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1、 ABNORMALLABORORDYSTOCIADefintion：Dystocia is defined as difficult labor.It may beassociatedwithvariousabnormalitiesthatpreventordeviatefromthenormalcourseoflaboranddelivery.Itistheconsequenceoffourdistinctabnormalitiesthatmay exist singly or combination: the power, passagepassengerandthepsyche.Caus
2、eofdystociaPowerPassagePassengPsycheDiagnosis:prolonged courses of labor.Lack ofprogressivecervicaldilatationandfetusdescending. prolongedlatentphase16h。 prolongedactivephase8hCervicaldilation:PrimigravidaPrimigravida1.2cm/h，Multiparaultipara1.5cm/h。Clinicalfindinganddiagnosis ProtractedactivephaseT
3、hecervicaldilationstopfor2hoursinactivephase。 ProlongedsecondstageThe second stage last more than 2 hours forprimigravidaormorethan1hourformultiparaprimigravidaormorethan1hourformultipara。Prolongeddescent:therateoffetusdescendingindecelerationphaseandthesecondstageoflaborlessthan1.0cm/h(primigravida
4、primigravida)，or2.0cm/h(multiparamultipara)。Protracteddescent:fetusdescendingindecelerationphasestopformorethan1h。Prolongedlabor:thetotalstagelastmorethan24h。TreatmentofdystociaAntepartum：RegularlyprenatalcareDuringlabor：Symptoms:abnormalprogressoflabororarrest.Preparatorydivision:ruleoutfalselabor。
5、Dilatationdivision:ruleoutcephalopelvicdisproportion.Pelvicdivision: ruleout abnormal fetalpresentationandposition.Pregnantwomencondition.Arrestedfetalheaddescending.Prolongedcervicaldilation.Dysfunctionofuterine.Prematureruptureofmembrane.Abnormaloffetus.PayattentiontoetiologyManagementofvaginaldel
6、ivery：Evaluation of uterine contraction,fetal size andposition,pelvic size, fetopelvic disproportion ornot.Prolongedlatentstage：Sedationmaycauseabsenceofuterinecontractioninfalselabor。Prolongedactivestage：Observetheprogressoflabor、expulsiveforce、fetalheartrate、fetalpositionfor24h,whenruleoutthefetop
7、elvicdisproportion.Prolongedsecondstageoflabor：Thefirst,performvaginalexaminationtoruleoutfetopelvic disproportion , correct the abnormalfetal position,then can improve the uterinecontractionbyoxytocine.Ceasreansection posteriorasynelitism、Anteriorasynelitism)、Browpresentation; Generalpelviccontract
8、 Fetalmacrosomia; Shoulderpresentation,Feetpresentation; Pathologiccontractingring;pelviccontractFetalmacrosomia uterineinertiaAbnormalfetalposition Fetaldistress Threateneduterinerupture ruputre member or ruputre member or oxytocine oxytocine unsuccess progress unsuccess progress Persistentocciputp
9、osteriorposition,ordeeptransversearrest Cesareansection Assistedvaginaldelivery rotate to LOA or RoA rotate to LOA or RoA VaginaldeliveryAbnormaluterineactionThe rhythm, symmetry, polarity and retraction ofuterinecontractionbecomeabnormal.Include：uterinehypocontractilityuterinehypercontractilityAbno
10、rmalities of the powers Uterine dysfunctionUterine dysfunction coordianted coordianted hypocontractility hypocontractility Uterine Uterine Uncoordinated Uncoordinated Dysfunction Dysfunction coordianted coordianted hypercontractility hypercontractility uncoordinated uncoordinatedEtiologyofuterineact
11、ion ：CephalopelvicdisproportionorfetalmalpositionPsychologicalfactorsAbnormaluterusEndocrinaldysfunctionOthersClinicalmanifestation1.Hypotonicuterineaction(coordianted)Havenormalrhythm、symmetryandpolarity,Buttheintensityislow,including:primaryandsecondaryhypotonicuterineaction.2、Hypotonicuterineacti
12、on(uncoordianted)lossthenormalrhythm、symmetryandpolarity.theintensityintheperiodsofrelaxationbetweencontractionsbecomelarger.Thepregnantwomenwillfellpersistingpain. EffectonmaternalandfetusmaternalFatigueAcidosisInfectionPostpartumhemorrhageCesareansectionrateincreasingfetusBirthinjurydistressProlap
