed without difficulty
   – Patient comfortable
        Epidural Analgesia
• Greater pain relief than non-epidural
  methods
• ?longer first and second stages
• Increased incidence of fetal malposition
• Increase use of oxytocin
• Increased operative vaginal delivery
  rates
• No effect of C/S rates
        Low Dose Epidural
• Preferred:
  – Less motor block
  – Shorter second stage
  – Less hypotension
  – Less fetal malposition
  Epidurals in the First Stage
• Pain and anxiety leads to an increase in
  catecholamines, resulting in
  dysfunctional contractions.
• Good pain control may convert
  dysfunctional contractions to effective
  contractions, and progress.
• Allows augmentation.
Epidurals in the Second Stage
• The second stage may be prolonged
• Delay pushing if there no urge is
  present:
  – Rates of operative vaginal delivery lower
  – Maternal/fetal status reassuring
  – Continuous progress measured by the
    descent of the fetal head
                 Scenario 2
• 2 hours after epidural started, patient is
  reassessed:
  – Cervix unchanged:
     • 6-7 cm dilated, very thin, station -1
  – Contractions now q 5-6 min, lasting 30 sec

• What do you think about her progress?
• Should we do something? If so, what?
Progress in the First stage
Triage
Early amniotomy (ARM)
Early high dose
     oxytocin
1:1 nursing support
Patient education
  Length of First Stage of Labour
                    Mean active phase   2SD
                         4 - 10 cm

Friedman (1955)           2.5 h         11.7 h
Albers (1996)             7.7 h         19.4 h
Zhang (2002)              5.5 h

                    Total first stage
Kilpatrick (1989)          10.2 h       19 h
 Diagnosis of Dystocia in the
        First Stage

WHO (1994)    <1 cm/h for minimum of 4 h

ACOG (1995)   <1.2 cm/h

SOGC (1995)   <0.5 cm/h over 4h
         Labour Time Frames
                              Nulliparous   Parous

Latent phase   Mean           6.4 h         4.8 h
               Longest normal 20.1          13.6


Active phase   Mean           3.0 cm/h      5.7 cm/h
               Slowest normal 1.2 cm/h      1.5 cm/h


Second stage   Mean           1.1 h         0.4 h
               Longest normal 2.9 h         1.1 h
                    Scenario 2
• No progress over 2 hours after epidural
  started (4 hours after admission at 5 cm):
   –   Cervix 6-7 cm dilated, station -1
   –   Good pain control with epidural
   –   Membranes intact
   –   FHR +
   –   Contractions less frequent
• What is the cause of her lack of progress?
          Causes of Dystocia
POWER:
  – hypotonic uterine contractions
PASSENGER:
  – CPD
     • Fetal position
     • Fetal size

PASSAGE:
  – bony pelvis
  – soft tissue
Labour = best test of a pelvis
      SOGC Dystocia Policy
          Statement
1. Continuous support for the labouring
   patient.
2. Upright posture in the first stage.
3. (PGE2 gel for cervical ripening.)
4. A low dose epidural with minimal motor
   blockade may not increase risk of operative
   delivery.
5. No absolute time limit for the 2 nd stage if
   good progress is maintained and in
   absence of fetal compromise.
     SOGC Dystocia Policy
         Statement
• Amniotomy (ARM) associated with:
  – shortened labour
  – FHR abnormalities
• Should be considered once diagnosis of
  dystocia made in active phase, prior to
  starting syntocinon.
• Ensure fetal head is well applied.
                    Scenario 2
• No progress over 2 hours after epidural
  started (4 hours after admission at 5 cm dilated):
   –   6-7 cm dilated, very thin, station -1
   –   Membranes intact
   –   FHR +
   –   Contractions less frequent
• Good pain control with epidural

