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PubMed1994

The contribution of dystocia to the cesarean section rate.

OBJECTIVE: Our purpose was to examine the indications for performing cesarean sections in current obstetric practice and to define and measure the true contribution of dystocia ("difficult labor") to the overall cesarean section rate. STUDY DESIGN: A prospective audit was done of all cesarean sections performed during 1991 at The Queen Mother's Hospital, Glasgow, a teaching hospital and tertiary referral center. RESULTS: The cesarean section rate for 1991 was 16.3%. Dystocia was the primary indication in 16% of all cesarean sections in 1991 but was actually a contributing factor, directly or indirectly, in the decision to operate in up to 38% of all cesarean sections that year. Seventy-eight percent of patients delivered because of dystocia were in spontaneous labor. We advocate more widespread use of a policy of active management in nulliparous women who labor spontaneously. If dystocia is addressed successfully, then many repeat cesarean sections may also be avoided. CONCLUSIONS: Improved management of dystocia in nulliparous women, such as the use of a policy of active management of labor, may be the most useful approach to reducing the cesarean section rate in modern obstetric practice.

Breech Presentation↗
PubMed2001

Dystocia: a study of its frequency and risk factors in seven cities of west Africa.

OBJECTIVES: To determine the incidence of dystocia in seven west African cities, to attempt to discover what, if any, factors at the prenatal visit might identify women at risk of dystocia, and to assess the utility of such screening. METHOD: This prospective population study of 20326 pregnant women in west Africa (MOMA) analyzed risk factors for dystocia on the basis of deliveries in health care facilities. RESULTS: Incidence of dystocia was 18.3%. In the multivariate analysis, the risk factors were small stature, previous cesarean, and nulliparity. As screening tools these factors have inadequate positive predictive values, either singly or combined. CONCLUSION: It is almost impossible to predict the occurrence of dystocia before the onset of labor. Therefore, labor must be carefully monitored, and there must be health care facilities available that can manage complications, especially cesarean deliveries. If such facilities are not accessible, an effective referral system must be established.

Africa, Western↗
PubMed1996

Perinatal outcome and the type and number of maneuvers in shoulder dystocia.

OBJECTIVES: To ascertain the type and order of maneuvers that should be used for the treatment of shoulder dystocia, and to determine its correlation with perinatal outcome. METHODS: We reviewed all consecutive cases of shoulder dystocia from January 1986 to August 1994 in our institution to obtain the type, order and number of maneuvers used for delivery. Patients were stratified by the number of maneuvers required for delivery. Outcome parameters included cord pH, Apgar score, neonatal trauma (Erb's palsy and fracture), and maternal trauma. RESULTS: The incidence of shoulder dystocia was 0.7% (39,280 total vaginal deliveries). Use of only two maneuvers, McRoberts and suprapubic pressure, resulted in resolution in 58% of cases. The addition of the Woods screw maneuver and/or delivery of the posterior arm was sufficient in all remaining cases. The rates of neonatal palsy and fracture, and maternal four-degree laceration, increased with the number of maneuvers. CONCLUSIONS: The McRoberts maneuver and suprapubic pressure should be first-line treatment for shoulder dystocia. More difficult and damaging maneuvers such as Woods screw and delivery of the posterior arm may be reserved for refractory cases. Additional maneuvers are rarely necessary for delivery. The number of maneuvers may serve as a measure of the severity of the shoulder dystocia.

Adult↗
PubMed2000

Relationship between intra-uterine bacterial contamination, endotoxin levels and the development of endometritis in postpartum cows with dystocia or retained placenta.

