SCENARIO II

A Woman, 28 years old, came to the emergency department at 23 o’clock, referenced

by a midwife in primary care with note : labor is not advanced. From Anamnasis, we
gain information that the woman was pregnant for the first time, abdominal paint
through the rear since 09 o’clock this dawn with discharge of mucus and blood. At 21
o’clock the woman felt straining, cervical opening 10 cm. The labor was conducted by
the midwife but no progress. On physical examination Fundus height 3 fingers below
Xyphoideus processus, the fetus spine was on the left side, the most lower part was
head, and 1/5. Distance between Simphysis os pubis and height of Fundus was 40 cm,
Abdominal circumference 98 cm. Fetal Heart Rate 130x/minute, His 4 times within 10
minutes with duration of 40-45 second. On intra vaginal examination, cervic opening
10 cm, membranes not palpable, the most lower part was face.

 Difficult Word
- His : uterine contractions at least 3 times for 10 minutes with a duration <40
seconds
- Height of Fundus : used to determine gestational age and estimated fetal
weight. with formula = height of fundus x maternal abdominal circumference
(pregnancy up to 24 weeks)
- Engaged : ratings decline fetal head is done by calculating the proportion of
the presenting part is still at the top edge of the symphysis and can be
measured with five fingers examiner
1. 0/5 : no palpable head
2. 1/5 : sinsiput palpable, osisiput impalpable
3. 2/5 :sinsiput palpable, some palpable osisiput
4. 3/5 :sinsiput easily palpable, palpable osisiput
5. 4/5 :sinsiput high, easily palpable osisiput
6. 5/5 : palpability above symphisis

 Keywords
 - A Woman 28 years old
- Labor is not advanced
- The woman was pregnant for the first time
- Abdominal paint through the rear since 09 o’clock this dawn with discharge of
mucus and blood
- At 21 o’clock the woman felt straining, cervical opening 10 cm
- The labor was conducted by the midwife but no progress
- On physical examination :
1. Fundus height 3 fingers below xyphoideus processus
2. The fetus spine was on the left side, the most lower part was head, and 1/5.
3. Distance between Simphysis os pubis and height of Fundus was 40 cm,
abdominal circumference 98 cm.
4. Fetal Heart Rate 130x/minute,
5. His 4 times within 10 minutes with duration of 40-45 second.
6. On intra vaginal examination,
7. Cervic opening 10 cm
8. Membranes not palpable
9. The most lower part was face.

 Questions & Answers

1. Explain the anatomy of the birth canal ?

Anatomy of Birth Canal

Birth canal is divided into: (a) Bone Section: Pelvic skeleton; and (b) Soft section : the
muscles, tissues, and ligament.

Pelvic Sceleton

The pelvic skeleton is formed posteriorly (in the area of the back), by the
sacrum and the coccyx and laterally and anteriorly (forward and to the sides), by a pair
of hip bones. Each hip bone consists of 3 sections, ilium, ischium, and pubis.The pubic
symphysis or symphysis pubis is the midline cartilaginous joint (secondary
cartilaginous) uniting the superior rami of the left and right pubic bones
 Functionally, pelvis consists into two parts called the pelvis major and pelvis.
Pelvis major located above the pelvis linea terminal, also called false pelvis. The
section which located below linea terminalis called pelvis minor or true pelvis

Pelvis Field

a. Pelvic Inlet or Apertura Pelvis Superior

Pelvic inlet is an area formed by the sacral promontory vertebral bodies 1,

lineainominata, and the upper edge of the symphysis. There are four on the pelvic
inlet diameter, ie the diameter anteroposterior, transverse diameter and 2 oblique
diameter.

The diameter that represents the shortest diameter through which the head must
pass in descending into the superior strait and measures, by means of x-ray, the
distance from the promontory of the sacrum to a point on the innersurface of the
symphysis a few millimeters below its upper margin called conjugate vera. The
length from the upper edge of the symphysis to the promontory is about 11 cm.

The distance of the bottom of the symphysis to the promontory known as

conjugate diagnoalis. Statistically, it is known that conjugate vera = conjugate
diagonalis - 1.5 cm.
 b. Pelvis Outlet or Apertura Pelvis Inferior
The pelvic outlet is a diamond-shaped area, best appreciated when
viewed from below. The boundaries of the pelvic outlet are: the pubic
symphysis, right and left rami of the pubic arch, the ischial tuberositiesm the
sacrotuberous ligaments and the tip of coccyx. The distance between the two
ischial tuberotiesm is an important size of the pelvic outlet, that is 10,5 cm.

