CERVICAL DYSTOCIA

INTRODUCTION
DYSTOCIA

 Difficult labor
 Slow labor progess
In cervical dystocia ,the cervix fails to dilate during labour. Failure of cervical
dialation can be to previous cone biopsy or cauterization for cervical dysplasia.
Other reason for failure to dilate include truma . sometimes ,if there are unco-
ordinated uterine contractions then the failure of cervical dilation may be
secondary to this and this should respond to oxytocin if dystocia continues
despite this then the infant will need to be delivered by caesarean section .

DEFINITION

 ACCORDING TO WILLIAM C.SHIEL

1) Failure of the cervix to dilate within a reasonable time in spite of good
regular uterine contractions
OR.
2) Cervical dystocia is a condition where the external OS fails to dilate in spite
of the normal behavior of the uterine contractions and where all other causes
of dystocia are excluded
OR

3) Cervical dystocia is a difficult labor and delivery caused by mechanical

obstruction at the cervix .dystocia comes from the greek word “dys’ meaning
‘Difficlt, painfull disordered ,abnormal’+’tokos’meaning ‘birth’

INCIDENCE
• Overall incidence varies between 53 times (16.7% related to the total
number of births) .this kind o f birth disorder is regularly followed by a
caesarean section (p <0.001).
 TYPES OF CERVICAL DYSTOCIA

1. PRIMARY CERVICAL DYSTOCIA (FUNCTIONAL)-=

 In spite of the absence of any organic lesion and the well
effacement of the cervix ,the external OS fails to dilate.
 This may be due to lack of softening of the cervix during
pregnancy or cervical spasm resulted from overactive
sympathetic tone

2..SECONDARY CERVICAL DYSTOCIA (ORGANIC) –

 Cervical stances as a sequel to previous amputation ,cone

biopsy,extensive cauterization or obstetric trauma.
 Organic lesions as cervical myoma or carcinoma

CAUSES OF CERVICAL DYSTOCIA

 MATERNAL CAUSES
 Cephalo pelvic disproportion
 Injudicious of oxytocin
 Uterine inrtia
 Small pelvic size
 Failure of cervical dilation
 Uterine torsion

 FETAL CAUSES
 Large sized fetal (macrosomia)
 Congenital anomalies;-
-Fetal ascites
-Hydrocephalus
 -Fetal tumors
 RISK FACTORS

a)MATERNAL RISK

• Abnormal anatomy of pelvis

• Maternal age
• Short maternal height
• Overweight
• Obesity
• Smoking
• Prolonged labour
• Labour dystocia

b)FETAL RISK

• Age of the mother ,height, weight before and during pregnancy

• Body mass index of the mother
• Weight gain during pregnancy
• Fundal height
• Bith weight and foot length of the mother

SIGN AND SYMPTOMS OF SHOULDER

DYSTOCIA

 SIGN

• Prolonged labour
• Small size of uterus
• Small size of pelvis

 SYMPTOMS

• Heavy severe pain due to uterine contractions

• Dry and oedematous vagina
 • Mother becomes tired and restless due to continue pain and discomfort
• Features of maternal ketoacidosis
• Abdominal palpation
-fetal part may be not well defined
-fhs usually absent
MANAGEMENT

 MEDICAL MANAGEMENT

 PHARMACOLOGICAL MANAGEMENT

1) HYPERCONTRACTLITY – Induce by oxytocins can be managed tocolytics

(Terbutaline 0.5 mg subcutaneous ,and salbutamol 2 mg orally gien )
2) Oxytocin infusion 5 IU in 500 ML solution ,2to 8 drops in 1to 4 minutes
3) CAESAREAN SECTION – Caesarean section is done in majority of the
cases specially when obstruction is suspected.

 NON-PHARMACOLOGICAL MANAGEMENT

• To provide immediate newborn care and maternal care or KMC care after
child birth.
• To check vital signs immediately both mother and newborn.
• To assess newborn condition. .
• To check if any palsy present in newborn.
• To check cervical condition of the baby .
• To check level of cervical dystocia.
• RESPIRATORY EXERCISE – To guide the patient about breathing
exercise ,as the uterine contractions began ,to inhale and exhale ,breathing
through the mouth slowly.
• Muscle relaxation :- teached the patient about muscle relaxaing exercise
,instruct the patient for loosing her arms and legs until the contractions
stopped.
 (these exercise used were 6 cm ,8 cm and 9 cm of cervical dilation in the
active phase of labour, from the beginning of the uterine contraction until its
relaxation.)

