4. WHAT IS DYSTOCIA?
● “difficult labor”
● abnormally slow labor progress
CATEGORIES:
● Power - poor uterine contractility and maternal expulsive effort
● Passenger - the fetus
● Passage - pelvis and lower reproductive tract
5. MECHANISMS OF
DYSTOCIA
UTERINE
DYSFUNCTION
● power & passenger
● uterine contractions
insufficient or uncoordinated
● overdistention, obstructed
labor, or both
CEPHALOPELVIC
DISPROPORTION
● passenger & passage
● obstructed labor from
disparity between the fetal
head size and maternal
pelvis
6. DIAGNOST
IC
CRITERIA
&
MANAGEM
ENT
LABOR PHASE:
Labor Disorder
Traditional Criteria and Treatment
Obstetrical Care
Consensus Criteria
Nullipara Multipara Management
LATENT PHASE : Prolongation Disorder
Prolonged latent phase > 20 hrs > 14 hrs Supportive care
Oxytocin/ amniotomy
CD not indicated
Supportive care
Oxytocin/ amniotomy
CD not indicated
ACTIVE PHASE
Protraction Disorders
Protracted active-phase dilation < 1.2 cm/ hr 1.5 cm/ hr Expectant care
CD for CPD
CD not indicated
Protracted descent < 1 cm/ hr < 2 cm/ hr
Arrest Disorders
Prolonged deceleration phase > 3 hrs > 1 hr
CD for CPD
No CPD: Oxytocin
CD indications
Ruptured
membranes and no
progress after 4 hrs
of adequate
contractions
OR
No progress after 6
hrs of inadequate
contractions despite
oxytocin stimulation
Secondary arrest of dilation > 2 hrs > 2 hrs
Arrest of descent > 1 hr > 1 hr
Failure of descent No descent in deceleration
phase/ second stage
8. Complications with Dystocia
Infection ● Intrapartum chorioamnionitis or postpartum pelvic
infection
● More common with desultory and prolonged labors
Postpartum hemorrhage ● Due to uterine atony with prolonged and augmental
labors
Uterine tears with hysterotomy ● May occur if the fetal head is impacted in the pelvis
Uterine rupture ● In women with high parity and in those with prior
CS delivery
Pathological Bandl retraction
ring
● Associated with marked stretching & thinning of
the uterine segment
Maternal
Complications
9. Complications with Dystocia
Fistula formation ● Pressure necrosis (due to impaired circulation from
prolonged 2nd stage)
● Can become evident after several days as a
vesicovaginal, vesicocervical, or rectovaginal fistula
Pelvic floor injury ● Due to direct compression from the fetal head and to
downward pressure from maternal expulsive efforts
● May affect urinary or anal continence and pelvic
support
Lower extremity nerve injury ● Due to prolonged 2nd stage labor
● Most common mechanism: external compression of the
common fibular nerve due to inappropriate leg
positioning in stirrups especially during prolonged 2nd
stage
Maternal
Complications
18. LABOR DISORDERS
Prolonged deceleration phase - cervical dilation arrested at 8-9 cm
Secondary arrest of cervical dilation - no change in cervical dilation
Failure of descent - fetal head remains at station “0”
Arrest of descent - progressive descent stops during pelvic division of labor, station +1
19. LABOR DISORDERS
Prolonged Second stage
Nulliparas: Multiparas:
>3 hrs (+) RA > 2 hrs (+) RA
>2 hrs (-) RA > 1
hr (-) RA
TREATMENT: Forceps/vacuum; CS
22. ABNORMALITIE
S OF THE
EXPULSIVE
FORCES
Uterine contraction
● Good power - should have fundal
dominance
● lower limit of contraction pressure
required to dilate the cervix is 15
mm Hg
William’s Obstetrics 26th edition
23. ABNORMALITIE
S OF THE
EXPULSIVE
FORCES
Uterine dysfunction
HYPOTONIC UTERINE DYSFUNCTION
(low uterine activity)
HYPERTONIC UTERINE DYSFUNCTION
aka Incoordinate Uterine Dysfunction
(high uterine activity)
● Basal tone normal
● Normal gradient pattern with fundal
dominance
● Pressure during contraction
insufficient to dilate the cervix
● More common
● Basal tone elevated
● Complete asynchronism of the
impulses originating from each
cornu
● Gradient pattern is distorted
● Less common
William’s Obstetrics 26th edition
24. ABNORMALITIE
S OF THE
EXPULSIVE
FORCES
Maternal Pushing Efforts
● Combined force created by contractions of the uterus and abdominal
musculature propels the fetus downward
● Factors that affect maternal pushing:
○ Heavy sedation or regional reduce the reflex urge to push
○ Intense pain created by bearing down overrides urge to push
William’s Obstetrics 26th edition
29. ● Because face presentations among term-size fetuses - more common with some
degree of pelvic inlet contraction, thus, cesarean delivery frequently is
indicated.