Soft Part of Birth Canal

Soft parts which serve as the birth canal consists of the vagina, cervix, and
uterus. In addition, muscles, connective tissues, and ligaments also give a role to
influence the birth canal.
 The muscles that hold the pelvic floor on the outside is the external anal
sphincter muscle, muscular bulbocavernosus encircling the vagina, and the superficial
transverse perineal muscle.In the center is found muscles that encircle utetra:
ilokoksigues muscle, the transverse perineal profundus muscle, and muscle koksigues.
Deeper found most powerful muscle, called the pelvic diaphragm, especially the
levatorani muscle which serves to hold the pelvic floor.

Reproducitve System

Hodge Plane

Hodge field is used to determine to where the lowest part of the fetus
down in the pelvis during childbirth.
 a. Hodge I : flat plane through the top of the symphysis and the
promontory.
b. Hodge II : field which parallel to the first , is as high as the bottom of
the symphysis
c. Hodge III : field which parallel to the hodge I & II, located as high as the
ischial spine left and right
d. Hodge IV : field which parallel with hodge I, II, and III, located as high
os coccyx

2. Explain the signs in partu ?

a. pain by contractions were detected more strongly, frequently and regularly

b. mucus mixed with blood that is more because of small tears in the cervix

c. can be accompanied by premature rupture of membranes

d. on examination, the cervix horizontal and cervical dilatation

3. Explain the mechanism of labor ?

Mechanism of labor
 Uterine contractions during active labor have two major functions: to dilate the
cervix and to push the fetus through the birth canal. However, the fetus is not merely
the passive recipient of these forces, rather, its ability to successfully negotiate the
pelvis is dependent upon the complex interaction of three mechanical variables, known
as the "three Ps": the powers, the passenger, and the passage.

The effect of maternal obesity on labor is discussed separately.

Powers (uterine contractions), powers refer to the force generated by the uterine
musculature during contractions. It is generally believed that the more optimal the
powers, the more likely a successful outcome; however, there are no data to support
this statement.

Uterine activity can be assessed qualitatively by simple observation of the mother

and palpation of the fundus of the uterus through the abdomen or by external
tocodynamometry. Both methods provide information about the frequency (number of
contractions in an average 10 minute window), intensity, and duration of the
contractions. It can also be measured quantitatively by direct measurement of
intrauterine pressure via internal manometry or pressure transducers. There is no
evidence that one method is significantly better than another

Despite technological improvements, the criteria for adequate uterine activity

during labor are unclear. Classically, the occurrence of three to five contractions in 10
minutes has been used to define adequate labor, and is observed in about 95 percent of
women in spontaneous labor at term. The advent of intrauterine pressure transducers
has enabled objective measurement of uterine activity, which is quantitated using
Montevideo units (Montevideo units are calculated by multiplying the average peak
strength of contractions in mm Hg by the number of contractions in 10 minutes). Using
this method, adequate labor is usually observed with 200 to 250 Montevideo units .
These criteria are supported by a retrospective series in which 91 percent of women in
spontaneous active labor achieved contractile activity greater than 200 Montevideo
units and 40 percent reached 300 Montevideo units
 Passenger (fetus), The passenger is the fetus. There are several fetal variables that
can affect the course of labor, including:

 Fetal size
 Lie (the long axis of the fetus relative to the longitudinal axis of the uterus).
Fetal lie can be longitudinal, transverse, or oblique
 Presentation (the fetal part that directly overlies the pelvic inlet). Presentation
is usually vertex or breech; shoulder, compound (eg, vertex and hand), and
funic (umbilical cord) presentations are other possibilities
 Attitude (degree of flexion/extension of the fetal head). The fetal head is in
flexion when the chin approaches the chest and in extension when the occiput
nears the back
 Position (relationship of a nominated site of the presenting part to a
denominating location on the maternal pelvis, eg, right occiput anterior).
Asynclitism refers to lateral deflection of the fetal head such that the sagittal
suture is deflected anteriorly toward the symphysis or posteriorly toward the
sacrum.
 Station (degree of descent of the leading edge of the presenting part of the fetus,
typically measured as distance in centimeters between the leading bony edge
of the fetus and the ischial spines)
 Number of fetuses
 Presence of fetal anomalies (eg, sacrococcygeal teratoma)

A small fetus in longitudinal lie, with vertex presentation, a flexed head in anterior
position that has passed through the pelvic inlet is the ideal candidate for negotiating
the maternal pelvis.

