Dystocia Flashcards
(182 cards)
1
Q
Most common indication for primary CS delivery
A
Dystocia
2
Q
Characterized by abnormally slow progress of labor
A
Dystocia
3
Q
What is TRUE LABOR?
A
There are regular uterine contractions with associated change in cervix effacement and dilation
4
Q
Hardest part of all stages of labor
A
Stage 2
5
Q
What is the first stage of labor?
A
From regular uterine contraction to full cervical dilation (10cm)
6
Q
What is the 4th stage of labor?
A
One hour after the 3rd stage, recovery
7
Q
What is the third stage of labor?
A
From delivery of the baby to placental expulsion
8
Q
2 phases of cervical dilation
A
Latent Phase and Active Phase
9
Q
Subdivisions of the Active phase of Cervical Dilation
A
Acceleration Phase
Phase of Maximum Slope
Deceleration Phase
10
Q
Start of the preparatory division of labor
A
Latent phase
11
Q
The latent phase commences with:
A
Maternal perception of regular uterine contraction
12
Q
The latent phase ends between ___________ cervical dilation
A
3 cm to 4 cm
13
Q
This phase determine the ultimate outcome of labor
A
Acceleration phase
14
Q
This phase is a good measure of overall efficiency of the uterus/machine (efficiency of uterine contraction)
A
Phase of Maximum Slope
15
Q
This phase reflects the feto-pelvic relationship
A
Deceleration phase
16
Q
The deceleration phase starts at _____ cm dilation
A
7-8cm
17
Q
What are the three functional divisions of labor?
A
Preparatory
Dilatational
Pelvic
18
Q
Which functional division of labor is sensitive to sedation and analgesia?
A
Preparatory
19
Q
The preparatory division of labor includes which phases of cervical dilation?
A
Latent and Acceleration Phase
20
Q
Which functional division of labor shows change in connective tissue components of the cervix (e.g., cervical softening)?
A
Preparatory division
21
Q
The Dilatational division of labor is in line with which subdivision of the active phase?
A
Phase of maximum slope
22
Q
Which of the three functional divisions of labor commences with the deceleration phase of cervical dilatation?
A
Pelvic division
23
Q
In which of the three functional divisions of labor the cardinal movements (ED-FIRE-ERE) occur?
A
Pelvic
24
Q
The cervical dilatation in the Friedman curve exhibits which shape?
A
Sigmoidal curve
25
The Fetal Head descent in the Friedman curve exhibits which shape?
Hyperbolic curve
26
Average rate of fetal head descent in Nulliparous women:
1 cm/hr
27
Average rate of fetal head descent in Multiparous women:
2 cm/hr
28
According to the WHO, the Latent phase should not last more than _____ hours
8 hours
29
What is the minimum hour delay in cervical dilation recommended for intervention as per the WHO partograph?
4 hours
30
Which of the following was developed for the purpose of improving labor management, "reducing maternal and perinatal morbidity and mortality" due to obstructed labor?
WHO partograph
31
Which set of the Modified WHO partograph (2006) focuses on the fetus?
2nd set
32
The 1st set of the Modified WHO partograph (2006) relates to the progress of which events during labor?
Cervical dilation
Descent of the fetal head
Uterine contractions
33
Which phase is not observed in the Modified WHO partograph (2006)?
Latent Phase
34
Which partograph presents the revolutionary steps towards individualized labor care?
WHO Next Generation Partograph (2021) or the
WHO Labour Care Guide (2021)
35
As per the WHO Labour Care Guide, the active phase stats from ____ cm of cervical dilatation
5 cm
36
Between the Modified WHO Partograph and WHO Labor Care Guide, which one records the strength, duration, and frequency of uterine contractions?
Modified WHO Partograph
The WHO Labour Care Guide records only the duration and frequency.
37
Which labor cares were added in the WHO Next Generation Partograph of 2021?
1. Second stage monitoring
2. Supportive care interventions (companionship, pain relief, oral fluid intake, and posture) recording
3. Requirement to respond to deviations from expected observations of any labor parameter
38
Zhang's labor pattern recommended that labor be allowed to continue for a longer period of time, before ___ cm dilatation, to reduce the rate of intrapartum and subsequent repeat CS
6 cm
39
Rate of cervical dilatation for Nulliparous women (Zhang)
0.5-0.7 cm/hr
40
What is the threshold for active labor according to Zhang?
