DYSTOCIA

L.D.27 y/omarriedJehovas witnessTandang Sora, Quezon CityMarch 1, 2010

CC: for induction of labor

HPIPatient is G2P1 (0-0-1-0) at 40 4/7 wks AOG

2 weeks PTA occasional uterine contractions no bloody/watery vaginal discharge good fetal movement went for prenatal checkup IE: done showed 1 cm cervical dilatation, posterior cervix, 30% effaced, floating, (+)BOW observation and follow up

Few hours same symptoms prenatal checkup done showed same IE advised admission for induction of labor

OBSTETRICAL HISTORY

LMP: May 21, 2009AOG: 40 4/7EDD: Feb 28, 2009G2P1 (0-0-1-0) G1: D&C, 2008, blighted ovum, 8 weeks AOG, TMC G2: present pregnancyPrenatal check-ups: >10 with OBScreening done: Hepatitis: nonreactive OGCT: normal

Past Medical History(-) DM(-) HPN(-) Asthma(-) Allergies(-) Previous Surgeries

Family History

(-) HPN/DM(-) Asthma(-) CA

Personal and Social History

Non-smokerNonalcoholic beverage drinkerDenies use of illicit drugs

ROS(-) anorexia, weight change, weakness, fever, sweats(-) shortness of breath, cough, hemoptysis(-)chest pain, easy fatigability, dypsnea, palpitations, tremors(-)nausea, retching, vomiting, diarrhea, food intolerance, flatulence, abdominal distension, constipation(-) anxiety, depression

Physical ExaminationConscious, coherent, ambulatory, not in cardiorespiratory distressBP 130/80 PR 68 RR 20 T36.8CHt 53 Wt 66.8 kgsWarm, moist skin, no active dermatosesPink palpebral conjunctiva, anicteric scleraSymmetrical chest expansion, clear breath sounds, no crackles or wheezesAdynamic precordium,regular rate and rhythm, no murmurs

Physical ExaminationAbdomen: FH 34 cm FHT: 140 bpm Leopolds Maneuver: LM1- breech LM2- fetal back, maternal left LM3- cephalic LM4- not engagedPelvic exam:IE: Cervix 2cm, 50% effaced, floating, (+) BOWClinical pelvimetry: sacral promontory not accessible, slightly prominent ischial spines, pelvic side walls not convergent, sacrum curve

Pulses full & equal, no cyanosis, no edema

Admitting CTGReactive, baseline FHR 140s, many accelerations, no decelerations, no contractions, many fetal movements

Assessment

Pregnancy uterine 40 4/7 weeks AOG, cephalic in beginning labor; G2P0 (0-0-1-0)

Lab exams

CBCHgb113Hct0.34Rbc3.74Wbc11.1Platelets348Neutrophils79Lymphocytes13Monocytes08

URINALYSISRbcnegativeproteinnegativesugarnegativewbc3epithelial1cast0bacteria44

Patient was admitted to LR (1 PM)NPOIVF: D5NR 1L x 8 hoursHNBB 1amp/IV q4 VS: BP 110-130/70-80, HR 68-88, T 36.5FHT: 140-160 bpmIE: 1cm, 50%, station -3, +BOW

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 StationCervical dilatationNo. of Hours

4th hour (5pm)Contractions every 4-5mins, moderate, lasting 50 secondsVS: stableIE: 2cm, 60%, station -3, (+)BOW

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 StationCervical dilatationNo. of Hours

6th hour (7pm): D5NR 1L +10 u oxytocin started at 8 gtts/minUterine contractions every 4-5mins, moderate to strong lasting 50 secondsVS: stableFHT: 150-160IE: 3 cm, 60%, station -3, +BOW

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 StationCervical dilatationNo. of Hours

7th hour (8pm)IE: 4cm, 70% station -3, +BOWD5NR 1L +10 u oxytocin increased at 10 gtts/minVS: stableUterine contractions every 3 minutes, moderate to strong lasting 50 secondsFHT: 150-160

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 StationCervical dilatationNo. of Hours

8th hour (9pm)AROM was done: clear amniotic fluidIE: 4cm, 70% station -3, +BOW

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 StationCervical dilatationNo. of Hours

10th hour (11pm)Contractions every 2-3 minutes, strong lasting for 60 secondsFHT : 127-150 bpmIE: 5cm, 70% -3, -BOW

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 StationCervical dilatationNo. of Hours

12th hour (1am)CEA inductedContractions every 2-3 minutes, strong lasting for 60 secondsFHT: 127-144IE: 5cm, 70%, -2, -BOW

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 StationCervical dilatationNo. of Hours

13th hour (2am)Contractions every 2-3 minutes, strong lasting for 60 secondsIE: 5cm, 70%, -2, -BOWCTG: baseline 140s, many accelerations, (+) variable decelerations, contractions every 2-3 mins strong, many fetal movements

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 StationCervical dilatationNo. of Hours

Manner of Delivery:Stat Primary Low Transverse Cesarean Section for Arrest of Cervical Dilatation for 3hours

MOTHERBABY

ConditionawakePostpartum VSstableUteruscontractedEBL

ACTIVITYDATETIMEOnset of laborMarch 1, 20101 pmOxytocin dripMarch 1, 20107pmRuptured BOWMarch 2, 20109 pmFull Cervical dilatation-----------Baby deliveredMarch 2, 20102:40 amPlacenta deliveredMarcj 2, 20102:42am