Passage (pelvis) ,The passage consists of the bony pelvis and the soft tissues of
the birth canal (cervix, pelvic floor musculature), both of which offer varying degrees
of resistance to fetal expulsion. The bony pelvis is assessed by pelvimetry (ie,
quantitative measurement of pelvic capacity), which can be performed clinically or via
imaging studies (x-ray, computed tomography, magnetic resonance imaging. Average
and critical limit values for the various parameters of the bony pelvis have been
established; however, such measurements are of limited clinical value as they are not
able to consistently predict women at risk for cephalopelvic disproportion. Pelvimetry
has been replaced, in large part, by clinical trial of the pelvis.

Stages

Although labor is a continuous process, it has traditionally been divided into three
stages to facilitate study and to assist in clinical management.

First stage, the first stage refers to the interval between the onset of labor and full
cervical dilatation. It has been subdivided into three phases according to the rate of
cervical dilatation:

 Latent phase ,the period between the onset of labor and the point at which a
change in the slope of the rate of cervical dilatation is noted. It is characterized
by slow cervical dilatation, and is of variable duration.
 Active phase,this phase is associated with a faster rate of cervical dilatation and
usually begins by 2 to 4 cm of cervical dilatation. The active phase is broken
down further into an acceleration phase, a phase of maximum slope, and a
deceleration phase, but these subdivisions are rarely employed today.
 Descent phase , descent of the fetus usually coincides with the second stage of
labor. Not all investigators accept the existence of a separate descent phase.

The characteristics of the labor curve do not appear to differ among varying
racial/ethnic groups, but there are significant differences between the labor curves of
nulliparous and multiparous women. In classic studies, Friedman determined the
average duration for each stage of labor in these two groups of parturients and
calculated the maximum duration of each stage, defined as two standard deviations
(SD) from the mean. As an example, the minimum rate of cervical dilatation of 1.2 cm
per hour for a nulliparous patient represents two SD below the mean rate of cervical
dilatation for nulliparas, not the average rate of dilatation among these women (which
is 3 cm/h).
 By comparing a parturient's rate of cervical dilatation with the normal profile
described by Friedman, it is possible to detect abnormal labor patterns and thus identify
pregnancies at risk for adverse events. This task can be facilitated by use of a
partogram, which is a graphical representation of the labor curve against which a
patient's progress in labor is plotted. In this way, abnormal labor patterns can easily be
identified and appropriate measures taken.

Friedman's curves were derived from studying laboring women in the 1950s. The
subject was revisited in a more recent study which measured the duration of active
labor (first and second stages) in 2511 low-risk women at term whom received
intrapartum care from certified nurse-midwives in nine hospital settings in the United
States and did not receive oxytocin or epidurals. The mean length of the active-phase,
first stage was 7.7 hours for nulliparas and 5.6 hours for multiparas (statistical limits
of 2 standard deviations from the mean were 17.5 and 13.8 hours, respectively). The
mean length of second stage was 54 minutes for nulliparas and 18 minutes for
multiparas (statistical limits 146 and 64 minutes, respectively). Variables associated
with longer labors were electronic fetal monitoring, ambulation, maternal age over 30
years, and narcotic analgesia.

Others have also noted that the pattern of labor progression in contemporary
practice is slower than described by Friedman. These studies suggest that current
diagnostic criteria for protraction and arrest disorders of labor may be too stringent.

Second stage ,the second stage of labor refers to the interval between full cervical
dilatation (10 cm) and delivery of the infant. It is characterized by descent of the
presenting part through the maternal pelvis and culminates with expulsion of the fetus.
The second stage of labor has been demonstrated to differ both by race/ethnicity and
maternal parity, but not by maternal obesity.

Indications that the second stage has started are an increase in bloody show,
maternal desire to bear down with each contraction, a feeling of pressure on the rectum
accompanied by the desire to defecate, and onset of nausea and vomiting .
 The mother typically assumes a more active role in the second stage than the first
stage, as she "pushes" to aid descent of the fetus.