AVOID TO ATTEMPT:
○ converting face presentation manually into a vertex presentation
○ manual or forceps rotation of a persistently posterior chin to a mentum
anterior position
○ internal podalic version and extraction
Management
31. Breech Presentation
➔ Occurs when the breech (fetal buttocks) or lower extremities present into the maternal
pelvis
Ethiopathogenesis
Risk factors for Breech Presentation Complications of Breech Presentation
● Prematurity
● Uterine relaxation (multiparity)
● Multiple pregnancy
● Hydramnios, oligohydramnios
● Hydrocephalus
● Anencephaly
● Uterine anomalies/tumor
● Placenta previa
● Perinatal morbidity/mortality
● Low birth weight
● Prolapsed cord
● Placenta previa
● Uterine anomalies/tumors
32. Breech Presentation
Diagnosis
Vaginal Examination
Frank Breech Presentation
● Lower extremities are flexed at the
hips and extended at the knees
● The feet lie in close proximity to the
head
● Findings:
○ palpable fetal buttocks, anus,
sacrum, ischial tuberosities
○ Feet cannot be palpated
34. Breech Presentation
Diagnosis
Vaginal Examination
Incomplete/Footling Breech Presentation
● One or both hips are not flexed
● One or both feet or knees lie below
the breech, such that a foot or knee is
lowermost in the birth canal
● Findings:
○ One or both feet
○ Sacrum cannot be palpated
35. Breech Presentation
Management
Vaginal Delivery may be
attempted for the following:
● Frank or complete breech
presentation
○ Partial breech
extraction (PBE)
○ Complete or (total)
breech extraction
36. Breech Presentation
Management
Cesarean Section is indicated for the following
Maternal Factors Fetal Factors
● Pelvis is contracted or has an
unfavorable shape
● Delivery is indicated
● Uterine dysfunction
● Lack of experienced operator for
vaginal breech delivery
● Large fetus
● Hyperextended head (“stargazing
breech”)
● Incomplete/Footling breech
● Healthy preterm fetus where delivery is
indicated
● Severe IUGR
● Previous perinatal death/birth trauma
37. Transverse Lie
➔ The fetus’ long axis lies
approximately perpendicular to
that of the mother
➔ Shlulder is usually positioned over
the pelvic inlet
➔ “Shoulder presentation”
➔ Always delivered by cesarean
section
39. Transverse Lie
Diagnosis
● No fetal pole is detected at the
fundus
● The ballotable head is found in
one iliac fossa and the breech
in the other
● Position of back is readily
identifiable
● When back is anterior, a hard
resistance plane extends
across front of abdomen
41. Compound Presentation
● an extremity prolapses
alongside the presenting part,
and both present
simultaneously in the pelvis
● Causes of compound
presentations are conditions
that prevent complete
occlusion of the pelvic inlet by
the fetal head, including
preterm labor
46. https://akusher-one.pdmu.edu.ua/
Fetopelvic disproportion
-Arises from diminished pelvic capacity or from
abnormal fetal size, structure, presentation or
position
-Any contraction of the pelvic diameter that
diminished the pelvic capacity can create
dystocia
William’s Obstetrics 26th edition
47. Contracted Inlet
● Fetal biparietal diameter: 9.5-9. 8 cm
● Shortest AP diameter: <10 cm