DYSTOCIAdifficult laborcephalopelvic disproportion/failure to progressmost common current indication for primary cesarean delivery

DYSTOCIAArises from distinct abnormalities: Power- expulsive forces, uterine contractility and maternal effort Passage- maternal pelvisPassenger- presentation, position, devt of fetusPain

POWER:

Fundal dominanceLower limit of contraction pressure: 15 mmHg 200 montevideo units

POWER: Abnormalities of the expulsive forces2 types of uterine dysfunction:1. Hypotonic uterine dysfunction: - no basal hypertonus, synchronous pattern but pressure is insufficient2. Hypertonic uterine dysfunction: -more force in the midsegment than the fundus -incoordinate, complete asynchronism of impulses

CAUSES OF UTERINE DYSFUNCTION:Epidural anesthesiaChorioamnionitisMaternal position

Abnormalities of Power:

Active phase disorders

Second stage disorders

Active-phase disordersProtraction disorder- slower than normalArrest disorder- complete cessation

Both criteria should be met: Cervix is dilated 4cm or more Uterine contraction pattern of 200 Montevideo units or more in a 10 minute period for 2 hours without cervical change

LABOR PATTERNPRIMIPARAMULTIPARATREATMENTEXCEPTIONAL TREATMENTLatent PhaseProlonged Latent Phase>20 hours>14 hoursBed restOxytocin or CS if there is an urgent problemProtraction DisordersActive Phase2 hoursArrest of descent>1 hour>1 hourFailure to descendStill no descent after deceleration phase or second stage of labor

76543210 3 6 9 12 15 18 21 24 27 -5-4-3-2-10+1+2+3+4+51098PROLONGED LATENT PHASE

76543210 1 2 3 4 5 6 7 8 9 10 -5-4-3-2-10+1+2+3+4+51098PROTRACTED ACTIVE PHASE OF DILATATION

76543210 1 2 3 4 5 6 7 8 9 10 -5-4-3-2-10+1+2+3+4+51098PROTRACTED DESCENT

76543210 1 2 3 4 5 6 7 8 9 10 -5-4-3-2-10+1+2+3+4+51098PROLONGED DECELERATION PHASE

76543210 1 2 3 4 5 6 7 8 9 10 -5-4-3-2-10+1+2+3+4+51098ARREST IN CERVICAL DILATATION

76543210 1 2 3 4 5 6 7 8 9 10 -5-4-3-2-10+1+2+3+4+51098ARREST OF DESCENT

76543210 1 2 3 4 5 6 7 8 9 10 -5-4-3-2-10+1+2+3+4+51098FAILURE OF DESCENT

Complications of DYSTOCIAMaternal complications: intrapartum chorioamnionitis, postpartum pelvic infections, hemorrhage, uterine rupture, fistula formations, pelvic floor injury, postpartum lower extremity nerve injury Perinatal complications: infection, mechanical injuries (caput succedaneum, molding, cephalohematoma, skull fracture)

THANK YOU

**********IE was 1cm dilatation, 50% effaced*IE was 2 cm, 60% , -3*3cm, 60%, -3 intact BOw***5cm, 70%, -3**5cm 70% -2*5cm, 70%,-2*When a woman experiences emotional stress in labor, the catecholamines in her body rise. The excessive level of catecholamines in her body will reduce circulation to the placenta and the uterus during labor which will cause ineffective contractions to take place. If ineffective contractions become the consistent labor pattern, an induction may become necessary, therefore increasing the chance of a cesarean.*The purpose of the partogram is: (1) To prevent obstructed labour and ruptured uterus (which cause 70% of maternal deaths in some areas) by enabling peripheral health workers to monitor labour, so as to detect deviations from the normal more effectively, and thus to refer mothers at the optimum momentbefore it is too late. This is the purpose of the alert line. Ideally, the partogram should only be used to monitor those labours which are expected to be normal; mothers with risk factors should have already been referred. (2) To monitor all labours in hospital, so that you know when to intervene. This is the purpose of the action line. If the progress line of a mothers cervical dilatation moves to the right of the alert line, be extra vigilant. If she reaches the action line you must do something, if you have not already done it (see below).The partogram depends on the principles that: (1) The latent phase of labour should not last longer than 8 hours, hence the thick vertical line at this point. (2) The latent phase ends and the active phase starts when her cervix is 3 cm dilated (4 cm is sometimes used). (3) During the active phase her cervix should dilate at not less than 1 cm per hour. (4) A lag time of 4 hours is usually acceptable between the slowing of labour and the need to intervene; this is the distance between the alert and the action lines. The WHO partogram uses fixed alert and action lines and transfers her to the alert line as soon as she reaches 3 cm, as has been done for Mother C, in Fig. 18-2a.Dilatation of the cervix and its relation to the action line is only one of the factors measuring the progress of labour, and the necessity to intervene. It and the descent of the babys head are the only two factors plotted on the cervicograph. Although they are the most useful and the most easily plotted ones, there are others which determine what you should do and when you should do it, they include: his presentation, his moulding score, his condition (fetal distress), his mothers condition, and the strength and frequency of her contractions. Consider all these factors, and dont be guided only by the dilatation of her cervix in relation to the action line and by the descent of his head, critical though these are.*