Cervical dystocia is a condition in which there is difficulty in labor due to the failure of cervical dilation within a reasonable time in spite of the presence of strong regular uterine contraction i.e. abnormalities in the uterine expulsive power.
Progressive cervical dilation need an effective stretching force by the presenting part .failure of cervical dilatation may be due to
- Inefficient uterine contraction
- Malpresentation malposion abnormal relationship between the cervix and the presenting part
- Spasm contraction of the cervix.
Cervical dystocia may be primary or secondary.
“Cervical dystocia is difficulty labor and delivery caused by mechanical obstruction at the cervix it is difficulty painful disorder abnormal birth”.
“Cervical dystocia is a condition in which there is difficulty in
labour due to the failure of the cervix to dilate within a reasonable time in spite of good regular uterine contraction.”
“Cervical dystocia is defined as the difficult labor and is
characterized by abnormal slow or no progress of labor.”
Over the last quarter of a century the cesarean section rate in
the united state has risen to approximately 25 of delivery done each year.
In the year 2010, this condition accounted for 19 000and 11000 deaths respectively.
ANATOMY AND PHYSIOLOGY
- The uterus is the part of the female reproductive system in which a body grows.
- The uterus is a hollow muscular pear shape organ flattened anterior-posterior.
- It lies in the pelvic cavity between the urinary bladder and the rectum.
- When the body is in the upright position the uterus lies in an almost horizontal position.
- It is about 7.5cm long 5cm wide and its wall is about 2.5cm thick
- It weighs from 30 40cm.
- The part of the uterus is fundus body cervix.
- THE FUNDUS -This is the dome shape part of the uterus about the opening of the uterine tubes.
- THE BODY -This is the main part .it is narrowest inferiorly at the internal os where it is continuous with the cervix.
- THE CERVIX-This protrudes through the anterior wall of the vagina opening into it at the external OS.
STRUCTURE OF THE UTERUS
The wall of the uterus is composed of three layers of tissue perimetrium myometrium mendometrium.
- Interiorly it extends over the fundus and the body where it is folded on to the upper surface of the urinary bladder .this fold of peritoneum forms the vesicouterine pouch.
- Posteriorly the peritoneum extends over the fundus of the body and the cervix then it continues on to the rectum to form the rectouterine pouch.
- Latterly only the fundus is covered because the peritoneum forms a double fold with the uterine tube in the upper free border.
- This double fold is the broad ligament which at its lateral ends attaches the uterus to the side of the pelvic.
- This is the thickest layer tissue in the uterine wall.
- It is the mass of smooth muscles fiber us interlayered with alveolar tissue blood vessels nerve.
- The consist of columnar epithelium containing a large number of the mucus-secreting tubular gland.
- It is divided functionally into two layers.
- The functional layer is the upper layer and its thickness and becomes rich in blood
- vessels in the first half of the menstruation cycles. It the ovum is not fertilized and not implants these layers shed during menstruation.
- The basal layer lies next to the myometrium and is not lost during menstruation.
The broad ligaments -These are the formed by a double fold of peritoneum one on each the side of the uterus.
The round ligament-These are bond of fibrous tissue between the two layers of broad ligament one on each side of the uterus.
The uterosacral ligament-This originated from the posterior wall of the cervix and vagina.
The transverse cervical ligament-These extend one from each side of the cervix and
the vagina of the side of the wall of the pelvis.
The pubocervical fascia -The extend forward from the transverse cervical ligaments on each side of the bladder and is attached to the posterior surface of the pubic bone.
FUNCTION OF UTERUS
- The uterus provides structural integrity and support to the bladder bowel pelvic bone and organ.
- The uterus is the organ in which developing fetus resides.
- Uterus accepts a fertilized ovum which passes through the uterotubal junction from the fallopian tube.
- Ovum is implanted into the endometrium and derives nourishment from blood vessels which develop exclusively for this purpose.
TYPES OF CERVICAL DYSTOCIA
Cervical dystocia is two types
- Primary cervical dystocia.