Third stage,the third stage of labor refers to the time from delivery of the baby to
separation and expulsion of the placenta. The major complication associated with this
period is hemorrhage, which remains an important cause of maternal morbidity and
mortality. There are no uniform criteria for the normal length of the third stage of labor.
Retention of the placenta for longer than 30 minutes at term is a commonly used
endpoint for intervention in the absence of complications (eg, hemorrhage). The World
Health Organization defines a retained placenta as one that has not been expelled by
60 minutes after delivery.

Precipitate labor and delivery, precipitate or precipitous labor and delivery refers
to a rapid labor and delivery of the fetus, variously defined as expulsion of the fetus
within two to three hours of commencement of contractions. It is rare, and not well
studied.

4. Explain the causes of obstructed labor ?

In general, abnormal labor is the result of problems with one of the following three P'
is:
 1. Passenger (infant size, fetal presentation [occiput anterior, posterior, or
transverse])
2. Pelvis or passage (size, shape, and adequacy of the pelvis)
3. Power (uterine contractility)

A prolonged latent phase may result from oversedation or from entering labor early
with a thickened or uneffaced cervix. It may be misdiagnosed in the face of frequent
prodromal contractions. Protraction of active labor is more easily diagnosed and is
dependent upon the 3 P' s.

The first P, the passenger, may produce abnormal labor because of the infant's size
(eg, macrosomia) or from malpresentation.

The second P, the pelvis, can cause abnormal labor because its contours may be
too small or narrow to allow passage of the infant. Both the passenger and pelvis cause
abnormal labor by a mechanical obstruction, referred to as mechanical dystocia.

With the third P, the power component, the frequency of uterine contraction may
be adequate, but the intensity may be inadequate. Disruption of communication
between adjacent segments of the uterus may also exist, resulting from surgical
scarring, fibroids, or other conduction disruption. Whatever the cause, the contraction
pattern fails to result in cervical effacement and dilation. This is called functional
dystocia. Uterine contractile force can be quantified by the use of an intra-uterine
pressure catheter. Use of this device allows for direct measurement and calculation of
uterine contractility per each contraction and is reported in Montevideo units (MVUs).
For uterine contractile force to be considered adequate, the force produced must exceed
200 MVUs during a 10-minute contraction period. Arrest disorders cannot be properly
diagnosed until the patient is in the active phase and had no cervical change for 2 or
more hours with the contraction pattern exceeding 200 MVUs. Uterine contractions
must be considered adequate to correctly diagnose arrest of dilation.

5. Explain the signs of obstructed labor ?

A. General condition
In cases of obstructed labour there will be signs of physical and mental
exhaustion.
Some or all of the following signs and symptoms may also be observed:
 maternal and/or fetal distress
 dehydration and ketoacidosis (sunken eyes, thirsty, dry mouth, dry
skin identified by skin pinch going back slowly)
 fever (raised temperature)
 abdominal pain which may be continuous
 shock, rapid, weak pulse (100 per minute or more), diminished urinary
output, cold clammy skin, pallor, low blood pressure (systolic less
than 90 mmHg), rapid respiratory rate (30 per minute or more),
anxiousness, confusion, or unconsciousness. Shock may be due to a
ruptured uterus or sepsis.
B. Abdominal examination
Signs of obstructed labour that may be revealed by an abdominal examination
are:
 The widest diameter of the fetal head can be felt above the pelvic brim
because it is unable to descend; a large caput succedaneum may be
fixed in the pelvic brim and this can be misleading, but careful
palpation should identify that the widest diameter of the head is still
above the brim; if the uterus is tonic, it will be very difficult to palpate
because it is continuously hard and very painful for the woman
 frequent, long and strong uterine contractions (although if a woman
has been in labour for a long time, contractions may have stopped
because of uterine exhaustion); they restart with renewed vigour
 the uterus may have gone into tonic contraction (i.e. it is continuously
hard) and sits tightly moulded around the fetus
 Fetal heart may not be heard in severe cases of obstructed labour
because the fetus dies from anoxia.
C. Vaginal examination
The signs of obstruction that must be looked for are as follows:
  foul-smelling meconium draining
 amniotic fluid already drained away
 catheterization will produce concentrated urine which may contain
meconium or blood
 vaginal examination
- oedema of the vulva, especially if the woman has beenpushing for a
long time
- vagina hot and dry because of dehydration
- oedema of the cervix
- incomplete dilatation of the cervix (may be fully dilated in case of
outlet obstruction)
- a large caput succedaneum can be felt
- the cause of the obstruction, e.g.excessively moulded head stuck in
pelvis, shoulder, brow or posterior face presentation, prolapsed arm.