● Greatest transverse diameter : <12cm
● Diagonal conjugate: <11.5 cm
William’s Obstetrics 26th edition
48. Contracted Midpelvis
● More common finding
● Causes transverse arrest of fetal head
○ difficult midforceps operation or CS
● Suspected interspinous diameter:<10 cm
○ <8 cm midpelvis is contracted
● No precise method permits measuring
○ spines are prominent, pelvic sidewalls converge or
the sacrosciatic notch is narrow
William’s Obstetrics 26th edition
49. Contracted Outlet
● Interischial tuberous diameter: <8cm or less
● Outlet contraction without concomitant midplane
contraction is rare
● Increased narrowing of the pubic arch, occiput cannot
emerge directly but is forced farther down the ischiopubic
rami
○ perineum becomes increasingly distended
■ exposed to risk of laceration
William’s Obstetrics 26th edition
50. Pelvic Fractures
● Trauma from automobile collisions was the most common
cause.
● Fracture pattern, minor malaligment, and retained
hardware
○ not absolute indications for CS
● Fracture healing requires 8 to 12 weeks
William’s Obstetrics 26th edition
51. Prematurely Ruptured
Membranes at TERM
● Labor stimulation was initiated if contractipms did not begin
after 6 to 12 hours
○ Labor with intravenous oxytocin was preferred
management
■ Fewet intrapartum and postpartum infections
● Lower rates of chorioamnionitis, metritis, and NICU admissions
for induced than expectant management
● Membrane ruptured longer than 18 hours, antibiotics are given as
GBS infection prohylaxis
52. Precipitous Labor and Delivery
● Expulsion of the fetus in <3 hours
○ Results from
■ low resistance of the soft parts of the birth canal
■ strong uterine and abdominal contractions
■ lack of pain with contractions
● Maternal complications
○ uterine rupture or extensive lacerations of the cervix, v
In normal labor, uterine contractions cause progressive dilation and effacement of the cervix ,accompanied by descent and expulsion of the fetus.
The Friedman Curve shows the different stages of labor.
1st stage - contractions to full dilation
Latent and active phase
2nd stage - full dilation to expulsion
3rd stage - placental expulsion
Dystocia literally means difficult labor and is characterized by abnormally slow labor progress. Causes are grouped into three distinct categories. Mechanistically, these simplify into abnormalities of the powers—poor uterine contractility and maternal expulsive effort; of the passenger—the fetus; and of the passage— the pelvis and lower reproductive tract.
Passenger - fetal abnormalities, presentation, position, or anatomy
Passage - structural changes can contract the maternal bony pelvis. Or, soft tissue abnormalities of the reproductive tract may block fetal descent
The three Ps act singly or in combination to produce dysfunctional labor.
Uterine dysfunction is a problem between the expulsive efforts and the fetus. Uterine contractions may be insufficiently strong or inappropriately coordinated to efface and dilate the cervix - secondary to overdistention, obstructed labor, or both.
CPD describes obstructed labor resulting from disparity between the fetal head size and maternal pelvis.