 SURGICAL MANAGEMENT

 CAESAREAN SECTION :-
Caesarean section also known as C-Section or Caesarean delivery, is the use of
surgery to deliver babies.A caesarean section is often necessary when a vaginal
delivery would put the baby or mother at risk. A caesarean delivery may be
performed based upon the shape of the mothers pelvis or history of previous c-
section.A trial of vaginal delivery after saesarean section possible.

“An operative procedure to deliver a viable foetus or more

(e.g. after 28 weeks or 20 weeks according to the ACOG) through an
abdominal and uterine incision.)

INCIDENCE :- In 2000 of year 14.5% and 2006 of year 22.7% of incidence

included.
 INDICATION :-

 Cephalo-pelvic disproportion
 Fetal mal presentation
 Previous caesarean section
 Fetal distress
 Placenta praevia
 Abruption placentae ( with live fetus)
 Dystocia
 Cord prolapse
 Multiparity

 CONTRAINDICATION –

There is no absolute contraindications ,but caesarean section is better to

be avoided in cases of fetal demise,major anomalies incompatible with
life,and in severe maternal disease as coagulopathy.

 TYPES OF CAESAREAN SECTION

 ACCORDING TO TIMING
 Elective caesarean section
 Selective caesarean section
 ACCORDING TO THE SITE OF UTERINE INCISION
 Upper segment caesarean section
 Lower segment caesarean section
 ACCORDING TO NUMBER OF OPERATION
 Primary caesarean section
 Repeated caesarean section
 ACCORDING TO OPENING OF THE PERITNEAL CAVITY
 Trans-peritoneal
 Extra-peritoneal

 Pre operative care of the patient :-

• Explain procedure to the mother

• Follow general principles of basic care and infection prevention
 • To check vital signs and FHR before surgery
• To instruct the patient for empty bladder before caesarean section .
• To take consent before surgery for caesarean section .
• Injection ranitidine 50 mg IV half to one hour before the surgery
• Injection metoclopramide 10 mg IV half to one hour before surgery
• Bladder should be catheterized
• Fetal presentation,position and FHS should be checked .

 Procedure of lower segment caesarean section

ANAESTHESIA – General inhalation anaesthesia with nitrous oxide +

oxygen (The most commonly used),epidural ,spinal or rarely local infiltration
anaesthesia .
POSITION- tilting the patient 150 to the left in the dorsal position minimize
the aorto-caval compression.
A).

 The loose peritoneum on the lower segment is cut transversely

 A short incision is made in the midline down to the membrane
 The incision of the lower segment is being enlarged using index finger of both
hand

B)

 Sagittal section showing insinuation of the fingers between the lower

uterine flap and the fetal head until the posterior surface is reached
 Methods of delivery of the head
 Placenta is being delivered.
C)

 Inserting the continuous suture taking deeper muscles excluding the

deciduas
 Similar method of continuous suture taking superficial muscles and facia down
to the first layer of suture
 Continuous peritoneal catgut suture
 POST-OPERATIVE CARE
 Palpate the uterine fundus
-Location
-Consistency
 Encourage early breath feeding
 Oral fluids after 24 hours
 Discharge from hospital after 96 hours
 Stitch removal on 7th post operative day
 To avoid exertion for 4-6 weeks
 Contraceptive advice

 HEALTH EDUCATION OF THE MOTHER IF BABY BORN

WITH SHOULDER DYSTOCIA
 To give emotional and psychological support of the patient.

 To educate the patient about chances of postpartum hemorrhage after baby

birth
  To educate the patient if any complication

 To educate the patient about personal hygiene and newborn care.

 To educate the patient foe avoid hard work after delivery of the baby with
caesarean section for prevent injury

 To advice the patient for intake healthy diet and liquid diet for better
improvement of health status .

 To teach about effective breast techniques of the mother .

 To advice the patient for perform postnatal exercises if possible..