• So, next step:
               Scenario 2
• Fetal head well applied
• ARM performed, fluid clear, cervix 6-7 cm
• FHR remains reassuring
Two hours later:
• Contractions are q5min, lasting 45 sec
• Fluid clear; maternal & fetal status +
• Cervix is 7-8 cm dilated, completely effaced,
  station 0
• Now what?
      SOGC Dystocia Policy
          Statement
• Augmentation with oxytocin should be
  implemented prior to any consideration of
  surgical intervention solely for the treatment
  of dystocia.
• Protocols:
   – Low dose:
      • 1-2 mU/min, increasing by 1-2 mU q30min to a max of 20
        mU/min
   – High dose:
      • 6 mU/min, increasing by 6mU q15min to a max of 40
        mU/min
                   Oxytocin
• SOGC (1995):
  – 2 to 3 hours to achieve therapeutic concentrations
    and a further period is required to observe a
    response.
• ACOG (1995):
  – Extending the minimum period of oxytocin
    augmentation for active phase arrest from 2 to 4
    hours appears effective.
• Rouse (1999):
  – Up to 6 hours of augmentation resulted in 92%
    vaginal delivery rate.
                  Scenario 2
• Oxytocin augmentation started:
   – Contractions increase to q3min, lasting 45 sec
   – FHR +, fluid clear
• Reassessed in 1 hour (7 hours after admission):
   – 8 cm dilated, 0 to +1 station, no caput
• In the following hour:
   – Fully dilated, +1 station, OA presentation, no caput
   – No urge to push
 Second Stage Components -
        TOH (2006)
• Hour 0: fully
• Hour 1: WAIT
• Hour 2: WAIT
• Hour 3: PUSH
• Hour 4: PUSH
      Second Stage: Waiting
• Waiting for up to 2 h prior to onset of pushing
  in:
   – nulliparous patient with epidural;
   – nulliparous patient w/o epidural; and
   – multiparous patient with epidural;
• Waiting for up to 1 h in multiparous patient
  w/o epidural;
• Is appropriate:
   – In the presence of:
      • Continued descent of the head
      • Reassuring maternal and fetal status
            When to Push?
• When guideline waiting time exceeded
• When there is urge in women w/o epidural
• In nulliparous patient with epidural:
   – Head is visible OR
   – station ≥ +2 AND OA, ROA, or LOA
• In multiparous patient with epidural;
   – When the urge to push is present OR
   – Head is visible OR
   – Station is station ≥ +2 AND OA, ROA, or LOA
           Duration of Pushing
• Reassessment should be made after a max of 2 h of
  active pushing, to decide if operative vaginal delivery
  is required for:
   – all nulliparous patients; and
   – multiparous patients with epidural.
• Multiparous patients w/o epidural, should be
  assessed after 1 h.
   – Unless spontaneous delivery appears imminent.
   – Even if guideline for total timeline of the 2nd stage has not
     been exceeded.
• Intervene earlier if maternal/fetal status is of concern.
 Total Duration of Second Stage
SOGC (1995):
  – Avoid placing limits on the duration of the
    2nd stage when epidural present.
  – Expectant management of the 2 nd stage is
    preferred:
    • As long as there is continuous progress
      measured by descent of fetal head, and
    • Maternal and fetal status remain satisfactory.
 Total Duration of Second Stage
ACOG (2003):
• Diagnosis of a prolonged 2nd stage should be
  considered:
           with epidural    w/o epidural
  Nullip          >3 h      >2 h
  Multip          >2 h      >1 h
 Total Duration of Second Stage
TOH (2006):
• Continuing beyond the following time limits
  may not be appropriate:
  – if there is slow/no progress
  – despite contractions augmented with oxytocin
• Extension of time limits may be appropriate if
  progress continues and SVD is imminent.
             with epidural     w/o epidural
  Nulliparous     4h                  3h
  Multiparous     3h                  2h
              Scenario 3
• Patient has been fully dilated for 4
  hours:
  – Pushing 2 h, commenced after 2 h waiting
  – Maternal/fetal status reassuring
  – Fluid clear, no meconium
  – Epidural working well
• What do you do now?
                Scenario 3
•   Head is visible !
•   No caput
•   OA
•   SVD!
 But when is the baby stuck?
SOGC (1995):
• Failure in descent of the presenting part

ACOG (1995):
• >1h with no descent
                Red Flags
Red flags for complications in labour:
 cervical dilatation <0.5 cm/h
 oxytocin >6 h
 first stage >15 h
 pushing >2 h
 >1 h with no descent
 second stage >4 h
 clinical chorioamnionitis
Strategies to Prevent Dystocia
• Prenatal education
• Avoid unnecessary induction of labour (IOL)
• Obstetrical triage:
  – Admit in active labour
• Continuous one-on-one labour support
• Appropriate analgesia:
  – Minimization of motor blockade with epidural
    Management of Dystocia
• Assess progress of labour
  – First stage
  – Second stage
• Intervention when appropriate:
  – Amniotomy
  – Oxytocin augmentation
  – Pain relief
• Continued assessment of maternal and fetal
  status
• Operative intervention when necessary
       Objectives of Labour
          Management
• Decreased maternal and fetal morbidity
• Increased likelihood of successful vaginal
  delivery
• Decreased operative vaginal delivery
• Decreased C/S for dystocia
  – Decrease repeat elective C/S


                Better outcomes!

				
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