DYSTOCIA

Ref : 1. Williams Obstetrics 23rd Ed

2. OBSTETRI PATOLOGI
3. PROTAP BAG .OB.GYN RSHS

Persalinan normal
Suatu keadaan fisiologis, normal dapat berlangsung sendiri tanpa
intervensi penolong.
Kelancaran persalinan tergantung 3 faktor P utama
Kekuatan ibu (power)
keadaan jalan lahir (passage)
keadaan janin (passanger).
(++ faktor2 "P" lainnya : psychology, physician, position)
keseimbangan / kesesuaian antara faktor-faktor "P" tersebut,
persalinan normal diharapkan dapat berlangsung.

Gangguan

Kelambatan atau kesulitan persalinan ini

disebut DISTOSIA.

A BABY IS DELIVERED UPON A CERTAIN POWER

IN A PHYSIOLOGICAL MANNER
THROUGH A CERTAIN ROUTE

PHYSIOLOGIC LABOR

SPONTANEOUS LABOR

PROBABILITY OF
AN OBSTETRIC COURSE
INPUT
(Pregnant woman)

PROCESS
(Labor)

OUTCOME
Mother Survive
Foetus
Death
Sequellae

PHYSIOLOGIC

PHYSIOLOGIC

PHYSIOLOGIC

PATHOLOGIC

PATHOLOGIC

PATHOLOGIC

DIAGNOSIS

PROGNOSIS

PROGNOSIS

Intervention
- Promotive
- Preventive
- Curative

- Promotive
- Preventive
- Curative

Promotive
Preventive
Curative
Rehabilitative

EUTOCIA ?
DYSTOCIA ?

A SUCCESFULL DELIVERY PROCESS DUE TO

THE WOMANS OWN NATURAL FORCES

( LABOR PAIN AND BEARING DOWN )

RESULTING TO A BIRTH OF A LIFE
HEALTHY BABY WITH MINIMAL TRAUMA

FOR BOTH THE MOTHER AND HER BABY.

DYSTOCIA
Abnormal labor

3 - P Abnormalities :
1. POWER

2. PASSENGER
3. PASSAGE

H i s / Labor pain

Tenaga mengejan / Pushing

power

PATHOLOGIC PRESENTATION
POSITION :

POPP

DEFLECTION

BREECH PRESENTATION

TRANVERSE LIE

COMPOUND PRESENTATION

FOETAL ABNORMALITY :

LARGE BABY

HYDROCEPHALUS

PELVIC ABNORMALITIES
PELVIC IN LET
MID PELVIC
PELVIC OUTLET

PELVIC TUMOR
NARROWNESS OF VAGINA/VULVA
EXOSTOSIS

ETIOLOGY

Overuse of analgesics

Contracted pelvis
Malpresentation
Over extended uterus
Psychological factor

TYPE OF LABOR PAIN

ABNORMALITIES

1. Hypertonic uterine inertia

2. Hypotonic uterine inertia
his lemah dan frekuensinya jarang.
- anemia
-uterus yang terlalu teregang misalnya akibat hidramnion atau
kehamilan kembar atau makrosomia, grandemultipara atau primipara
-keadaan emosi kurang baik.

 Primary uterine inertia

permulaan fase laten. Sejak awal telah
terjadi his yang tidak adekuat

Secondary uterine inertia

pada fase aktif kala I atau kala II.
Permulaan his baik, kemudian pada
keadaan selanjutnya terdapat gangguan /
kelainan

Differences of uterine
inertia

Incidence

Hypotonic
Hypertonic
Uterine Inertia Uterine Inertia
4 %
1%

Phase

Stage I - Active

Stage I Latent

Pain

None

Exagerated

Fetal
distress
Therapy

Slow onset

Rapid onset

Oxytocin

Sedative

Criteria for detecting abnormal

uterine contraction :
No / slow progress of labor :
Tool : PARTOGRAPH ( WHO )

Clinical values :
Dilatation

Descend of the presenting part

Internal rotation

Complications

Prolonged labor :
Fetal morbidity
Maternal morbidity

MANAGEMENT

1.Hypertonic uterine Inertia

Morphine 10 mg ( Inj )
Pethidine 50 mg ( Inj )

Caesarean Section

2. Hypotonic uterine inertia

OXYTOCIN INFUSION :
RSHS : TRIPLE PROCEDURE
Membrane ruptured
Oxytocin 5 IU/500 cc Dextrose 5%
Pethidine 50 mg + Phenergan 50 mg
Fail :

Caesarean section

MODE OF ADMINISTRATION :

Starting dose 20 gtt / min

Increased 10 gtt / 30 min
Maintained if adequate
contraction has achieved.
Maximum 60 gtt / min
Tool for observation CTG
MAXIMUM 2 BOTLES

Complications :
1. Fetal distress /Tetanic contraction
> Fetal heart beat : Irregular / > 160
> CTG : Late deceleration/Var.decel

2. UTERINE RUPTURE :
> Contraction disappeared
> FHB ( - )

> Fetal parts are easily palpable

> Shock : BP

PULSE : impalpable

MANAGEMENT OF COMPLICATIONS

Fetal distress detected :

Stop oxytocin infusion or

Decreased number of drops

Intrauterine resuscitation

Re evaluation
Fetal distress ( + )

CS

UTERINE RUPTURE :

Stop oxytocin drip

Prepare blood transfusion

Laparotomy
Hysteroraphy + Sterilization

Hysterectomy

INADEQUATE PUSHING POWER :

Most frequent causes :