6 cm
40
Rate of cervical dilatation for Multiparous women (Zhang)
0.5-1.3 cm/hr
40
The 2nd stage of labor lasts for ___ hours as per the 95th percentile for nulliparas WITHOUT epidural anesthesia.
2.8 hours
41
The 2nd stage of labor lasts for ___ hours as per the 95th percentile for nulliparas with epidural anesthesia.
3.6 hours
42
What is the purpose of the Friedman's curve?
To define the normal labor pattern
43
What is the purpose of Zhang's labor pattern?
To prevent premature caesarian section
44
What is the shape of the labor curve for WHO partograph (cervical dilation)?
Diagonal or straight lines
45
What is the shape for the Zhang labor pattern curve (cervical dilation)?
Exponential staircase line
46
The cervical dilation progression pattern as per Friedman is ____ cm/hr for nulliparas and ____ cm/hr for multiparas
Nulliparas 1.2 cm/hr cervical dilation
Multiparas 1.5 cm/hr cervical dilation
47
The action line of the WHO partograph is ___ hours from alert line
4 hours
48
Cervical dilation during the active labor as per the WHO partograph is ___ cm/hr
<1 cm/hr
49
Which labor pattern validity and usefulness historically governs the labor management?
Friedman's curve
50
What are the Maternal Effects of Dystocia
1. Intrapartum Infection
2. Postpartum hemorrhage from atony
3. Pathological retraction ring of Bandl
4. Uterine rupture
5. Fistula formation
6. Pelvic floor injury
mnemonic: PIPPUF
51
Fetal Effects of Dystocia
Caput succedaneum
Cephalohematoma
Molding
52
This fetal effect of dystocia results from mechanical trauma of the initial portion of the scalp of the baby pushing though a narrowed cervix in a prolonged or difficult delivery
Caput succedaneum
53
This fetal effect of dystocia results from the rupture of a periosteal capillary due to pressure of birth or instrumental delivery
Cephalohematoma
54
This fetal effect of dystocia manifests as swelling that extends across the midline and over suture lines
Caput succedaneum
55
This fetal effect of dystocia results to swelling of infant's head for 24 to 48 hours after birth, manifested as clear edges that end at the suture lines
cephalohematoma
56
Abnormal labor pattern manifested as slower rate of cervical dilation or descent
Prolongation or Protraction disorder
57
This type of abnormal labor pattern of fast delivery can result to intracranial hemorrhage and atony
Precipitate
58
How many percent of patients with prolonged or protracted disorders had cephalo-pelvic disproportion (CPD)?
30%
59
What is the criteria for prolonged latent phase for nulliparas and multiparas?
Nullipara: >20 hours
Multipara: >14 hours
60
What is the criteria for protracted active phase for nulliparas and multiparas?
clue: same cervical dilatation reference as to Friedman
Nullipara: <1.2 cm/hr
Multipara: <1.5 cm/hr
61
This pertains to arrested cervical dilatation at 8-9 cm beyond the normal duration
Prolonged deceleration
62
What is the criteria for prolonged deceleration for nulliparas and multiparas?
Nullipara: >3 hours
Multipara: >1 hour
63
How many percent of patients with arrest disorders have cephalo-pelvic disproportion?
45%
64
This is defined as prolonged latent phase
Prolongation disorder
65
Which of the following is not an etiology of prolongation disorder?
A. Excessive sedation
B. Unfavorable cervix
C. False labor
D. Uterine dysfunction
E. Absence of painful sensation
E. Absence of painful sensation
66
How many percent of patients with prolongation disorder had false labor?
10%
67
How many percent of patients with prolongation disorder had ineffective contraction and will benefit from oxytocin stimulation?
5%
68
A multipara at 15 hours of latent phase will benefit from which management according to POGS (2019)?
Observation, rest, and therapeutic analgesia or strong sedatives
69
The OCCC admonish against cesarian delivery in the latent phase of labor in the abscence of indications such as:
CPD
Fetal distress (e.g., abnormal FHR)
70
Abnormal labor pattern that occurs during the first stage of labor, characterized by slow progress of cervical dilatation
Protraction disorder
71
What is the criteria for protracted descent disorder for nulliparas and multiparas?
clue: same average rate of fetal head descent as to Friedman
Nullipara: < 1 cm/hr
Multipara: < 2 cm/hr
72
According to the POGS (2019), ______ shortens labor in protracted active phase by as much as 2 hours compared to expectant care.