6. Explain the pathophysiology of obstructed labor ?

Pathophysiology of dystocia is described by disorder-the disorder are:
- Dystocia due to abnormal power
- Dystocia Because fetal abnormalities (Passenger).
- Dystocia due to abnormalities in the Born (Passage)

Dystocia is difficult delivery. The causes are generally divided into three
groups, namely:
- Distosia as power abnormalities (abnormal His). His abnormal in terms of its
strength or cause that obstacles in the birth canal that is prevalent at every birth,
can not be overcome, so that pesalinan experiencing barriers or bottlenecks.
- Distosia fetal abnormalities (Passenger). Labor may be susceptible to
interference or congestion due to abnormalities in the layout or form janinyang
too big so it is difficult to enter PAP.
 - Distosia for abnormalities Jalan Born (Passage). The disorder can be any size
or shape of the birth canal are relatively small or narrow that hinder the progress
of labor or cause a hour.

7. Explain the effects of obstructed labor to the mother and baby ?

 The danger for the mother

Prolonged labor cause adverse effects either to the mother or child. The severity
of injury increases with the length of the delivery process, the risk rises rapidly after
24 hours. There is an increase in the incidence of atonic, lacerations, bleeding,
infection, maternal exhaustion and shock. The birth rate with a high action exacerbated
the danger to the mother.

 The danger to the fetus

The longer the labor, the higher fetal mortality and morbidity as well as the
increasingly frequent cases:

a. Asphyxia due to prolonged labor itself

b. Cerebral trauma caused by pressure on the fetal head
c. Injuries resulting from acts of extraction and rotation with a difficult forceps
d. Rupture of amniotic long before birth. This situation resulted in the infection
of the amniotic fluid and can then carry a lung infection and systemic
infection in the fetus.

Even if there are no real damage, infants in prolonged labor requiring special care.
While any type of long pertus bring bad consequences infant child, the greater the
danger especially the progress of labor never stops. Most doctors consider even
prolonged labor increases the risk to children during childbirth, but the effect on the
baby's development just a little further. Some states that babies born through a long
labor was experiencing so distinctly different intellectual deficiency with babies born
after a normal delivery.

8. Explain the handling of obstructed labor ?

 a. did augmentation of labor with oxytocin and / or amniotomi if there is a
power interruption. make sure there is no disruption of passenger or passage.
b. do operative action (forceps, vacuum, or cesarean section) for passenger
disorder and / or passage, as well as to power disturbances that can not be
overcome by augmentation of labor.
c. if found obstruction or cpd, the management is cesarean section.
d. give antibiotics (combination of ampicillin 2 g IV every 6 hours and
gentamicin 5 mg / kg every 24 hours) if found:
- Signs of infection (fever, smelling vaginal fluid)or
- the membrane broke more than 18 hours, or
- age of the gestation <37 weeks
e. Monitor for signs of fetal distress.