To describe ineffective labors:
CPD
failure to progress in either spontaneous or stimulated labor - lack of progressive cervical dilation or halted fetal descent
UTERINE DYSFUNCTION (power and passenger)
uterine contractions may be insuciently strong or inappropriately coordinated to efface and dilate the cervix
Secondary to overdistention, obstructed labor, or both
Fetopelvic disproportion can cause this
Relationship between power and passenger
FEATURES OF UTERINE DYSFUNCTION
Protracted labor - slow progress
Arrested labor - no progress
Inadequate expulsive effort
CEPHALOPELVIC DISPROPORTION (passenger and passage)
describes obstructed labor resulting from disparity between the fetal head size and maternal pelvis
Features
Macrosomic baby (normal weight of baby?)
Inadequate pelvic capacity (pelvic shapes?)
Malpresentation of fetus
MATERNAL
Postpartum hemorrhage - uterine atony
Uterine rupture - women with high parity / those with prior CS delivery
Pathologic ring of Bandl - marked stretching and thinning of lower uterine segment
Pelvic floor injury - direct compression from the fetal head and downward pressure from maternal expulsive efforts
Stretch and distend the floor
Affect urinary, anal continence
PERINATAL
Caput succedaneum and molding - swelling of fetal head due to prolonged labor
Pelvic floor injury
Due to direct compression from the fetal head and to downward pressure from maternal expulsive efforts
These factors stretch and distend the pelvic floor, resulting in functional and anatomic alterations in the muscles, nerves, and connective tissues
May affect urinary or anal continence and pelvic support
Active labor is divided into 2: protraction & arrest D/O. PROTRACTION DO are slower-than-normal progress while ARREST DO are complete cessation of progress.
The first stage of labor has been historically divided into the latent phase and the active phase based on the work by Friedman in the 1950s and beyond. The latent phase of labor is defined as beginning with maternal perception of regular contractions 17. On the basis of the 95th percentile threshold, historically, the latent phase has been defined as prolonged when it exceeds 20 hours in nulliparous women and 14 hours in multiparous women 18. The active phase of labor has been defined as the point at which the rate of change of cervical dilation significantly increases.
Criteria of Normal Labor
Concept of 3 functional divisions of labor by Friedman
Preparatory division
latent & acceleration phases
sensitive to sedation & conduction analgesia
little cervical dilatation occurs, but considerable changes take
place in the ground substance of cervix
(collagen & other connective tissue component)
Dilatational division
phase of maximum slope of cervical dilatation
most rapid rate of dilatation occur
unaffected by sedation or conduction analgesia
Pelvic division
deceleration phase & second stage
cardinal fetal movements in the cephalic presentation take place
principally during this phase
Latent-phase Prolongation
Uterine dysunction can in turn lead to labor abnormalities (Table 23-2). First, the latent phase may be prolonged, which is dened as >20 hours in the nullipara and >14 hours in the multipara (Friedman, 1961, 1963b). In some, uterine contractions cease, suggesting false labor. In the remainder, an abnormally long latent phase persists and is often treated with amniotomy and oxytocin stimulation (Friedman, 1963a). The diagnosis of uterine dysunction in the latent phase is difficult and commonly is made retrospectively. Women who are not yet in active labor often are erroneously treated or perceived uterine dysunction.
Remains in the latent phase (Friedman: <4 cm, or Zhang: <6cm),
Phase
1-3cm Latent
Prerequisite before diagnosing ''failed induction of labor:"
There is an acceptable indication for induction (e.g., preeclampsia)
Bishop score should be ;,5 prior to induction with oxytocin (if score is ,;4,
then cervical ripening must be employed until a score of 5 is achieved)
Failed induction of labor, defined as:
•ruptured bag of waters with adequate uterine contractions (.e200 MVU), and at least 12 hours of oxytocin administration, OR
• Induction of labor with intact bag of waters due to difficult amniotomy or other safety issues (e.g., presence of Group B Streptococcus) with adequate contractions for a duration of 12-, 15-, 18-, or 24-hours, depending on the clinical judgement of the
clinician. There is no consensus as of this writing
4-5 cm early active phase
(Acceleration phase)
Active phase- cervical dilatation of 3 to 6 cm or
more, descent of fetal part in the presence of
uterine contractions.