Aminiotomy with early oxytocin augmentation
73
In the recommendations of POGS (2019) for protracted active phase, oxytocin should be used to achieve adequate contractions of ____ MVU vefore operative delivery is considered.
200 MVU
74
Arrest disorder occurs when cervical dilatation stops at ____ hours for both nulligravid and multigravid.
> 2 hours
75
Failure of descent is no change of descent from fetal station 0 or higher in the deceleration phase or the second stage of labor/ pelvic division of ____ hour
> 1 hour
76
This is noted when cervical dilation does not progress for more than 2 hours below the deceleration phase at the maximum slope
Secondary arrest of cervical dilation
76
This is noted when progressive descent abruptly stops during pelvic division (may be beyond station 0) for > 1 hour
Arrest of descent
77
The OCCC recommends CS delivery for active-phase arrest to be reserved for women at or beyond ____ cm of dilatation with ___________ who fail to progress despite ____ hours of adequate uterine activity.
CS delivery for active-phase arrest to be reserved for women at or beyond 6 cm of dilatation with ruptured membrane who fail to progress despite 4 hours of adequate uterine activity.
78
The OCCC recommends CS delivery for active-phase arrest to be reserved for women having at least _____ hours of oxytocin administration with inadequate contractions and no cervical change.
6 hours
78
Prolonged 2nd stage of labor when there is no progress for _____ hour/s in nulliparous and multiparous without regional anesthesia
Nulliparous > 2 hours
Multiparous > 1 hour
79
Prolonged 2nd stage of labor when there is no progress for _____ hour/s in nulliparous and multiparous WITH regional anesthesia
Nulliparous > 3 hours
Multiparous > 2 hours
80
Before 2nd stage labor arrest is diagnosed
→ Allow a nullipara to push for at least __ hours
→ Allow a multipara to push for at least __ hours
Before 2nd stage labor arrest is diagnosed
→ Allow a nullipara to push for at least 3 hours
→ Allow a multipara to push for at least 2 hours
81
Precipitate second stage of labor is delivery in _____ hours
Less than 3 hours
82
What are the etiologies of precipitate 2nd stage of labor?
1. Abnormal low resistance of soft parts of the birth canal
2. Abnormal strong uterine and abdominal contractions
3. Absence of painful sensations and thus lack of awareness of vigorous labor
83
What are the maternal effects of precipitate labor?
1. Uterine rupture and extensive lacerations due to vigorous uterine contractions combined with a long, firm cervix and non-compliant birth canal
2. Amniotic fluid embolism
3. Uterine atony and postpatum hemorrhage
84
What are the fetal and neonatal effects of precipitate labor?
1. Increased perinatal mortality and morbidity
2. Intracranial trauma
85
Which part has the greatest and longest myometrial activity?
Fundus
*Fundal dominance
85
What is the lower limit of contraction pressure required to dilate the cervix?