A study was conducted to investigate the relationship between intra-uterine bacterial contamination, endotoxin levels and the development of endometritis in cows that experienced a dystocia or retained their placenta. Fifteen healthy cows, 31 cows with retained placenta (RP) and 13 cows that had dystocia were clinically examined 1 or 2 days after parturition when a uterine swab for bacteriological examination was taken. In addition, plasma and uterine lochia samples were collected to determine lipopolysaccharide (LPS) and the plasma IgG anti-LPS concentrations. Subsequently, 15 RP and 6 dystocia cows were initially left untreated and another uterine swab was collected at 2 and 4 wk postpartum. Immediately after calving, RP cows had significantly higher LPS levels in uterine lochia (average of 2.24 x 10(4) Endotoxin Units (EU)/mL) as compared to dystocia and healthy postpartum cows (average of 0.10 and 0.26 EU/mL, respectively). However, plasma LPS levels were below the detection limit (<0.036 EU/mL platelet-rich plasma) in all groups of cows. IgG anti-LPS levels in plasma were not significantly different between the 3 groups immediately postpartum (average of 26, 16 and 44 Median Units (MU)/mL) for healthy, dystocia and RP cows, respectively), but they were significantly lower when compared to plasma IgG anti-LPS levels of healthy cows at more than 2 months postpartum (mean 83 MU/mL). High LPS levels in lochia at 1 or 2 days postpartum were significantly related to abnormal cervical discharge, the presence of Escherichia coli, black pigmented gram-negative anaerobes and Clostridium spp. shortly after calving, and Arcanobacterium pyogenes and gram-negative anaerobes in the uterus at 14 days postpartum. These results suggest that the presence of E. coli and LPS (endotoxins) in lochia early postpartum favor the development of uterine infections by A. pyogenes and gram-negative anaerobes later postpartum. LPS were not observed in plasma, suggesting that either they are not absorbed into the blood, or they are efficiently detoxified by IgG anti-LPS or other detoxification mechanisms.

Animals↗
PubMed2004

[Trial of labor in moderate pelvic dystocia at Dakar University Teaching Hospital].

OBJECTIVE: To study frequency of moderate pelvic dystocia, to evaluate the diagnosis value of clinical pelvic evaluation and prognosis of trial labor with only clinical monitoring. MATERIAL AND METHOD: This is a prospective, exposed and non-exposed study concerning 296 women selected among deliveries presenting moderate pelvic dystocia recorded at Dakar University Teaching Hospital from February 1st 2001 to July 31 2002. Trial labor was undertaken in 148 patients; the control group was chosen among women who underwent prophylactic caesarean section and had no other risk factors of maternal and perinatal complications. Pearson's chi-square test was used or statistic analysis with p value 5% and test of Kappa. RESULTS: Moderate pelvic dystocia was observed 5.3 per 100 deliveries. The most common epidemiological profile was primipara, young age (mean 24 years), height 161 cm (mean), 38-week pregnancy (mean). Clinical evaluation had good diagnosis value comparable with the radiological pelvimetry. Trial labor was undertaken in 148 women, 109 trials (73.6%) were successful; vaginal delivery rate was 27% in women with moderate pelvic dystocia. There were no maternal deaths, maternal morbidity was 4% in trial labor patients and 2.7% in prophylactic caesarean section patents (mainly infection). Post-natal mortality was 7.4% after trial of labour versus 4.1% of newborn child after prophylactic caesarean. CONCLUSION: These results confirm that trial of labor on moderate pelvic dystocia should be the rule whenever possible, even when only clinical monitoring is available.

Adult↗
PubMed1998

Does epidural analgesia cause dystocia?

STUDY OBJECTIVE: To analyze the effects of epidural analgesia for labor when dystocia occurs. DESIGN: Retrospective cohort study. SETTING: Academic health center. PATIENTS: 641 low risk, nulliparous women in spontaneous labor. INTERVENTIONS: 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. MEASUREMENTS AND MAIN RESULTS: Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1. 9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0. 9 to 4.8) were associated with dystocia. CONCLUSION: Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.

Adult↗
PubMed2006

What factors are associated with neonatal injury following shoulder dystocia?

OBJECTIVE: To identify factors associated with the development of neonatal injury in the setting of shoulder dystocia. STUDY DESIGN: Medical record ICD-9 codes and a computerized perinatal database were reviewed to identify cases of shoulder dystocia from January 1996 to January 2001 in a tertiary care center. For confirmation of the diagnosis and collection of data, both maternal and neonatal charts were then reviewed and neonatal injuries categorized as either neurological (brachial plexus injury) or skeletal (clavicular fracture, humeral fracture). Shoulder dystocia cases were divided into groups based on the presence of neonatal injury at delivery or at discharge (with or without Erb's palsy). The group with neonatal injury was compared for demographic and obstetrical factors to the group without injury (control). chi (2) test, Mann-Whitney test and logistic regression were used as appropriate. RESULTS: During this 5-year period, there were 25,995 deliveries and 206 (0.8%) confirmed cases of shoulder dystocia. Of these cases, 36 (17.5%) had neonatal injury diagnosed at delivery and 25 (12%) remained with significant residual injury at discharge. Of these there were 19 cases of Erb's palsy and six cases of clavicular fracture. No association was found between neonatal injury and maternal age, ethnicity, diabetes, operative vaginal delivery or number of obstetrical maneuvers. However, maternal body mass index >30 kg/m2, a second stage of labor >20 min and a birth weight >4500 g were all associated with an increased risk of neonatal injury at delivery and at discharge, including Erb's palsy. After logistic regression analysis, only a second stage of delivery >20 min remained significantly associated with neonatal injury at discharge. CONCLUSION: In our population, maternal obesity was associated with an increased risk of neonatal injury after shoulder dystocia. In addition, a short second stage of labor (<20 min) was associated with a lower rate of neonatal injury.