Acceleration phase-a gradual increase in the rate of
dilation initiates the active phase and marks a change to
rapid dilation
Arrest disorders will not apply in this phase
phase
• In the presence of a protraction, reassess the 3 P's and manage
expectantly or augment with oxytocin if needed
acceleration
• If CS is decided, indicate the reason in the operative record (e.g.,
phase CPD, pelvimetry findings, fetal/maternal indications)
Active-phase Disorders In active labor, disorders are divided into those with slow progress—a protraction disorder or those with halted progress—an arrest disorder.
Disorders in the Active phase of labor is divided into 2: protraction & arrest D/O. PROTRACTION DO are slower-than-normal progress while ARREST DO are complete cessation of progress. For these disorders, a woman must be in the active phase of labor, which is defined by cervical change. ((Active phase dilation starts at 6cm.)) Protracted active phase dilation is defined as <1.2 cm/hr cervical dilation (nullipara) and <1.5 cm/hr (multipara) for a minimum of 4 hrs. For this disorder, observation or further progress is appropriate treatment.
If insufficient Montevideo units are noted, oxytocin augmentation is initiated. Cesarean delivery is indicated for CPD.
Protracted descent should be diagnosed in nulliparous labor when descent is proceeding at less than l cm/h and in multiparous labor when descent is proceeding at less than 2 cm/h.
Dilatational division
Dilatational division
phase of maximum slope of cervical dilatation
most rapid rate of dilatation occur
unaffected by sedation or conduction analgesia
☆6-7cm true active phase
Phase of maximum slope
• Active phase arrest is defined as cervix of .e6 cm with ruptured bag
of waters with no cervical dilatation for:
;,4 hours with adequate uterine contractions (.e200 MVU), OR
>6 hours with inadequate uterine contractions despite oxytocin
Arrest disorder as indication for CS will only apply at this phase
ARREST DO is labor with complete cessation of progress.
Prolonged deceleration phase is cervical dilatation arrested at 8 to 9 cm for >3 hrs in nulliparas and >1 hr in multiparas.
The deceleration phase is the third phase of active labor, after the phase of maximum slope. The onset of deceleration phase begins at 9 cm for nulliparous and multiparous labor. Active descent should start by the beginning of deceleration phase, although in many labors active descent begins earlier in active labor. Engagement that does not occur by the beginning of deceleration phase (i.e., 9 cm) in nulliparas and by the end of deceleration phase in multiparas is abnormal. Prolonged deceleration phase requires at least 3 hours for diagnosis in nulliparous labor and 1 hour for diagnosis in multiparous labor.
Secondary arrest of dilation is no change in cervical dilation for at least 2 hrs.
Failure of descent is diagnosed when fetal head remains at station “0” or above (-1 to -5) for >1 hr.
Arrest of descent is diagnosed when fetal head is at station +1 to +5 for >1 hr.
Similar to 1st-stage labor, time boundaries have been supported to limit second-stage duration to minimize adverse maternal and fetal outcomes. The second stage in nulliparas has been limited to 2 hours and extended to 3 hours when regional analgesia is used. For multiparas, 1 hour has been the limit, extended to 2 hours with regional analgesia
So let’s talk about the 3Ps
The causes of prolonged labor are abnormalities in any of these 3
We have the Power, Passenger and Passage
So 1st is the Power
So under the abnormalities of the expulsive forces.
We have Uterine contractility and exclusive powers
Cervical dilation and propulsion of the fetus are brought about by contractions of the uterus as well as the “pushing” of the mother during the second stage of labor. Lack of intensity of either of these two, uterine contractility and expulsive power may result in delayed or interrupted labor.
In regular labor, the contractions in the uterus happen in a specific way. They start off strong and last the longest at the top part of the uterus (called the fundus).thats is why it is called-- fundal dominance—
Thus, a uterus with good power should have fundal dominance.