15 mmHg
86
Normal spontaneous contraction pressure
60 mmHg
87
Uterine activity where clinical labor starts
80-120 MVU
88
Types of uterine contraction dysfunction
Hypotonic
Hypertonic
89
This pertains to the increase in uterine pressure above the baseline tone in 10-minute period
Montevideo units
90
Pressure of adequate uterine contractions
200 MVU
91
Pertains to inadequate uterine contraction
< 180 MVU
92
Uterine dysfunction with NO basal hypertonus
Hypotonic uterus
93
TRUE or FALSE:
A hypotonic uterus has a synchronous uterine dysfunction
TRUE
94
What is the management for a Hypotonic uterus
Augmentation by Oxytocin
95
Preparation of oxytocin for hypotonic uterus
10 U oxytocin in 1L D5W
96
Appropriate infusion rate of Oxytocin
30-40 mL/min
97
Half-life of oxytocin
3 minutes
98
Cardiovascular side effects of oxytocin
1. Transient fall in BP with abrupt increase in CO
2. ECG changes in MI
3. Increase in mean pulse rate
99
The antidiuretic action of Oxytocin can cause:
water intoxication
100
Uterine dysfunction of increased in basal tone of approximately 25-40 baseline pressure
Hypertonic or incoordinate uterus
101
Pertains to a distorted uterine pressure gradient
Hypertonic uterus
102
Management of hypertonic uterus
Sedation
103
Uterine Activity is quantified as the number of contractions present in a ___-minute window, averages over ___ minutes
The number of contractions present in a 10-minute window, averaged over 30 minutes
104
Normal uterine activity
5 contractions or less in 10 minutes
105
Pertains to >5 uterine contractions in 10 minutes, qualified as to +/- of associated fetal heart rate decelerations
Uterine tachysystole
106
What are the specific abnormalities in the passenger that causes dystocia:
clue: Fat Baby Tiger Came Pouncing Squirrels
1. Face presentation
2. Brow Presentation
3. Transverse lie
4. Compound lie/presentation
5. Persistent Occiput Posterior
6. Shoulder Dystocia
107
Presenting part of Face presentation
chin or mentum
108
Presenting diameter for face presentation (give the normal)
Submento-bregmatic diameter of 9.5 cm
109
Which Face presentation position is an indication for CS?
Mentum posterior
* mentum anterior is possible for vaginal delivery but prolonged
110
Etiologies of face and brow presentation:
● Marked enlargement of the neck or coils of cords
● Anencephalic fetus (usual for face presentation)
● Contracted pelvis
● Very large fetus
● Pendulous abdomen
● High parity (relaxed abdominal muscles)
111
Recommendations for Face presentation
● CS is frequently indicated
● Continuous Electronic Fetal Monitoring
● Oxytocin if mentum anterior, adequate pelvis, and reassuring FHR
● Forceps for mentum anterior
112
Maneuver used to convert face to vertex presenation or rotating mentum posterior position to mentum anterior (NOT RECOMMENDED due to high perinatal morality)
Thom Maneuver
113
Presenting diameter for brow presentation (give normal)
vertico-mental diameter of 13.5 cm
114
Rarest presentation
Brow presentation
115
This presentation denotes an impossible engagement
Brow Presentation
116
POGS 2009 recommendation for Brow presentation
Expectant management for spontaneous conversion to vertex or face
117
Which interventions are contraindicated for Brow Presentation?
Forceps delivery and manual conversion
118
This is noted when shoulder of the fetus may be impacted firmly in the upper part of the pelvis
Neglected transverse lie
119
A gridiron feel on vaginal exam signifies which lie?
transverse lie
120
Which of the following is not a common etiology of transverse lie?
● Unusual relaxation of the abdominal wall
● Anencephaly
● Preterm fetus
● Placenta previa
● Abnormal uterus
● Polyhydramnios
Anencephaly = face or brow presentation
121
Pertains to fetus doubled/ folded upon itself
Conduplicato corpore
122
In doing CS for a transverse lie, ___________ is often indicated
Vertical hysterectomy
123
Abnormality in passenger when extremity prolapses alongside the presenting part and both present simultaneously in the pelvis
Compound lie
124
This is more likely to occur when the pelvis is not fully occupied by the fetus
Compound lie
125
During the course of labor of a passenger in compound lie, the prolapsed part should be:
left alone
126
What can be done if the prolapsed part fails to retract during compound lie labor?
the prolapsed arm should be pushed gently upward and the head simultanously downward by fundal pressure
127
TRUE or FALSE:
Oxytocin augmentation can be given in a patient with compound presentation
False because this may cause uterine rupture
128
This abnormal passenger presentation results to a severe painful labor
Persistent Occiput Posterior
129
The most common presentation indicating CS
Persistent Occiput Posterior
130
Shoulder dystocia is described as "anterior shoulder against _________"
Pubic symphysis
131
This abnormal passenger presentation is increased due to bigger babies common in obese, multiparous, and diabetic mothers
Shoulder dystocia
132
Sign of transient brachial plexus palsies common in shoulder dystocia
Waiter's Tip sign
133
Estimated fetal weight indicating CS for non-diabetic moms
> 4.5 kg
134
Estimated fetal weight indicating CS for diabetic moms
> 5 kg
135
This is the most frequently used maneuver for shoulder dystocia
Mazzanti maneuver or Modified Suprapubic Pressure
136
Surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis for shoulder dystocia
Symphysiotomy
137
In deliberate fracture of the clavicle, the thumb is used to press the clavicle against the _________.
