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Fetal Dystocia

By Julie S. Moldenhauer, MD, Associate Professor of Clinical Obstetrics and Gynecology in Surgery, The Garbose Family Special Delivery Unit; Attending Physician, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia; The University of Pennsylvania Perelman School of Medicine

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Fetal dystocia is abnormal fetal size or position resulting in difficult delivery. Diagnosis is by examination, ultrasonography, or response to augmentation of labor. Treatment is with physical maneuvers to reposition the fetus, operative vaginal delivery, or cesarean delivery.

Fetal dystocia may occur when the fetus is too large for the pelvic opening (fetopelvic disproportion) or is abnormally positioned (eg, breech presentation). Normal fetal presentation is vertex, with the occiput anterior.

Fetopelvic disproportion

Diagnosis is suggested by prenatal clinical estimates of pelvic dimensions, ultrasonography, and protracted labor.

If augmentation of labor restores normal progress and fetal weight is < 5000 g in women without diabetes or < 4500 g in women with diabetes, labor can safely continue.

If progress is slower than expected in the 2nd stage of labor, women are evaluated to determine whether operative vaginal delivery (by forceps or vacuum extractor) is safe and appropriate.

Occiput posterior presentation

The most common abnormal presentation is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Many occiput posterior presentations require operative vaginal delivery or cesarean delivery.

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Breech presentation

The 2nd most common abnormal presentation is breech (buttocks before the head). There are several types:

  • Frank breech: The fetal hips are flexed, and the knees extended (pike position).

  • Complete breech: The fetus seems to be sitting with hips and knees flexed.

  • Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Breech presentation is a problem primarily because the presenting part is a poor dilating wedge, which can cause the head, which follows, to be trapped during delivery, often compressing the umbilical cord.

Umbilical cord compression may cause fetal hypoxemia. The fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries.

Predisposing factors for breech presentation include

  • Preterm labor

  • Uterine abnormalities

  • Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

  • Birth trauma

  • Dystocia

  • Perinatal death

Preventing complications is more effective and easier than treating them, so abnormal presentation must be identified before delivery. Cesarean delivery is usually done at 39 wk or when the woman presents in labor, although external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 wk. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic (terbutaline 0.25 mg sc) may help some women. The success rate is about 50 to 75%.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Shoulder-first presentation requires cesarean delivery unless the fetus is a 2nd twin.

Shoulder dystocia

In this infrequent condition, presentation is vertex, but the anterior fetal shoulder becomes lodged behind the symphysis pubis after delivery of the fetal head, preventing vaginal delivery. Shoulder dystocia is recognized when the fetal head is delivered onto the perineum but appears to be pulled back tightly against the perineum (turtle sign).

Risk factors include a large fetus, maternal obesity, diabetes mellitus, prior shoulder dystocia, operative vaginal delivery, rapid labor, and prolonged labor. Risk of neonatal morbidity (eg, brachial plexus injury, bone fractures) and mortality is increased.

Once shoulder dystocia is recognized, extra personnel are summoned to the room, and various maneuvers are tried sequentially to disengage the anterior shoulder:

  • The woman’s thighs are hyperflexed to widen the pelvic outlet (McRoberts maneuver), and suprapubic pressure is applied to rotate and dislodge the anterior shoulder. Fundal pressure is avoided because it may worsen the condition or cause uterine rupture.

  • The obstetrician inserts a hand into the posterior vagina and presses the posterior shoulder to rotate the fetus in whichever direction is easier (Wood screw maneuver).

  • The obstetrician inserts a hand, flexes the posterior elbow, and sweeps the arm and hand across the fetal chest to deliver the infant’s entire posterior arm.

These maneuvers increase risk of fracture of the humerus or clavicle. Sometimes the clavicle is intentionally fractured in a direction away from fetal lung to disengage the shoulder. An episiotomy can be done at any time to facilitate the maneuvers.

If all maneuvers are ineffective, the obstetrician flexes the infant’s head and reverses the cardinal movements of labor, replacing the fetal head back into the vagina or uterus; the infant is then delivered by cesarean (Zavanelli maneuver).

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