So when the fundus contracts effectively it will push the fetus towards the birth canal and causes the cervix to dilate
And the lower limit of contraction pressure required to dilate the cervix is 15 mm Hg.
----------------------------
From these observations, it is possible to define two types of uterine dysfunction. (next slide)
(Adequate contraction is more than or equal to 200 montevideo units per 10 minutes for 2 hours. Montevideo units can be calculated by subtracting baseline uterine pressure from the peak contraction for each contraction in a 10 min window and adding the pressures generated by each contraction.)
In abnormal labor there are 2 types of uterine dysfunction ..
Hypotonic uterine dysfunction and the hypertonic uterine dysfunction.
In the hypotonic disorder, there is absence of basal tone hypertonous and the uterine contractions have normal gradient pattern with fundal dominance. The rise in pressure during contraction is insufficient to dilate the cervix. It is also the more common type between the two.
In the second type, hypertonic uterine dysfunction or incoordinate uterine dysfunction, either basal tone is elevated appreciably or the pressure gradient is distorted. Gradient distortion may result from more forceful contraction of the uterine midsegment than the fundus or from complete asynchrony of the impulses originating in each cornu or a combination of these two.
-------------------------
myometrial activity greatest and last longest at the fundus
60 mmHg – pressure exerted by normal spontaneous contractions
15 mmHg – lower limit of contraction pressure required to dilate the cervix
The maternal pushing efforts is the combined force created by contractions of the uterus and abdominal musculature propels
However, at times, force created by abdominal musculature is compromised sufficiently to slow or even prevent spontaneous vaginal delivery.
So the factors that affect maternal pushing includes
Heavy sedation or regional analgesia which reduce the reflex urge to push
And some intances the intense pain created by bearing down overrides urge to push
The second P is the passenger,
So this refere
Fetopelvic disproportion can also arise from large fetal head size or malposition of the head (includes asynclitism, occiput posterior position, face or brow presentation)
With Face presentation, this is rarely delivered vaginally ,
So we can see the head is hyperextended, and the occiput is in contact with the fetal back, and the chin (mentum) is presenting in the birth canal
The fetal brow (bregma) is pressed against the maternal symphysis pubis. this position precludes lexion of the fetal head necessary to negotiate the birth canal.
thus, a mentum posterior presentation is undeliverable except with a very preterm fetus.
The etiology of face presentation includes conditions that favor extension or prevent head flexion.
Examples are those Preterm fetuses, with their smaller head dimensions, can engage before conversion to vertex position.
Marked enlargement of the neck or coils of cord around the neck may cause extension.
Fetal malformations and hydramnios were risk factors for face or brow presentations.
Anencephalic fetuses (as shown on this picture) naturally present by the face.
And when the pelvis is contracted or the fetus is very large (which causes extended neck positions to develop more frequently)
Lastly , High parity --which is a predisposing factor for face presentation
How do we manage such cases?
Because face presentations among term-size fetuses - more common with some degree of pelvic inlet contraction, thus, cesarean delivery frequently is indicated.
And there are things ways we avoid to attempt:
Attempts to convert a face presentation manually into a vertex presentation, manual or forceps rotation of a persistently posterior chin to a mentum anterior position, and internal podalic version and extraction, these are dangerous and should not be attempted.
--------
(In the absence of a contracted pelvis and with effective labor, successful vaginal delivery usually will follow)..
Caution should be used with internal monitoring devices, which can cause ophthalmic injury or trauma to the forehead, mandible, or zygomatic areas. Midpelvic forceps, version with breech extraction, and manual manipulation are not recommended and increase the risk of maternal and neonatal morbidity. Neonatal outcomes for both face and brow presentations include facial edema, bruising, and soft tissue trauma. With appropriate management, neonatal and maternal morbidity is low. Vaginal delivery is more likely to be successful in small or preterm infants.