MOTHER FATIGUENESS :
Rapid pulse
Rapid respiration
MANAGEMENT :
1.Dextrose 5 % Infusion
2.Damp Oxygen 3 L/minute
3.F.E

THREATENED UTERINE RUPTURE

SYMPTOMS AND SIGNS :

Contraction strong / Tetanic

RING OF BANDL
Round ligament tense & hard

Painful

Mother restlessness

Fetal distress / IUFD

Urine bloody

MANAGEMENT :

PREGNANCY TERMINATION
1. CAESAREAN SECTION

2. FORCIPAL EXTRACTION
3. EMBRYOTOMY

4. DOUBLE SET UP

Constriction ring

Bandl ring

Locally thickness

Border of Upper and

Lower Ut.segment

Thicknes at the ring

site

Upper segment thick

lower part thin

Lower uterine
segment normal

Lower uterine
segment
stretched

Stage I II III

Stage II

Stationary

Getting higher

Palpable through
Palpable through
internal examination Abdominal wall
Good general cond
Prem rup membran /
operative delivery

Bad gen.condition
CPD

DYSTOCIA

PART - 2

CERVICAL DYSTOCIA

As long as the labor pain is physiologic

a full cervical dilatation should be
achieved , except in case of :
1. CERVICAL DYSTOCIA
2. Contracted pelvis

PASSENGER ABNORMALITIES

MALPOSITION
MALPRESENTATION
PHYSICAL ABNORMALITIES

MALPOSITION :

o POPP : Persistent Occipital

Posterior
Position
o Transverse Arrest
o Deep Transverse Arrest

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

DEFLECTION

FACE Pr

BROW Pr

Leopold II

Fabre angle

Fabre angle

Auscultation

Small part

Small part

Int.Exam

Orbital nose ,

Large fontanel

Large dilatation

mouth , chin

, frontal suture
orbital edge

Delivery

Chin ant : SP

CS

Chin post : CS
Forcipal Extraction
Maneuvers
Etiology for dystocia

Chin anterior

Never

ABANDONED
Maximally
Diameter >>>
head
deflection

BREECH PRESENTATION
Frank

Compl

Incompl

Breech

Breech

Breech

LEOPOLD I

Head

Head

Head

Head

LEOPOLD III

Breech

Breech

Breech

Breech

Auscultation

Umb

Umb

Umb

Umbilical

Presenting

Foot (-)

Both

One

Feet

feet

foot

part

Footling

DELIVERY

SHOULD BE CONSTRAINTLESS

HS Hospital

Primi : BW > 3500 gram

Caesarean

C a e s a r e a n S e c t i o n BW >1800
BW < 3500 & Multipara

Spontaneous : Bracht
Manual A i d

Caesarean

Forceps Piper

BW > 1800

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

PROFILAXIS :

External version
Condition :
Dilatation < 2-3 Cm
Membrane : in tact
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
prolapsed of umbilical cord
Fetal distress
Solutio placentae
Uterine rupture

TRANSVERSE LIE
Uterine congenital malformation
UTERUS ARCUATUS

TRANSVERSE LIE
LEOPOLD I , III

Empty

LEOPOLD II

Large parts left & right side

Heart sound

Around the umbilicus

Int.Ex : Membrane ( - )
Dilatation >>>
PROFILAXIS

DELIVERY

Shoulder

External Version :
1.Single
2.Second twin
Foetus alive aterme CS
Death foetus a terme
Embryotomi / Double set up

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

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

: Reposition/FE/CS

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

MANAGEMENT :

Prompt pregnancy termination :

Fetus alive : FE/ VcE / CS
Fetus 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
Occipital presentation :
Spontaneous /Consider
pelvic cavity wideness
Woods maneuver
FE / Vc E
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

PASSAGE ABNORMALITIES

Diameter

CV
Transver
+
Sagit Post
Transver

Pelvic inlet
ABSOLUT RELATIVE Mid Pelvic Pelvic
out let
< 8,5 cm
8,5 - 10
cm
< 13,5 cm < 15 cm

< 9 cm

DIAGNOSIS :
Leopold :
Primi : 36 Weeks + ; undescended
head
Malpresentation
PELVIC MEASUREMENT :
Clinic : Promontorium - InnLin - Isch
Spine - Pub Arch - Sacrum Side walls
Roentgen Pelvimetri / CT Scan /MRI

COMPLICATIONS :
Incarceratous Retroflexed uterus
Malpresentation
Pendulous abdomen
Prolonged labor
Uterine Rupture

MANAGEMENT :

Type of pelvic
abnormalities
Absolute :
Relative :
Trial of labor
Succeed
Failed

Mode of delivery

CS

Spontaneous/FE/VcE
CS

TRIAL OF LABOR :

Conditions :
Occipital presentation
Mother and fetus in good condition
Start : at the beginning of labor
End :
Improbability of vaginal delivery
Successful vaginal delivery
( Spontaneous / FE /VcE)

Successful trial of labor :

Vaginal delivery ; mother and child
survive in good condition ( Sp / FE /
Vc E )
Complete failed trail of labor :
Dilatation full ; CS due to un
engagement or failed of FE /Vc E
Incomplete failed trial of labor :
CS was performed before fully
dilatation was achieved , due to
other indications.

Management during next pregnancy :

Failed - complete : CS
Failed incomplete : Shortened trial
of labor

PELVIC TUMOURS :
Fibroid
Ovarian cyst
Large bowel tumors
Diagnosis during at term pregnancy
/ delivery : CS

THANK YOU FOR YOUR ATTENTION

Good Luck with your examinations !!