- Secondary cervical dystocia.
- The primary type of dystocia occurs predominantly during the first birth.
- The non-dilatation may be due to the presence of excessive fibrous tissue or spasm of circular muscles fibers surrounding the OS. Commonly observe during the.
- A first birth where the external os fails to dilate.
- Rigidity cervix.
- Inefficient uterine contraction and the other.
- Primary cervical dystocia is there for a condition in which the first stage of labour is complicated and protracted by an abnormal cervix in the presence of other causes of dystocia.
The secondary cervical dystocia results usually from the effect of scaring or rigidity of cervix from the effect of previous operation or disease.
- Post delivery.
- Cervical cancer.
CAUSES OF CERVICAL DYSTOCIA
- Abnormalities of the maternal bony pelvis or birth canal.
- Cervical cancer.
- Inefficient uterine contraction-: The uterine muscles may fail to contract properly when it is grossly distended as in cases of twin pregnancy and hydramnios [excess liquor amniI] presence of tumors like fibrous in the uterine musculature can also affect uterine contraction.
- Malpresentation-any change in this position can cause prolong in the duration in labour. a breech presentation in which the fetus is in the buttocks down position a face presentation in which the fetus face the mother abdomen or a deflexed position of the head in which the neck of the fetus is less flexed or even straight or extend can all causes prolonged labor
Due to etiological factors
Surrounding the external os presence of external fibers tissue
That leads to rigidity of cervix
Spite of presence of stormy regular uterine contraction
External os fails to dilate
Failure of dilation of cervix difficulty to labour
DIAGNOSIS OF CERVICAL DYSTOCIA
- The risk for infection related to cesarean section.
- Acute pain related to the descent of fetus.
- Anxiety related to impending delivery.
- The risk for trauma related to during performs the surgical procedure.
- knowledge deficiency related to asking question and answering.
- Prolong labor with severe and continuous pain.
- Evidence of dehydration and ketoacidosis.
- Fetal parts are not well defined.
- Fetal heart sound is not audible on auscultation.
- Fetal distress may develop.
- Pulse rate is often high due to dehydration exhaustion and stress.
- The large intestine is dilated and can be palpated along both sides of the uterus as large thick structure filled with air .they give off the hollow sound of drums on tapping.
History taking– To collect all data on the patient presence medical history and past medical history and any previous complication of the patient.
Physical examination-The pelvic examination focus on more than the determination of cervix dilation effacement and station. It provides an excellent opportunity to assess the patient pelvic and perform clinical pelvimetry
- Fetal presentation and position must be assessed.
- It is beneficial to know fetal position as early as possible in that fetal position can be a major contributor to dystocia.
Dystocia should not be diagnosed before the active phase of labor –
- In primigravida women– The cervix should be reached 3-4cm and 80-100 %effacement.
- In multigravida women– The cervix should have reached 4-5cm and 70-80%effacement.
- Heaving postpartum bleeding.
- Decrease brain oxygenation which can lead to brain damage.
- Rectal tearing.
- Nerve injury to the shoulder, arm, and hand that typically resolves within 6-12 month.
- Personal hygiene– To advise the patient to maintain the proper personal hygiene.
- Diet –To advice the client for intake the proper diet.
- Rest and sleep –To advice the patient for proper rest and sleep maintenance.
- Medication– For advice, the client forgives the administration of medication for physician order.
- Follow up -To advice the client for the check up the follow of the hospital for physician order.
The cervical dystocia if the uterine activity is unco-coordinated or contracting short or infrequent then labour will be difficult and prolonged. To discuss the introduction, definition, types, incidence, and anatomy and physiology, causes, and management.
At the end of my article on topic cervical dystocia in delivery management especially attention should be directed to primiparous women and multipurpose women with no previous vaginal delivery. Women give EAD especially at cervical dilatation =5cm are also of particular interest fourth or more rigors routine for ld diagnosis and Oxytocin ox augmentation are important.