DYSTOCIA:

A CASE PRESENTATION
Objectives
1. To discuss the case of a G2P1 patient with a chief complaint of
labor pains with cephalopelvic disproportion.
2. To discuss the Friedmann’s curve
3. To discuss the normal labor
4. To discuss the abnormal labor (Dystocia)
General Data
SJ, 31 years old, Filipino
G2P1
Married
Roman Catholic
Cogon, San Jose St. Tagbilaran City
Employee
Chief Complaint
Labor Pains
Medical History
•(-) hypertension, (-) asthma, (-) diabetes
•No known drug allergies
•Allergic to crustaceans
•Previous surgical/hospitalization: Low Segment Transverse Cesarian
Section for CPD, Tagbilaran Maternity Hospital, 2016; S/P
Marsupialization, OPD, 2017
Family History
•Paternal side:
• Hypertension
• Thyroid disorder
• Arthritis

•Maternal side
• Hypertension
• Diabetes Mellitus
Personal and Social History
A college graduate
Teller at a money transfer establishment
Eats vegetables, a cup of rice and meat
5-6 glasses of water a day
Non-smoker, an occasional alcoholic drinker and a non-illicit drug
user.
Doesn’t engage in any kind of physical exercise
Menstrual History
Menarche: 11 years old
Interval: 28-32 days
Duration: 3-5 days
Amount: 2-3 pads per day, moderately soaked
Symptom: (+)dysmenorrhea
Menstrual History
LMP: January 9, 2018
PMP: 1ST week of December 2017
AOG: 39 weeks
EDD by LMP: October 16, 2018
EDD by UTZ: October 19, 2018
Sexual History
Coitarche: 18 years old
Partners: 3
Contraceptive use: condom
Sexually Transmitted Infection: none
Obstetric History
Year Place Term/Pre Mode of Weight Complications
Term Delivery

G1 2016 Tagbilaran Full term Cesarian 6.5 lbs/ No

Maternity (40 weeks) Section for 2.9 kg complications
Hospital cephalopelvic
disproportion
-----
G2 Present
Pregnancy
PRENATAL HISTORY
9 weeks AOG:

 first prenatal visit

Diagnostics:
Papsmear
Gram stain of cervicovaginal discharges
CBC, blood typing
Urinalysis
HBsAg, RPR
9 weeks AOG:

Medications:
Folic Acid 5mg 1 cap OD
Dydrogesterone 10mg 1 tab TID x 1 week
Milk 1 glass BID
LABORATORY RESULTS
>Gram staining: Gram+ bacilli moderate; (-)
intracellular diplococci
>Pap smear: Moniliasis with severe inflammation
-Treatment: Metronidazole + Miconazole nitrate
vaginal suppository once for 7 nights
>HBsAg: 0.000 (Non-reactive)
>Bloodtyping: AB Rh (D) positive
Urine Flow Cytometry
Red Cells 21.90 (0-11)
Pus cells 18.7 (0-17)
Epithelial cells 50. 0 (0-17)
Bacteria 32.3 (0-278)
Physical Properties
Color Yellow
Transparency Clear
Chemical Properties
pH 7.0
Specific gravity 1.010
Blood Neg
Leukocyte Trace
Glucose Neg
Nitrite Neg
Protein Neg
Urobilinogen Normal
Ketones Neg
Bilirubin Neg
WBC 8.3 x 10 ^9 /L
RBC 5.09 x 10 ^12/L
Hemoglobin 13.90 g/L
Hematocrit 42.4 %
MCV 83.3 fL
MCH 27.3 Pg
MCHC 32.8 g/dL
RDW-CV 13.1 %
Platelet count 284 x 10 ^9 /L
Differential Count
Neutrophil 72 %
Lymphocytes 21 %
Monocytes 4%
Eosinophil 2%
Basophil 1%
Total Differential 100 %
12 weeks AOG
Left Bartholin cyst
28 weeks AOG
OGTT results:
FBS: 102 mg/dL
1st hr: 166. 5 mg/dL
2nd hr: 153. 3 mg/dL
31 weeks AOG
OGTT results:
FBS: 94.4 mg/dL
1st hr: 186.6 mg/dL
2nd hr: 118. 2 mg/dL
Urine Flow Cytometry
Red Cells 0.9 (0-11)
WBC 24.3 (0-17)
Epithelial cells 37.6 (0-17)
31 weeks AOG
Bacteria 846.2 (0-278)
Physical Properties
Repeat
Color OGTT results Yellow
Transparency Slightly cloud
FBS: 94.4 mg/dL
Chemical Properties
pH 1st hr: 186.5 mg/dL 7.0
Specific gravity 1.020
Blood 2nd hr: 118.2 mg/dL Neg
Leukocyte Neg
Plan:
Glucose Neg
Nitrite
Referred to Dr. Cepedoza or Dr.NegCardino
Protein Neg
Repeat Urinalysis
Urobilinogen Normal
Ketones Neg
Bilirubin Neg
31 weeks
 4 units insulin TID before breakfast and after supper
Blood sugar monitoring 2 hours after BF
Urine Flow Cytometry
Red Cells 17.7 (0-11)
WBC 44.0 (0-17)
Epithelial cells 41.7 (0-17)
31 weeks AOG
Bacteria 1,247.1 (0-278)
Physical Properties
Repeat
Color OGTT results Yellow
Transparency Slightly cloud
FBS: 94.4 mg/dL
Chemical Properties
pH 1st hr: 186.5 mg/dL 7.0
Specific gravity 1.020
Blood 2nd hr: 118.2 mg/dL Moderate
Leukocyte Neg
Plan:
Glucose Neg
Nitrite
Referred to Dr. Cepedoza or Dr.NegCardino
Protein Neg
Repeat Urinalysis
Urobilinogen Normal
Ketones Neg
Bilirubin Neg
36-37 weeks AOG
Urinary Tract Infection
Medications:
Cefuroxime 500mg 1 cap BID x 7 days
History of Present Illness
16 hours PTA
The patient was due for a prenatal visit in a private clinic.
7 hours PTA
Gradual onset of intermittent, gnawing, 6/10 hypogastric pain
that radiates to the back with a 5-minute interval and is associated
with a bloody show.
History of Present Illness
1 hour PTA
persistence of symptoms prompted patient to seek medical
care.
•Patient is desirous of trial of labor, patient apprised of condition,
prognosis.
Physical Examination
awake, alert, coherent, oriented to time and place, afebrile, not in
respiratory distress