9. How to assess their progress in labor ?

The partograph is a graphical presentation of the progress of labour, and of fetal
and maternal condition during labour. It is the best tool to detect whether labour is
progressing normally or abnormally, and to warned as soon as possible if there are
signs of fetal distress or if the mother’s vital signs deviate from the normal range.
Research studies have shown that maternal and fetal complications due to prolonged
labour were less common when the progress of labour was monitored by the birth
attendant using a partograph. For this reason, you should always use a partograph
while attending a woman in labour, either at her home or in the Health Post.
Component Of the Partograph :
A. The fetal condition
The fetus is monitored closely on the partograph by regular observation of
the fetal heart rate, Liquor, and the moulding of the fetal skull bones.
1. Fetal Heart Rate
The normal fetal heart rate at term (37 weeks and more) is in the range
of 120–160 beats/minute. If the fetal heart rate counted at any time in labour
is either below 120 beats/minute or above 160 beats/minute, it is a warning
for you to count it more frequently until it has stabilised within the normal
range. It is common for the fetal heart rate to be a bit out of the normal
 range for a short while and then return to normal. However, fetal
distress during labour and delivery can be expressed as:
 Persistent fetal bradycardia :Fetal heart beat persistently (for 10
minutes or more) remains below 120 beats/minute.
 Persistent fetal tachycardiaFetal heart beat persistently (for 10
minutes or more) remains above 160 beats/minute.
2. Liquor
If the fetal membranes are intact, write the letter ‘I’ (for ‘intact’).
If the membranes are ruptured and:
 liquor is absent, write ‘A’ (for ‘absent’)
 liquor is clear, write ‘C’ (for ‘clear’)
 liquor is blood-stained, record ‘B’
 liquor is meconium-stained, record ‘M1’
3. The Moulding of The fetal Skull Bones
To identify moulding, first palpate the suture lines on the fetal and
appreciate whether the following conditions apply. The skull bones that are
most likely to overlap are the parietal bones, which are joined by the sagittal
suture, and have the anterior and posterior fontanels to the front and back.
 Bones are separated and the sutures can be felt easily.
 +1 Bones are just touching each other.
 +2 Bones are overlapping but can be separated easily with
pressure by finger.
 +3 Bones are overlapping but cannot be separated easily with
pressure by finger.

B. Progress of labour
1. Cervical Dilatation
The first stage of labour is divided into the latent and the active phases.
The latent phase at the onset of labour lasts until cervical dilatation is 4
cm and is accompanied by effacement of the cervix.The latent phase may
last up to 8 hours, although it is usually completed more quickly than this.
Although regular assessments of maternal and fetal wellbeing and a record
 of all findings should be made, these are not plotted on the
partograph until labour enters the active phase.
Vaginal examinations are carried out approximately every 4 hours from
this point until the baby is born. The active phase of the first stage of
labour starts when the cervix is 4 cm dilated and it is completed at full
dilatation, i.e. 10 cm. Progress in cervical dilatation during the active phase
is at least 1 cm per hour (often quicker in multigravida mothers).
In the cervical dilatation section of the partograph, down the left side,
are the numbers 0–10. Each number/square represents 1 cm dilatation.
Along the bottom of this section are 24 squares, each representing 1 hour.
The dilatation of the cervix is estimated by vaginal examination and
recorded on the partograph with an X mark every 4 hours. Cervical
dilatation in multipara women may need to be checked more frequently
than every 4 hours in advanced labour, because their progress is likely to
be faster than that of women who are giving birth for the first time.
2. Descent of the fetal head
For labour to progress well, dilatation of the cervix should be
accompanied by descent of the fetal head, which is plotted on the same
section of the partograph, but using O as the symbol. The station can only

be determined by examination of the woman’s vagina with your gloved

fingers, and by reference to the position of the presenting part of the fetal
skull relative to the ischial spines in the mother’s pelvic brim.
When the fetal head is at the same level as the ischial spines, this is
called station 0. If the head is higher up the birth canal than the ischial
 spines, the station is given a negative number. At station –4 or –3 the fetal
head is still ‘floating’ and not yet engaged; at station –2 or –1 it is
descending closer to the ischial spines.
If the fetal head is lower down the birth canal than the ischial spines,
the station is given a positive number. At station +1 and even more at
station +2, you will be able to see the presenting part of baby’s head bulging
forward during labour contractions. At station +3 the baby’s head

is crowning, i.e. visible at the vaginal opening even between contractions.

The cervix should be fully dilated at this point.
3. Uterine Contraction
Normally, contractions become more frequent and last longer as labour
progresses. Contractions are recorded every 30 minutes on the partograph
in their own section, which is below the hour/time rows. At the left hand
side is written ‘Contractions per 10 mins’ and the scale is numbered from
1–5.
 I. The Alert and Action lines

In the section for cervical dilatation and fetal head descent, there are
two diagonal lines labelled Alert and Action. The Alert line starts at 4 cm
of cervical dilatation and it travels diagonally upwards to the point of
expected full dilatation (10 cm) at the rate of 1 cm per hour. The Action
line is parallel to the Alert line, and 4 hours to the right of the Alert line.
These two lines are designed to warn to take action quickly if the labour is
not progressing normally.