Adult↗
PubMed1991

Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas.

A retrospective study assessing the effect of epidural analgesia in labor on the incidence of cesarean section was performed. The first 500 consecutive nulliparas meeting the following criteria were included in this study: term (37 weeks or longer) and singleton gestation, cephalic presentation, spontaneous onset of labor, and 5 cm or less of cervical dilation on admission. Patients were grouped according to their rate of cervical dilation in early labor (greater than or equal to 1 cm/hr, and less than 1 cm/hr) and the timing of epidural placement (none, early, or late). There was no effect of epidural analgesia on the incidence of cesarean section for fetal distress. The incidence of cesarean section for dystocia was significantly greater (p greater than 0.000001) in the epidural group (15.6%) than in the nonepidural group (2.4%). The greatest effect of epidural analgesia on the incidence of cesarean section for dystocia was observed in nulliparas who dilated at slower rates (less than 1 cm/hr) in early labor and who had epidural analgesia placed at 5 cm or less of cervical dilation (20.6% versus 3.4%, relative risk of 6, p less than 0.0005). The increase of cesarean section for dystocia associated with epidural analgesia could not be accounted for when other possibly confounding variables were studied. Both the dilation rate prior to epidural placement and the cervical dilation at epidural placement were significantly correlated to frequency of cesarean section for dystocia (p less than 0.01). This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparas.

Adolescent↗
PubMed2006

A scoring system for detection of macrosomia and prediction of shoulder dystocia: a disappointment.

OBJECTIVE: To develop a scoring system for the detection of a macrosomic fetus (birth weight (BW) >or= 4000 g) and predict shoulder dystocia among large for gestational age fetuses. STUDY DESIGN: We retrospectively identified all singletons with accurate gestational age (GA) that were large for GA (abdominal circumference (AC) or estimated fetal weight (EFW) >or= 90% for GA) at >or=37 weeks with delivery within three weeks. The scoring system was: 2 points for biparietal diameter, head circumference, AC, or femur length >or=90% for GA, or if the amniotic fluid index (AFI) was >or=24 cm; for biometric parameters <90% or with AFI <24 cm, 0 points. The predictive values for detection of shoulder dystocia were calculated. RESULTS: Of the 225 cohorts that met the inclusion criteria the rate of macrosomia was 39% and among vaginal deliveries (n = 120) shoulder dystocia occurred in 12% (15/120; 95% confidence interval (CI) 7-20%). The sensitivity of EFW >or=4500 g to identify a newborn with shoulder dystocia was 0% (95% CI 0-21%), positive predictive values 0% (95% CI 0-46%), and likelihood ratio of 0. For a macrosomia score >6, the corresponding values were 20% (4-48%), 25% (5-57%) and 2.3. CONCLUSION: Though the scoring system can identify macrosomia, it offers no advantage over EFW. The scoring system and EFW are poor predictors of shoulder dystocia.

Dystocia↗
PubMed1999

No mutations found in candidate genes for dystocia.

Dystocia is a disorder characterized by prolonged or dysfunctional labour. Delivery that starts late or not at all, leads to an increased risk for Caesarean section, infant morbidity and mortality. Familial aggregations of dystocia suggest a polygenic background. We have studied three candidate genes for dystocia, i.e. the genes for testosterone 5-alpha reductase type 1, prostaglandin F2alpha receptor and endothelin 1 and performed mutational screening in 23 women with dystocia, of which 12 have affected relatives. No mutations were found, making it unlikely that any of these genes represent a major cause of dystocia in man.

3-Oxo-5-alpha-Steroid 4-Dehydrogenase↗
PubMed1980

Comparison in the same environment of calving problems in heifers from herds with a history of a low and high incidence of dystocias.

