DYSTOCIA

Bagian / UP Obgin FK.UNHAS /RS.Dr.Wahidin Sudirohusodo Makassar

DYSTOCIA
A difficult labor

3-P
1. POWER

2. PASSAGE
3. PASSENGER

A BABY IS DELIVERED UPON A CERTAIN POWER

THROUGH A CERTAIN ROUTE

PHYSIOLOGIC LABOR

SPONTANEOUS LABOR

3-P

1. POWER :

Pushing power
H i s / Labor pain

PROBLEMS
The latent phase is longer than 8 hours
Cervical dilatation is to the right of the

alert line on the partograph The woman has been experiencing labour pains for 12 hours or more without delivery

Prolonged latent phase

The diagnosis is made retrospectively. When

contractions cease, the woman is said to have had false labour. When contractions become regular and dilatation progresses beyond for 4 cm, the woman is said to have been in the latent phase.

Misdiagnosing false labour or prolonged latent phase leas to unnecesaary induction or augmentation, which may fail. This may lead to unnecessary caesarean section and amnionitis.

PROLONGED ACTIVE PHASE

If no signs of CPD or Obstruction and the

membranes are intact, rupture the membranes with a Kocher clamp If contraction are inefficient, suspect inadequate uterine activity If contraction are efficient suspect CPD, obstruction, malposition or malpresentation

Inefficient contractions are less common in a multigravida than in a primigravida. Hence, every effort should be made to rule out disproportion in a multigravida before augmenting with oxytocin.

Source: WHO/UNFPA/UNICEF/WORLD BANK. IMPAC-Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO 2000 (WHO/RHR/ 00.7)

His Adekuat Kontraksi yang

lamanya 60 detik mencapai tekanan 50 - 60 mm Hg terjadi setiap 2 - 3 menit

menghasilkan kemajuan persalinan yang baik

AUGMENTATION
Initiation Dose oxytocin
Interval Dosis kenaikan Optimal dose

1 - 2 mU / min
every 30 min. 1 - 2 mU 8 - 10 mU / min.

Side Effects Oxytocin

Side effect
Hypoxia fetal Ruptur Utery

Mecanism
Hiperstimulasi Hiperstimulasi

Prophylacis
Optimal dose Optimal dose

Water intoxycation
Hypotensi

ADH effect
Vasodilatation

Batasi cairan
Low dose

2. PASSAGE

2.1. PELVIC ABNORMALITIES 2.2. PELVIC TUMOR

2.3. NARROWNESS OF VAGINA/VULVA

2.4. EXOSTOSIS

PELVIC
Ginekoid :

transversa p.a.p A.P

Antropoid :

A.P p.a.p > transversa

Android

p.a.p (Narrowing to anterior)

Platipelloid

A.P < < < transversa

3. PASSENGER :

3.1. PATHOLOGIC PRESENTATION /POSITION

3.1.1 : POPP 3.1.2 : DEFLECTION

3.1.3 : BREECH PRESENTATION

3.1.4 : TRANVERSE LIE 3.1.5 : COMPOUND PRESENTATION 3.2 FOETAL ABNORMALITY : 3.2.1 : LARGE BABY

3.2.2 : HYDROCEPHALUS

PASSENGER ABNORMALITIES

MALPOSITION MALPRESENTATION PHYSICAL ABNORMALITIES

MALPOSITION :

POPP : Persistent Occiput Posterior Position Transverse Arrest Deep Transverse Arrest

MALPOSITIONS AND MALPRESENTATIONS

Malpositions are abnormal positions of the

vertex of the fetal head (with the occiput as the reference point) relative to the maternal pelvis.
Malpresentations are all presentations of

the fetus other than vertex

DETERMINE THE PRESENTING PART

The most common presentation is the

vertex of the fetal head. If the vetex is not the presenting part.
If the vertex is the presenting part, use

landmarks of the fetal head

DETERMINE THE POSITIONS OF THE FETAL HEAD

The fetal head normally engages in the

maternal pelvis in an occiput transverse position, with the fetal occiput transverse in the maternal pelvis.

OCCIPUT POSTERIOR POSITION

occurs when the fetal occiput is posterior in relation to the maternal pelvis
Abdominal examination Vaginal examination

OCCIPUT TRANSVERSE POSITION occurs when the fetal occiput is transverse to the maternal pelvis. If an occiput transverse position persists into the later part of the first stage of labour, it should be managed as an occiput posterior position

MANAGEMENT OCCIPUT POSTERIOR POSITIONS

Spontaneous rotations to the anterior positions occurs in 90% of cases. Aressted labour may occur when the head does not rotate and/or descend. Delivery may be complicated by perineal tears or extention of an episiotomy.
Signs of obstruction or the fetal heart rate is abnormal Membranes are intact Cervix is not fully dilated and there are no signs of obstruction Cervix is fully dilated but there is no descent in the expulsive phase

BROWN PRESENTATION
is caused by hyper-extension of the fetal head

so that neither the occiput is higher than the sinciput

Abdominal examination Vaginal examination

FACE PRESENTATION
is caused by partial extension of the fetal

head so that neither the occiput nor the sinciput are palpable on vaginal examination

COMPOUND PRESENTATION
occurs when an arm prolapses alongside the

presenting part. Both the prolapsed arm and the fetal head present in the pelvis simultaneously

occurs when the buttocks and/or the feet

arethe presenting parts.