The Alert Line refer the woman to a health centre or hospital if the
marks recording cervical dilatation cross over the Alert line, i.e. indicating
that cervical dilation is proceeding too slowly. (The Action line is for
making decisions at health-facility level.)

C. The maternal condition

Regular assessment of the maternal condition is achieved by charting
maternal tempratures, pulse and blood pressure, and by regular urinalysis. The
partograph also contain a space to chart administration of drug, IV fluids, and
oxytosin if labour is augmented.

10. Explain how the process of checking and monitoring of pregnancy ?

ATTITUDE

Greetings and introductions Bring witnesses informed consent Mother

positioned on the bed, feet in flex (lithotomy) Open mother clothing taste (of
proc.Xiphoideus - symphysis pubis) Close the unnecessary parts with blankets.

INSPECTION

At 2-3 trimester of pregnancy Looks abdominal bloating Transverse or

longitudinal abdominal enlargement Pigmentation linea alba / striae +/- Sikatriks
+/- Visible movement +/- children
EXAMINATION OF LEOPOLD

Leopold 1

Examining overlooking advance mother.Determine the height of the

fundus.Palpating the fetus which is located in the fundus with both hands.Do palpable
round, large soft (buttocks) / round, big, loud(head) / palpable prisoners lengthwise
(back) / palpable small parts (extremities).

In term pregnancies with cephalic presentation, the examination will be palpable

Leopold first round, large, soft (buttocks).

Leopold 2

Examining overlooking advance mother.Palpating the fetus is located to the

right or left of the uterus with both hands.Do palpable round, large soft (buttocks) /
round, big, loud (head) / palpable prisoners lengthwise (back) / palpable small parts
(extremities).

In term pregnancies with cephalic presentation, the examination will be palpable

prisoners Leopold 2 aft (back) on one side and palpable small parts (extremities) on
the other side.

Leopold 3

Examining overlooking advance mother. Palpating the fetus is located above

the symphysis pubis while his other hand to hold the fundus fixation. Do palpable
round, large soft (buttocks) / round, big, loud (head) / palpable prisoners lengthwise
(back) / palpable small parts (extremities).

In term pregnancies with cephalic presentation, the examination will be palpable

Leopold third round, large, loud (head)

Additional: Osborn examination test

Hold the head of the fetus and attempted to enter PAP, If you can not get in
because it is still high, must be measured with a finger to find out how high from the
pubic symphysis. If the height is about 3 fingers above the symphysis or more means
Osborn test + (head of the fetus has not entered into PAP = possibility of Cephalopelvic
disproportion).

Leopold 4

Examining facing the mother's feet Determine whether the presenting part has entered
or passed the PAP by means immure presenting part, when the presentation:

o Convergent: presenting part has not entered into PAP

o Parallel: the presenting part has been partially entered into PAP

o Divergent: presenting part has been entered enter into PAP

Leopold
Note: Gemelli on Leopold examination will be palpable at least 3 major sections

ADDITIONAL
High measurement Fundus uteri

Make sure there are no contractions during high ratings fundus The tape measure
should be attached to the skin of the abdomen Measure the height of the uterine fundus
by using a tape measure from the start to the upper edge of the pubicsymphysis to the
top of fundus uteri (specified in px Leopold 1) through a midline abdominal
Measurement Estimated Fetal Weight Measured using the formula Johnson

Formula: TBJ = (TFU-n) x 155TBJ: Estimated Fetal Weight; TFU: High Fundus uteri
N = 11 = if the head had entered PAPN = 12 = if the head has not entered PAP

ASSESSMENT UTERINE CONTRACTION (HIS)

Place your hands carefully on top of the uterus and feel the contraction that
occurred within 10 minutes Sign when uterine contractions: uterus palpable hard and
fetal parts impalpable Determine whether the contraction is adequate based on the
interval, duration, relaxation His adequate is if within 10 minutes of going at least 2
times the contraction (maximum of 4x) with long contractions of 40-60 seconds per
contraction as well as between contractions is no relaxation phase

CALCULATION OF FETAL HEART RATE (auscultation)

Define punctum maximum in the region that has been determined by the time
of examination, putting a stethoscope Leopold Laennec in the back of the fetus
CalculateDJJnya 5 seconds of the first, third and fifth. Then the number and the result
is multiplied by 4 to obtain the frequency of FHR one minute