13、seofumbilicalcordStillbirthManagemant1 . Coordinated dysfunctionVaginalexaminationtoruleoutCephalopelvicdisproportionorfetalmalposition；Evaluatefetusandmaternalcomplexion.Oxytocininfusion:InthefirststageoflaborRelax,TakegoodcareImprovethecontractionRupturethemembraneOxytocinstimulationoflabor:fromlo
14、wdose.Narcoticagentsuchasmorphinesulfateisgivenindoseslarge enough to arrest uterine contractions and providefrom6-12hoursofrest;InsecondstageoflaborThereisnocephalopelvicdisproportion：improvetheexpulsiveforceFetaldistress:finishthelaborinshortesttime；Cephalopelvicdisproportion：cesareansectionInthir
15、dstageoflabor：preventionofpostpartumhemorrhageUncoordinateddysfunction：Sedationisgenerallyeffectiveinconvertinguncoordinatedcontractiontonormallaborpatterns.Hypertonicdysfunction(coordinated)ManifestationanddiagnosisThe contraction have normal rhythm 、symmetryandpolarity,buttheintensityistoostrong.P
16、recipitatedelivery:Thetotalstageislessthan3hourswhentheratesofcervical dilation is more than 5cm/h, the cervicaldilationof10cmandexpulsionoffetusoccursinshorttime.HypertonicofuncoordinatedcontractionConstrictionringofuterusCharacteristic:Localsmoothmuscleinuterusspasmodiclycontracttoformcircularcont
17、raction.Theringislocatedatjuncturebetweenloweruterinesegmentandcorpusuteri.Tetaniccontractionofuterus:LossofrhythmnThe titanic contraction of uterus persistcontracting and dont relax, always appearwhenoxytocinbemisused.EffectonmaternalandfetusPrecipitatedeliverySoftbirthcanaltraumaRuptureofuterusFet
18、aldistressFetaldeathstillbirthPreventionismaindoctrine; Useoxytocin,clysis,artificialruptureofmembranecarefully; Aspirationoxygen,prohibituterinecontractionMagnesiumsulfate,pethidine; Fetaldistress,pathologicretractionring-Cesarean。ManagementAbnormalpassageCausesofabnormalitiesofpassageincludebonyab
19、normalities(pelvicdystocia),softtissueobstructionofthebirthcanal.Pelvicdystocia,particularlythatduetosmallbonyarchitecture,isthemostcommoncauseofpassageabnormalities.Pelvic contractionTypeofPelvic: femalemaleandropoidpelvisplatypelloidpelvisinletoutletcavityfemalemaleContractedpelvicinletplatypelloi
20、discomonThe platypelloid pelvis is characterized by atransversediameterthatiswidewithrespecttotheanteroposteriordiameter.SimpleflatpelvisRachiticflatpelvisMidpelviscontractionMidpelviscontractionisdefinedasvalueslessthan10cmforthe interspinous diameter, always occurs in android pelvisandanthropoidpe
21、lvis.ContractedpelvicoutletPelvicoutletcontractionisdefinedasvalueslessthan8cmfortheintertuberousdiameterandthesumoftheintertuberousandposteriorsagittaldiameterlessthan15cm.alwaysoccursinandroidpelvis GenerallycontractedpelvicEachpelvicplaneis2cmlessthannormalvalueormore,which is called generally co
22、ntracted pelvic and can beseeninshapemoreshortandsmall,well-balancedwomenoftypeoffigure.PelvicmalformationThepelviclossthenormalshapeandsymmetry.Contracted pelvic inlet Clinical manifestation Abnormalpresentationandlieposition.Lack of progressive cervical dilatation and fetusdescending:prolongedlate
23、ntphaseandactivephase.Prematureruptureofmembraneandumbilicalcordprolapse.MidpelviscontractionClinicalmanifestation:AbnormalpositionPersistent occiput posterior position,or deep transversearrestProlongedsecondstageForcepincreasingForceps deliveryContractedpelvicoutletClinicalmanifestation: Secondary
24、hypotonic uterine action andprotractedsecondstageoflabor. Thefetalbiparietaldiametercantpassthepelvicoutlet.Managementofpelvicbonycontraction: Consideringtypeofpelvic,power,fetuspositionandfetaldistress.ContractedpelvicinletExternal conjugate 16.5 17.5cm、 anteroposteriordiameter8.59.5cm.Externalconj