The incidence of dystocias and the calving performance of primiparous Hereford heifers from 2 herds, one with a low (A) and the other a high (B) dystocia history, were compared when all animals were run on the same property in southern Queensland. The dystocia incidence was 21.4% for Herd A heifers and 40.5% for Herd B heifers (P approximately equal to 0.10). While Herd A heifers had significantly (P < 0.05) heavier calves than Herd B heifers (29.1 v 27.7 kg), the ratio of calf birth weight to dam pelvic brim area was 0.11 kg/cm2 for both groups. Differences in the size of the maternal pelvis, calf oversize and the type of presentation recorded for assisted births did not satisfactorily explain the difference in the incidence of dystocias. The circumstantial evidence indicated that inherent factors may affect dystocia.

Animals↗
PubMed1995

Feline dystocia: prevalence, and association with cranial conformation and breed.

The litter prevalence of feline dystocia was investigated using a questionnaire survey of cat breeders. Information was obtained on 2928 litters, from 735 queens. Dystocia was reported to have occurred in 5.8 per cent of litters. The level of dystocia in individual breeds ranged from 0.4 per cent of litters born in a large colony of cats of mixed breeding, to 18.2 per cent of litters in the Devon rex. Pedigree litters were at significantly higher risk than litters of cats of mixed breeding (odds ratio: 22.6). Relatively high levels of dystocia were identified in Siamese-type, Persian and Devon rex litters, whereas cats of mixed breeding showed a relatively low litter prevalence. Dolicocephalic and brachycephalic types were found to have significantly higher levels of dystocia than mesocephalic cats.

Animals↗
PubMed1998

Antepartum risks of shoulder dystocia and brachial plexus injury for infants weighing 4,200 g or more.

A cohort of 236 vaginally delivered neonates weighing > or = 4,200 g was evaluated. Shoulder dystocia was encountered in 27 deliveries (11.4%) and brachial plexus injury was diagnosed in 3 infants (1.3%). The 'traditional' antepartum risk factors could not be associated with shoulder dystocia. In this cohort, primiparity was significantly more frequent among the dystocia cases (OR = 8.58, 99% CI = 1.35-54.35, p = 0.021). Shoulder dystocia could not be attributed to a particular difference between the current and the previous heaviest birth weight. A policy of cesarean section for all infants weighing > or = 4,200 g would result in at least 5- to 6-fold increase in cesarean rate in this group of patients. Our data reconfirm that shoulder dystocia and brachial plexus injury are unpredictable, even in macrosomic infants. It is a matter of policy whether to accept the expected 1:9 and 1:79 respective risks associated with vaginal births.

Adult↗
PubMed1996

Factors affecting dystocia in Brahman-cross heifers in subtropical southeastern United States.

This study was conducted to determine relative relationships among factors affecting dystocia in Brahman-cross heifers. Body and pelvic measurements were obtained in mid-June (when heifers were approximately 17 mo old), 45 d after a 60-d breeding season. Heifers studied were 207 Red Brangus, 209 Simbrah, and 250 Braford bred to Black Angus bulls; calving began on December 1. Heifers grazed stockpiled bahia and hemarthria grass or ryegrass supplemented with 0.9 kg of 32% protein cottonseed meal and 1.8 kg of mill-run black strap molasses daily during calving. Calvings were scored (1 = no difficulty to 4 = major difficulty). A random sample of birth weights were obtained on 131 and 210 calves in 1992 and 1993. Data were analyzed within year by SAS procedures. Breed differences in dam size and pelvic measurements were highly significant. Residual correlations between body weight and pelvic area were .20 and .35 (both P < .01) for 1991 and 1992. Dystocia incidence was 6.9% in 1992 and 10.5% in 1993, with higher incidence in males than in females (1992, 10.6 vs 3.1%, P = .08; 1993, 15.6 vs 4.2%, P < .01, male vs female, respectively). Male birth weight exceeded (P < .01) that of females (26.7 vs 24.3 kg, 1992; 28.1 vs 26.1 kg, 1993). Correlations among dam size and calf birth weight were not significant. Birth weight was significantly correlated with dystocia score (.19 and .49, 1992 and 1993). Path analyses of influences on dystocia found birth weight, dam heart girth, and body weight significant in 1992, but only birth weight significant in 1993. Regression of calving score on birth weight was curvilinear and significant in both years, with the birth weight inflection point at 22 kg. We conclude that dam body size data obtained following the breeding season were of minor value in determining dystocia, but birth weight was consistently important.