pubic ramus
138
This is the cutting of the clavicle with scissors for the management of shoulder dystocia
Cleidotomy
139
Maneuver for shoulder dysplacia wherein the thighs and knees are sharply flexed up onto the abdomen while pressure is applied on the suprapubic area
McRobert's Meneuver
140
Maneuver for Shoulder Dystocia wherein pressure is applied to the anterior aspect of the posterior shoulder rotating it to the anterior position
Wood Corkscrew maneuver
141
Shoulder dystocia maneuver wherein the more easily accessible fetal shoulder is pushed toward the anterior chest of the fetus, abducting both shoulders, reducing the shoulder-to-shoulder diameter and freeing the impacted shoulder
Rubin Maneuver
142
Last resort maneuver typically indicated for dead baby, done by returning the head to the occiput anterior/posterior position by flexing the head and pushing it back into the vagina
Zavanelli Maneuver
143
Maneuver for Shoulder Dystocia wherein pressure is applied to the fetal jaw and nech in the direction of the maternal rectum, with strong fundal pressure applied as the anterior shoulder is freed
Hibbard maneuver
144
Gentle downward pressure to the posterior shoulder, the anterior shoulder may become more impacted but will facilitate the freeing up of the posterior shoulder
Gaskin Maneuver
145
ALARMER
Ask for help
Lift the leg
Anterior shoulder disimpaction
Rotation of the Posterior shoulder
Manual removal of the Posterior Shoulder
Episiotomy
Roll over into "all fours" position
146
Patients with poorly controlled DM is recommended to delivery at ____ AOG
37 weeks
146
Does labor induction prevent shoulder dystocia in non-diabetic mothers?
NO
147
Patients with well controlled GDM is recommended to delivery at ____ AOG
40 weeks
148
Does labor induction prevent shoulder in dystocia in patients with GDM/DM?
YES
149
CS may be considered in DM mothers with EFW of:
> 4 kg
150
Distance from the anterior lower border of the pubis to sacral promontory
Diagonal Conjugate
151
Normal DC
11.5 cm
152
The narrowest diameter of the pelvic inlet
Obstetric conjugate
153
Formula for OC
DC - 1.5
154
Normal OC
10 cm
155
Most important measurement in the pelvic inlet
Obstetric conjugate
156
Upper margin of pubis to sacral promontory
True or Anatomic Conjugate (TC or AC)
157
Formula for True Conjugate
DC - 1.2
158
Normal TC
11 cm
159
Feature of Contracted Pelvic Inlet
* Obstetric Conjugate (OC): <10cm
* Diagonal Conjugate: <11.5cm
160
Narrowest diameter of pelvic cavity
Interspinous diameter
161
Distance between the sacrum and a line created by the interspinous diameter
Post-sagittal diameter
162
The largest diameter in the pelvic cavity
Transverse diameter
163
The transverse diameter is the distance between the:
linea terminalis
164
Interspinous diameter that suggests contracted midpelvis
< 8 cm
(normal is 10.5cm)
165
Normal post-sagittal diameter of the midpelvis
4.5 cm
166
IS + PS that suggest contracted midpelvis
≤ 13.5 cm (normal is 15.5 cm)
167
3 anatomical features that suggest midpelvic contraction
→ Spines are prominent
→ Pelvic sidewalls converge
→ Narrow sacrosciatic notch
168
Anatomical Level or Landmark of the Pelvic Outlet
Ischial tuberosity
169
Anatomical Level or Landmark of the Pelvic Inlet
Symphysis pubis
170
Anatomical Level or Landmark of the Midpelvis
Ischial spine
171
Normal Interspinous diameter
10.5 cm
172
Narrowest distance of the Pelvic Outlet
Transverse diameter
173
The Transverse diameter is the distance between:
Inner edges of the ischial tuberosity
174
Inter-ischial tuberous diameter that indicates contraction:
< 8 cm (normal is 11.0 cm → Transverse diameter)
175
Management for Pelvic outlet contraction
Episiotomy
176
The pathological retraction ring of Bandl signify:
impending rupture of the lower uterine segment