 To advice the patient for intake plenty of water for maintain electrolyte
balance

 SUMMARY
 Cervical dystocia cannot be reliably predicted in the antenatal period
 Clinical estimation of macrosomia is as accurate as ultrasound .
 No consistent patterns of labor or delivery reliably predict cervical
dystocia
 Caesarean section is recommended

 PROGNOSIS

In many cases cervical dystocia is not completely preventable permanently in

vaginal delivery but after performance of caesarean section 50% chances of
prevents cervical dystocia and newborn death.

 NURSING MANAGEMENT:

1. Fluid electrolyte imbalance related to excessive loss of body fluid and blood
loss from the body  

2. Risk for maternal and fetal injury related to prolonged labor due to cervical
dystocia  
3. Ineffective airway clearance related to obstrution in respiratory tract and
muconium aspiration  

4. Altered  body temperature related to intrauterine to extrauterine environment

5. Risk for infection related to surgical procedure

6. Impaired mother and child bonding related to situational crisis and

ineffective breast feeding techniques

7. Anxiety related to death of fetus

8. Activity intolerance related to cervical dystocia of the baby

9. Ineffective individual coping related to inadequate support system

10.Risk for infection related to surgical procedure

 Nursing Care Plan
Assessment
Subjective Data Objective Data Nursing Diagnosis Goal
My patient is says I observe that patient is Electrolyte imbalance To maintain
that she is suffering suffering from related to loss of blood Normal
from very weakness dehydration and she feels and excessive fluid Electrolytic
in her body and very weak in her r body from body balance in
dehydration Patient body

Planning Nursing Intervention Expected Outcome

1To.. provide 1.Provided comfortable 1.Patient feels good after
comfortable position of position of the patient provide comfortable
the patient. position.
2..To check vital signs of 2.Checked vital signs of the 2.Altered vital signs after
the patient. patient. checked due to electrolyte
 3 .To check fluid level in 3.Checked fluid volume in imbalance.
patient body. patient body. 3.Altered fluid volume in
4. To record intake and 4..Recorded intake and output patient body before
output of the patient. of the patient. nursing care plans
5. To check body weight 5.Checked body weight of the implementation.
of the patient. patient. 4. Less intake of oral
6. To provide IV fluids 6.Provided iv fluids e.g.-rl 500 fluids according to body
for maintenance of ml ,d-10% for maintain requirement
electrolyte imbalance in electrolyte imbalance . 5. patient is able to
patient body. 7..Provided all prescribed maintain her body weight
7. To provide all medications of the patient. after implementation of
prescribed medicines of nursing care plan
the patient. 6. patient is able to
maintain her nor body
fluid volume and
electrolyte imbalance
after provide IV fluid
therapy
7. Patient feels better than
their previous condition
after medication .

Nursing Care Plan

Assessment
Subjective Data Objective Data Nursing Diagnosis Goal
My patient is says I observe that patient is Risk for maternal and To reduce risk of
that she s worried Worried about self and fetal injury related to maternal and
about fetal and self fetal injury due to prolonged labor due to fetal injury
injury due to prolonged labour cervical dystocia of the
prolonged labor baby

Planning Nursing Intervention Expected Outcome

1. To provide 1provided comfortable 1 Patient feels better after
comfortable position of the patient during provide comfortable
position of the labour position
patient during 2. Checked vital signs of the
labor patient and FHR of the fetus 2.Normal vital signs of
2. To check vital 4.called for help when baby the mother and normal
signs of patient born with cervical dystocia FHR of the fetus
and FHR of the 5. provided newborn care 4.present specialized
fetus immediately and special care gynaecologist and nursing
when baby born with cervical staff
3. To call for help if dystocia 5. baby condition is better
baby born with after provide newborn
cervical dystocia 6.checked maternal and fetal care and KMC care
 4. To provide injury 6.minor injury occurs in
immediate 7.Provided treatment of the mother and baby due to
newborn care and mother and baby according to cervical dystocia
special care of the injury 7. condition of mother
baby born with and baby is better than
cervical dystocia their previous condition
after provide treatment
5. To check maternal
and fetal injury