25、ugate16.0cm、anteroposteriordiameter8.0cm、CesareaSectionMidpelviscontractiontreatment VaginalexaminationtoruleoutCephalopelvicdisproportionorfetalmalposition； Enhanceuterinecontractility:oxytocin VaginaldeliveryorCesareansectionPelvicoutletTreatment Cesareansectionisthefirstchoice. Whenasumoftheinter
26、tuberousdiameterandtheposteriorsagittaldiametergreaterthan15cm,thefetalheadmaypassthebirthcanalusingtheposteriortriangle. .Abnormalfetalpositionpersistentocciputposteriorposition、persistentocciputtransversepositionDefinition：Duringtheprocessofdelivery,thefetal head in occiput posterior(transverse)po
27、sition engages in the pelvic inlet, aftervigorousuterinecontraction,theocciputpersistlocatingontheposterior(transverse)portionofmaternalpelvic,whichmayresultindystocia.persistentocciputposteriorposition、persistentocciputtransverseposition persistentocciputposteriorposition、persistentocciputtransvers
28、epositionLOPROPLOTROTVaginal examinationDiagnosisofAbnormalfetalpositionClinicalmanifestation：Engageslaterattheonsetoflabor； Secondaryhypotonicuterineaction； Usetheabdominalpressurebeforethecervixdontdilateto10cm； Fetalheaddescendslowly；TreatmentInthefirststageoflabor：Ruleoutcephalopelvicdisproporti
29、on；Observethebirthprocessseriously；Improveuterinecontraction；Inthesecondstageoflabor：thevaginalexaminationshouldbecarriedoutandmakeadecisionofdeliverystyle:vaginaldelivery,assisteddelivery,cesareansection.S Sincipitalpresentationoccipitopubicposition;occipitosacralposition;DiagnosisClinical manifest
30、ation：prolonged active stage of labor ,persistingpainoftheloweruterinesegment.palpation：cephalopelvicdisproportion.Vaginalexamination： thebregmaticfontalelleandlambdoidsutureareequallyprominent.ManagmentOccipitopubic position:expectant management for shorttime.Occipitosacralposition：cesareansection.
31、AnteriorasynelitismClinicalfinding:Diagnosis:Clinical manifestation：fetal descending protracted；dysuria；palpation：falsesignsoffetalengagement；Vaginalexamination：Management:cesareansectionshouldbeperformed.Includeing:Completebreechpresentation.Frankbreechpresentation.Incompletebreechpresentationkneeo
32、rfootlingpresentationBreechpresentationBreechpresentationIncompletebreechpresentationFrankbreechpresentationIncompletebreechpresentation Classify of breech presentationDiagnosis:Symptoms：Thepregnantwomenfeelthehard,roundfetalheadbelowthecosta.Uterineinertia,slowdilationofcervixoccur,prematurerupture
33、ofmembranewilloccurs,whichcauseprolongedstage.Palpationandballottement：ManagementAntepartum：If breech presentation persistsbeyond 30 weeks, some rectification methodshouldbeconsidered:genucubitalposition,externalcephalicversion.Duringlabor：Deliverystyleshouldbedeterminedaccording to maternal age, fe
34、tal size, fetalmalformationornot,dilationdegreeofcervix,pregnantcomplicationornot.ExtractionofbreechItshouldperformcesareansectionwhen:vcontractedpelvic,abnormalsoftbirthcanal,vestimatedfetalweightof3500gormore,vfetaldistress,vprematureruptureofmembrane,vprolapseofthecord,pregnancycomplications,veld
35、lyprimiparity,vdystociahistory,vincompletebreechpresentation,etc.Assisted breech delivery：As the umbilicusappears at the maternal perineum, the operator places afinger medial to one thigh and then the other, pressinglaterallyasthefetalpelvicisrotatedawayfromthesidebyanassistant.Extractionofbreech：Th
36、edeliveryofinfantisassistedcompletelybymidwife.thisoperationisharmfultofetus,soitisforbiddeningeneral.ShoulderpresentationShoulderpresentationoccurswhenthelongaxisofthefetusisapproximatelyperpendiculartothatof the usually over the pelvic inlet,with the headlyinginoneiliacfossaandthebreechintheother.