BP= 110/70 mmHg P = 89 bpm R= 20 cpm T = 36.5

HT = 150 cm WT = 52.9 kgs Ht = 150 cm BMI = 23
 Physical Examination
Skin: good skin turgor, warm to touch

HEENT: normocephalic, atraumatic, pinkish palpebral conjunctivae,

no eye, ear or nasal dishcarges, tonsils are not inflamed, no difficulty
swallowing

Neck: supple, no palpable lymph nodes

Breast: engorged, non-erythematous, no mass palpated, non-tender

Physical Examination
Chest and Lungs: Equal chest expansion, clear breath sounds

Heart: adynamic precordium, distinct heart sounds with normal rate

and regular rhythm, (-) murmurs
Physical Examination
Abdomen: Gravid, (+) diffuse brownish patches,
FH: 30 cm EFW: 2945 grams FHB: 145 bpm
L1: breech
L2: R – Fetal back; L – Fetal small parts
L3: cephalic
L4: engaged
 Physical Examination
GUT:
IE findings: 3 cm, slightly effaced, cephalic, station -3, intact bag of
water; (+) 2 x 2 cm nontender, fluctuant mass at 5 o’clock position labia
minora
Pelvimetry:
Sacral promontory easily reached
Extremities: (+) non-pitting edema on both legs, equally palpable
peripheral pulses, CRT <2s
Admitting Diagnosis
G2P1 (1001) PREGNANCY UTERINE 38 WEEKS AGE OF GESTATION
CEPHALIC, IN LATENT PHASE OF LABOR,
PREVIOUS LOW SEGMENT TRANSVERSE CESARIAN SECTION X 1 FOR
CEPHALOPELVIC DISPROPORTION (RELATIVE) (2016, MATERNITY)
GDM
BARTHOLIN CYST, LEFT
Patient was admitted with the following orders:
Diagnostics:
◦ CBC, U/A, HBsAG, Hba1c, blood typing
◦ Baseline CTG
Therapeutics:
◦ Hyoscine N-butylbromide 1 amp IVTT for 3 doses
◦ Evening Primrose oil capsule 6 caps q 6 hours
◦ Diabetic diet
CTG
Friedmann Curve
Pre-op diagnosis
G2P1 (1001) PREGNANCY UTERINE 38 1/7 AGE OF GESTATION,
CEPHALIC IN LABOR, PROLONGED DECELERATION PHASE WITH
FAILURE OF DESCENT SECONDARY TO CEPHALOPELVIC
DISPROPORTION;
FAILED TRIAL OF LABOR,
PREVIOUS LOW SEGMENT TRANSVERSE CESARIAN SECTION for
CEPHALOPELVIC DISPROPORTION
Operation performed
REPEAT LOW SEGMENT TRANSVERSE CESARIAN SECTION WITH
INSERTION OF INTRAUTERINE DEVICE
Post-op diagnosis
G2P2 (2002) PREGNANCY UTERINE, FULL TERM, LIVE BABY BOY
DELIVERED VIA LOW SEGMENT TRANSVERSE CESARIAN SECTION.
PREVIOUS LOW SEGMENT TRANSVERSE CESARIAN SECTION DUE TO
CEPHALOPELVIC DISPROPORTION (PELVIC INLET CONTRACTION)
Fetal outcome
Delivered cephalic a live baby boy, non-cord coil, non-meconium
stained, AS 8,9 BW 2850 grams, BL 51 cm, BS 39 weeks appropriate
for gestational age.
Post-op Day 1
>S (-) fever, (-) headache, (-) profuse bleeding, (-) flatus, (-) bowel
movement, used 2 sanitary pads moderately soaked