Animals↗
PubMed1985

Discriminant analysis for predicting dystocia in beef cattle. II. Derivation and validation of a prebreeding prediction model.

Discriminant analysis was utilized to derive and validate a model for predicting dystocia using only data available at the beginning of the breeding season. Data were collected from 211 Chianina crossbred cows (2 to 6 yr old) bred to Chianina bulls. A proportionally stratified sampling procedure divided females into an analysis sample (n = 134) on which the model was derived and a hold-out sample (n = 77) on which the prediction model was validated (tested). Variables available during the derivation stage were cow age, cow weight, pelvic height, pelvic width, pelvic area and calf sire. Dystocia was categorized as either unassisted or assisted. Occurrence of dystocia was 17.2 and 18.2% in the analysis and hold-out samples, respectively. All data were standardized to a mean of zero and a variance of one before statistical analysis. The centroid of cows experiencing dystocia differed (P less than .01) from that of cows calving unassisted in the analysis sample. Significant variables were pelvic area and cow age (standardized coefficients = .56 and .51, respectively). This model correctly classified 85.1% of the cows in the analysis sample. This was 13.5% greater than the proportional chance criterion. For model validation, prediction accuracy was 84.4% in the hold-out group, which was 14.2% greater than the proportional chance criterion. However, only 57.1% of the cows that experienced dystocia were correctly classified. Examination of the data revealed that those cows misclassified were 3 yr of age or older.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1981

Age of dam and maternal effects for dystocia in Holsteins.

Genetic correlations between dystocia in first with later parities and between direct with maternal effects for dystocia were estimated. Dystocia in first and later parities represent similar traits because of a large genetic correlation of .84. This similarity should allow calving reports on older dams and heifers to be combined in predicting a bull's calving performance. Correlations for direct with maternal effects were -.38 for the heifer population and -.25 for the cow (second and greater parities) population. This correlation would reduce progress from selecting for reduced dystocia if only direct effects were considered. Breeding programs to reduce dystocia should consider both direct and maternal performance.

Age Factors↗
PubMed1988

Genetic analysis of dystocia and calf mortality in Israeli-Holsteins by threshold and linear models.

Calvings of 106,751 Israeli Holstein heifers were analyzed for dystocia and calf mortality, scored dichotomously, and a composite trait, scored trichotomously. Dystocia was also studied with 146,973 second and third parity records. Models fitted included herd-year-season, sex of calf, calving age, calving month, sire of cow, sire of calf, and groups of sire of cow and of calf. Herd-year-season, sire of cow and calf, and residuals were random with diagonal variance-covariance matrices. Herd-year-season variance was assume to be 10% of the residual component. Other variance components were estimated by REML for linear models and by the counterpart of REML for threshold models. Heritability estimates were two to five times greater in threshold than in linear models, but correlations between corresponding sire evaluations were all greater than .9. Linear model sire evaluations were skewed positively, whereas threshold model evaluations had symmetrical distributions. Heritability for dystocia was greater in first than in later parities. Correlations between first and later parity sire evaluations were less than .5. Thus, the genetic control of dystocia seems to be different for heifers and cows. Correlations between sire of cow and calf evaluations were less than .3. Correlations between dystocia and calf mortality evaluations were about .7.

Animals↗
PubMed1989

Models for genetic analysis of dystocia and calf mortality.

Calvings of 106,750 Israeli Holstein heifers were analyzed for dystocia and calf mortality, which were scored dichotomously. Models fitted included herd-year-season, sex of calf, calving age, calving month, sire of cow, sire of calf, and groups of sire of cow and calf. Herd-year-season, sire of cow and of calf, and residuals were random with diagonal variance-covariance matrices. Traits were analyzed with and without a herd-year-season effect, and dystocia was analyzed separately for male and female calvings and with both sexes combined. Variance components were estimated by REML for linear models and by the counterpart of REML for threshold models. Heritability estimates were two to four times larger in threshold than in linear models, but correlations between corresponding sire evaluations were all greater than .9. Correlations between evaluations computed with and without herd-year-season effects were .9 for sire of calf evaluations for dystocia and greater than .97 for all other evaluations. Correlations between sire evaluations computed separately for male and female calvings were between .3 and .7. Thus, calving difficulty is expressed differently in male and female calvings. Genetic trends were unfavorable for dystocia but favorable for calf mortality. Phenotypic trends were curvilinear with maxima in 1982 and 1983 for calf mortality and dystocia.

Age Factors↗