6. To provide
treatment of
injured part

Nursing Care Plan

Assessment
Subjective Data Objective Data Nursing Diagnosis Goal
My patients I observe that Ineffective airway
mother is says condition of baby clearance related to To maintain
that her baby not and I see baby muconium aspiration airway
breath properly having breathing and prolonged labor clearance and
difficulty normal
breathing
pattern of the
baby
 Expected
Planning Nursing Intervention
Outcome
1. To provide 1.Provided comfortable 1.Patient feels better
comfortable position of the baby after provide
position of the 2.Checked vital signs of the comfortable position
baby baby 2.altered vital signs of
2. To check vital 3.Checked breathing pattern the baby
signs of the baby 3.ineffective breathing
immediately 4.Checked oxygen level in pattern of the baby
of the baby patient body 4.oxygen level is low in
3. To check 5. Checked respiratory tract patient body
breathing and obstruction present in 5. obstruction present in
pattern of the respiratory tract respitroy tract
baby 6.Provided oxygen therapy 6. baby is able to
4. To check as body requirement maintain oxygen level
oxygen level 7.Performed suction for and normal vital signs in
in patient body clear present obstruction their body after provide
5. To check oxygen therapy
repiratory tract 7.clear all obstruction
and present present respitory tract
obstruction after suction of the baby
6. To provide
oxygen
therapy if
needed
 7. To perform
suction
immediately
for clear
present
obstruction

Assessment
Nursing Diagnosis Goal
Subjective Data Objective Data
My patient I observe that babys Altered body To prevet from
mother is says skin is very hot and temperature related hypothermia of
that her childs hyperthermia is to intrauterine to the baby
body temperature present extra-uterine
is not normal environment
and very hot skin
of baby
 Expected
Planning Nursing Intervention
Outcome
1.To provide 1 provided comfortable 1.Baby is feels better
comfortable position of position of the baby after provide
the baby 2.Checked vital signs of the comfortable position
2. To check vital signs of baby 2. Altered vital signs
the baby 3 Checked body temperature 3.body temperature is
3. To check body of the baby not normal and baby
temperature of the baby 4..Provided KMC care having hyperthermia
4..To provide KMC care immediately 4..babys condition is
immediately 5.Provided adjustable and better than their previous
5/ To provide adjustable cooperative environment of condition after provide
and cooperative the baby KMC care
environment of the baby 6.Provided sponge bath of 5.body temperature is
6.To provide sponge the baby maintain in minor level
bath of the baby 7..Provided antipyretics after provide cooperative
7.To provide antipyretics medication as prescribed by environment
medication as prescribed doctor 6 Baby id able to
by doctor maintain body
temperature after sponge
bath
7.Normal vital signs and
body temperature after
provide antipyretics of
the baby
 Assessment
Subjective Data Objective Data Nursing Diagnosis Goal
My patient mother I observe that mother Impaired mother and To maintain
is says that her and baby bonding is not child bonding related to mother and child
bonding is impaired good situational crisis and bonding and
with her her baby lack of knowledge improve breast
related to breast feeding feeding
techniques tachniques

Expected
Planning Nursing Intervention
Outcome
1To provide comfortable 1 Provided comfortable 1..Mother and child both
position of the mother position of the mother and are feels better after
and baby child provide comfortable
2.To provide immediate 2. provided immediate KMC position
KMC care care 2..mother is able to
3..To assess mother and 3..Assessed mother and child maintain good bonding
child bonding bonding with her baby after
4..to teach about child 4..Teached the mother about provide KMC care
care of the mother child/newborn care 3..Good mother and
5 To assess breast 5..Assessed breast feeding child bonding
feeding techniques techniques of the mother After implementation of
6 ..To teach the mother 6.. Teached the mother about the nursing care plans
about techniques of effective breast feeding 4..Mother is able to take
breast feeding techniques care of her child/baby
5..Ineffective breast
feeding techniques used
by mother
6.. mother is able t
To perform effective
breast feeding
techniques after teaching
and maintain strong
bond with her baby

BIBLIOGRAPHY
(A) G. Gabbe Steven, obstetrics normal & problem pregnancies, 3rd addition, library of
congress cataloging, new York, 490-494

(B)Kumari Neelam Shivanisharma,Text Book of Midwifery and Gynaecological

Nursing,Edition- 1st 2016,Jalandhar,S.Vikas And Company,306-308

(C) Datta D.C.,Textbook of Obstetric ,Hiralal Kumar ,Perinatology and contruption

Edition- 7th Medical publishers delhi ,2011,360-363

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