Another cause of Fetopelvic disproportion is Brow presentation
This is diagnosed when that portion of the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet.
The fetal head occupies a position midway between full felxion and extensioin
Engagement of the fetal head and subsequent delivery cannot take place as long as brow presentation persists. --- Except when the fetal head is small or pelvis is unusually large..
Next is breech presentation
Occurs when the breech or fetal buttock present into thematernal pelvis
Risk factors for breech presentation includes --- read--
Complications includes Perinatal morbidity/mortality- such as preterm delivery, birth trauma, congenital anomalies ,LBW - prematurity, IUGR
we have different typres of breech presentation.. 1st is the frank
---read----
So upon vaginal exam the usual findings are
For the management, it depends what type of breech presentation
For frank or complete breech -- we can do partial breech or complete breech extraction
In partial breech extraction, the healthcare provider delivers the baby's body down to the level of the baby's umbilicus (belly button) before stopping.
At this point, the provider allows the baby's head to remain inside the birth canal to keep the cervix from closing, allowing the baby's body to continue to be born slowly.
In complete breech extraction, the healthcare provider delivers the entire baby, including the head, in a single motion without pausing.
Complete breech extraction may be chosen when the baby is in a favorable position for delivery, and there are no signs of distress or complications.
We can do CS also with the following indications:
---read---
Delivery is indicated: meaning the patient is not in labor
-- footling breech--- so among the types of breech presentatio , the footling breech usuallyy is delivered via Cesarean section…
Another cause of fetopelvic disprportion is the transverse lie
In a transvere lie the long axis of the fetus is approximately perpendicular to that of the mother.
Shoulder is usually positioned over the pelvic inlet
Which Usually creates a shoulder presentation
Usually Spontaneous delivery of a fully developed newborn is impossible with this kind of presentation so , this is always deliered by cesarean section.
The common causes of Transvers lie include --
XX---------------
A relaxed abdomen allows uterus to fall forward deflecting the long axid of the fetus away from the axis of the birth canal into an oblique or transverse position..
Abnormal uterine anatomy- multiple myoma, especially if occupying the lower uterine segment
Then for diagnosis, we can do abdominal exam
So no fetal pole is detected at the fundus
The ballotable head is found in one iliac fossa and the breech in the other
Position of back is readily identifiable
When back is anterior, a hard resistance plane extends across front of abdomen
Then we can also vaginal exam where in we can palpatethe acromion and the hands
XXXX-------------------
When back is posterior, irregular nodule (small parts) are felt in abdominal wall
For the management
Usually transverse lie is an indication for cesarean delivery
XXX---------------
With cesarean delivery because neither the feet nor the head of the fetus occupies the lower uterine segment, Low transverse incision may lead to difficult extraction, that is why a Vertical or classical incision is usually indicated
Then last is the Compound presentation
In a compound presentation an extremity prolapses alongside the presenting part, and both present simultaneously in the pelvis
So in the picture we can see here we have a fetal hand that is prolapsing along side with the head of the fetus
Causes of compound presentations are conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm labor
So how do we manage these cases??
In most cases------
This finding is more common than inlet contraction. It frequently causes transverse arrest of the fetal head, which potentially can lead to a difficult midforceps operation or to cesarean delivery. The definition of midpelvic contractions has not been established with the same precision possible for inlet contractions. However, there is reason to suspect midpelvic contraction whenever the interspinous diameter is < 10 cm. When it measures < 8 cm, the midpelvis is contracted.
This finding is more common than inlet contraction. It frequently causes transverse arrest of the fetal head, which potentially can lead to a difficult midforceps operation or to cesarean delivery. The definition of midpelvic contractions has not been established with the same precision possible for inlet contractions. However, there is reason to suspect midpelvic contraction whenever the interspinous diameter is < 10 cm. When it measures < 8 cm, the midpelvis is contracted.
This neonate after vaginal birth shows significant caput succedaneum and elongated molding