>O awake, conscious, coherent, not in respiratory distress:

VS: BP= 100/60 mmHg, T=36.5 C, P=94 bpm, R=20cpm
U/O: 350 mL
Post-op Day 1
HEENT: isocoric pupils, equally reactive to light and
accommodation, pinkish palpebral conjunctivae, anicteric
sclerae, no difficulty swallowing

Chest & Lungs: equal chest expansion, clear breath sounds, no

adventitious breath sounds
Breast: engorged, non-erythematous, no mass palpated, non-
tender
Abdomen: dry and clean post operative wound with no discharges,
NABS, soft, (+) tenderness at post-op site, well contracted uterus

GUT: Foley bag catheter in place

Extremities: non-pitting edema, equally palpable peripheral pulses,

CRT <2s
>A: S/P Low Segment Transverse Cesarian Section

>P:
1. Continue Antibiotics (Ampicillin-Sulbactam 1.5 grams IVTT) ANST
then 750 mg IVTT q 8
2. Celecoxib 200 mg/tan PRN
3. FeSO4 tab once a day
4. Encourage ambulation
5. Encourage breastfeeding
6. Change dressing
7. Monitor Vital Signs and refer accordingly
Post-op Day 2
>S (-) fever, (-) abdominal pain, (+) flatus, (-) bowel movement, used
2 sanitary pads, mildly soaked

>O: awake, conscious, coherent, not in respiratory distress

VS: BP= 110/70 mmHg, T=36.4 C, P=96 bpm, R=19 cpm
U/O: 320 mL
Post-op Day 2
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no eye, ear
or nasal discharges, tonsils are not inflamed, no difficulty swallowing.
Breast: engorged, non-erythematous, no mass palpated, non-tender
Chest & Lungs: equal chest expansion, clear breath sounds
Abdomen: dry and clean dressing site, NABS, soft, tender at post-op
site, well contracted uterus

GUT: Foley bag catheter in place

Extremities: non-pitting edema, equally palpable peripheral pulses,

CRT <2s
>A: S/P Low Segment Transverse Cesarian Section
>P:
1. Continue Antibiotics (Ampicillin-Sulbactam 750 mg IVTT) q8H
2. Daily wound dressing
3. Elevate both legs
4. Encourage breastfeeding
Post-op Day 3
>S (-) fever, (-) abdominal pain, (+) bowel movement, micturated
twice.

>O: awake, conscious, coherent, not in respiratory distress

VS: BP= 120/80 mmHg, T=36.5 C, P=92 bpm, R=20 cpm
Post-op Day 3
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no eye,
ear or nasal discharges, tonsils are not inflamed, no difficulty
swallowing.
Breast: engorged, non-erythematous, no mass palpated, non-
tender

Chest & Lungs: equal chest expansion, clear breath sounds

Abdomen: dry and clean dressing site, NABS, no tenderness upon
palpation, well contracted uterus

Extremities: non-pitting edema, equally palpable peripheral pulses,

CRT <2s
>A: S/P Low Segment Transverse Cesarian Section

>P:
-Continue medications
-Daily wound dressing
-May go home
CASE DISCUSSION
Dystocia
Friedmann Curve
 DYSTOCIA
“difficulty of labor”
Four distinct abnormalities:
◦ Expulsive forces
◦ Fetal abnormalities
◦ Maternal bony pelvis abnormalities
◦ Soft tissue abnormalities of the reproductive tract
Simplified into:
◦ Powers
◦ Passengers
◦ Passage
Active Phase disorders
Protraction disorder
◦ Slower than normal progress

Arrest disorder
◦ Complete cessation of progress
Second stage disorders
Disproportion of the fetus and pelvis becomes apparent during
second-stage of labor
Labor Pattern Nulliparas Multiparas Preferred Expectant

Prolongation Disorder

Prolonged Latent phase >20 >14 Bed Rest Oxytocin or cesarian

delivery

Protraction Disorders

Protracted active phase <1.2 cm/hour <1.5 cm/hr Expectant and Cesarian Delivery for
dilation support CPD

Protracted descent <1 cm/hr <2 cm/hr Expectant and Cesarian Delivery for
support CPD
Labor Pattern Nulliparas Multiparas Preferred Expectant

Arrest Disorders

Prolonged Deceleration >3 >1 Evaluate for CPD Rest if exhausted

Phase CPD: Cesarian Cesarian delivery
No CPD: Oxytocin
Secondary Arrest of >2 >2
Dilation

Arrest of Descent >1 >1 Evaluate for CPD Rest if exhausted

CPD: Cesarian Cesarian delivery
No CPD: Oxytocin

Failure of descent No descent in No descent in Evaluate for CPD Rest if exhausted

deceleration phase or deceleration CPD: Cesarian Cesarian delivery
second stage phase or second No CPD: Oxytocin
stage
Thank you!