Abdominal examination Vaginal examination during labour

OA ROA ROT LOA LOT

ROP
OP

LOP

MALPRESENTATION
DEFLECTION :
1. Face presentation 2. Brow presentation BREECH PRESENTATION TRANVERSE LIE COMPOUND PRESENTATION

BREECH PRESENTATION
occurs when the buttocks and/or the feet

arethe presenting parts.

Abdominal examination Vaginal examination during labour

 COMPLETE (FLEXED) BREECH PRESENTATION

occurs when Both legs are flexed at the hips and knees
FRANK (EXTENDED) BREECH PRESENTATION

occurs when both legs are flexed at the hips and extended at the knees.
FOOTLING BREECH PRESENTATION occurs when a

leg is extended at the hip and the knee

 Types of Breech

Complete

Footling

Frank

 Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

BREECH PRESENTATION
Frank Compl Incompl Footling Head Breech Umbilical

Breech
LEOPOLD I LEOPOLD III Auscultation Head Breech Umb

Breech
Head Breech Umb

Breech
Head Breech Umb

Presenting
part DELIVERY

Foot (-)

Both
feet

One
foot

Feet

SHOULD BE CONSTRAINTLESS

Hospital

Primi : BW > 3500 gram Caesarean Section

C-Section

BW < 3500 & Multipara Spontaneous : Bracht Manual A i d Forcep Piper

C-Section

 Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

 Spontaneous Expulsion

spontaneous expulsion to the umbilicus the sacrum should be gently guided anteriorly singleton breech extraction is contraindicated C/S is indicated for failure of descent or expulsion
Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Hurry up & Wait!

DONT PULL! traction deflexes the fetal head may cause nuchal arm

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

 Deliver Legs by lateral rotation of thighs and

flexion of knees - keep sacrum anterior

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of Arms
good maternal pushing deliver when winging of scapulae seen rotate arm to anterior sweep humerus across the chest and deliver rotate other arm anterior and repeat to deliver
Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

 Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

 Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

 Delivery of the head

Forceps assistant elevating babe direct application

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

TRANSVERSE LIE AND SHOULDER PRESENTATION

occurs when the long axis of the fetus is

transverse. The shoulder is typically the presenting part.

Abdominal examination Vaginal examination

PROGNOSIS :
BAD , Fetal death 3-4 X vertex presentation

PROFILAXIS :

External version
Condition : Dilatation < 2-3 Cm Membrane : intact Presenting part : above in let

Contra indication of Ext.Version : Contracted pelvis Hypertension Ante partum bleeding Uterine ( Myometrial ) scar

Constraints for External Version : Abdominal wall hardness

Placenta lies Anteriorly

Uterine malformation Short umbilical cord Frank breech

Complications : Rupture of the membrane prolaps of umbilical cord Foetal distress Solutio placentae Uterine rupture

TRANSVERSE LIE
Uterine congenital malformation UTERUS ARCUATUS

TRANSVERSE LIE

LEOPOLD I , III LEOPOLD II Heart sound Int.Ex : Membrane ( - ) Dilatation >>> PROFILAXIS DELIVERY

Empty Large parts left & right side Around the umbilicus Shoulder External Version : 1.Single 2.Second twin Foetus alive aterme CS Death foetus a terme Embryotomi / Double set up

COMPLICATIONS : Umbilical cord prolaps Arm / hand prolaps Neglected transverse lie Uterine rupture

COMPOUND PRESENTATION Diagnosis during 1st stage of labor aktive phase / Second Stage . Hand / arm /was felt beside the head MANAGEMENT : Hand prolaps : Spontaneous /FE Arm prolaps : Reposition/FE/CS

CORD PROLAPS TYPES : Occult Prolapse True Prolapse DIAGNOSIS : Membrane ( - ), cord was felt beside the presenting part. CTG : Variable deceleration

MANAGEMENT :

Prompt pregnancy termination : Foetus alive : FE/ VE / CS Foetus dead : Vaginal delivery

LARGE BABY : Birth weight > 4000 gram DIAGNOSIS : Fundal height > 42 cm

USG
COMPLICATIONS :

CPD
Shoulder Dystocia

MANAGEMENT :
Fetus alive: Breech presentation : CS Occiput presentation : Spontaneous /Consider pelvic cavity wideness Woods manuver FE / VE CS Fetus dead : Embriotomy/FE/CS

HYDROCEPHALUS
Diagnosis :

Leopold III : Large bulky head ;

undescended.

Leopold IV : Both hand //

or Diverge.

USG : Brain Ventricles >>>

Face <<< other head parts

Diagnosis : ( continued ) During delivery : Head presentation : high Sutures >>> Large fontanel >>> and bulging

Ping pong phenomenon

MANAGEMENT :
USG Brain tissue : Sufficient : CS Small : Perforation Complication : Uterine Rupture

THREATENED UTERINE RUPTURE

SYMPTOMS AND SIGNS :

Contraction strong / Tetanic

RING OF BANDL Round ligament tense & hard Painful Urine bloody Mother restlessness Fetal distress / IUFD

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