DJJ normal: 120-160x per minute

At the Gemelli will sound 2 punctum maximum with different frequencies

Abdominal palpation fives FOR DETERMINING THE DEGREE DESENSUS

Degrees desensus examined by palpation of the abdomen

On abdominal palpation examination, an examiner should be able to answer six key

questions

1. Is the fundus in accordance with the high estimate gestational age

2. Does the fetus is in longitudinal layout
3. How does the presentation of the fetus in the uterus.
The presentation is the lowest part of the fetus that occupies the lower part of
the uterus.In pregnancy about 30 weeks, 25% of the fetus is in breech
presentation.After 32 weeks, the fetus will normally be at the presentation of
the head.
4. Does the fetus is in vertex presentation (back of head)

- Flexion perfect head

- Chin off the front of the chest
- The lowest part subocciput
- Presentation normal physiological vaginal delivery.
 - Abnormalities deflection attitude: Hyperextension head
- The lowest part of the fetal face
- Denominator: chin
- At the posterior chin may not happen spontaneous vaginal delivery of the
fetus at term

5. What is the position of the fetus

The position is the relationship between the lowest part of the fetus
(denominator) with the mother's pelvis.When the fetus is in a posterior
position (occiput rotates the sacrum and the face of the fetus rotate forward)
then the delivery will take longer.The percentage back of the head (vertex)
that occurs in the process of normal vaginal delivery, the small anterior
fontanelle is anterior.

6. Is the head already engage

What is meant by engagemen is desensusbiparietal diameter through the

inlet. The easiest way to determine the amount of the head is still above the
pelvic inlet is to assess how many fingers of the fetal head is still above the
symphysis. When the head is already engage, then the head is still above the
symphysis is the second finger (2/5) or less.

Engagemen usually occurs when inpartu and whether the lowest part
already included in the pelvic or not and to what extent the inclusion of the
lowest part of the fetus (presentation) in the pelvic use Leopold IV
examination.

The lowest part of the fetus has entered PAP lowest part of the fetus is
still not entered PAP

VAGINAL toucher IN CASE OBSTETRIC

Indications vaginal toucher in the case of pregnancy or childbirth:

a. As part of the diagnosis of early pregnancy.

b. In primigravida with gestational age of 37 weeks are used to evaluate the
capacity of the pelvis (pelvimetry clinics) and determine if there are
abnormalities in the birth canal that is expected to be able to disrupt the process
of vaginal delivery.
c. On entry to the delivery room is done to determine the diagnosis phase of labor
and location of the fetus.
d. At the time of inpartu used to assess whether the progress of labor as
expected.
e. At the time of rupture of membranes used to determine whether there is a
small part of the fetus or prolapsetalipusat.
f. At the time of inpartu, mother appeared want meneran and used to determine
whether the delivery phase has entered the second stage of labor.

Technics:
Vaginal examination toucher in pregnancy and childbirth:
a. Preceded by inspecting the external genitalia.
b. The next phase, inspection inspekulo to see the state of the birth canal.
c. The labia minora aside left and right with the thumb and forefinger of the
left hand of cranial side to expose the vestibule.)
d. The index finger and middle finger of the right hand in the upright and
tightly put towards the back - of the vagina and palpate servik.
 Determining dilatation (cm) and the flattening of the cervix
(percentage).
 Determine the state of the membranes were intact or had broken, when
it broke specify: Color, Smell. The amount of amniotic fluid is flowing
out
 Determining the presentation (the lowest part) and position (based on
the denominator) and the degree of descent based station.
  Determine whether there are small parts of other fetal or talipusat which
are next to the lowest part of the fetus (presentation copies - compound
presentation).
 In primigravidas used more to do pelvimetry clinic:
- Examination form the sacrum.
- Coccygeus determine whether prominent or not.
- Determine whether the spine ischiadica stand or not.
- Measuring distansiainterspinarum.
- Checking arch lateral wall of the pelvis.

Fingering promontory, when palpated it can be suspected the

narrowness of the pelvis (measuring conjugatadiagonalis).

Determine the distance between the two tuber ischiadica.

11. The influence of age with prolonged labor ?

Within a healthy reproductive age, it’s known that the save age for pregnancy and
childbirth is 20-30 years, because at this age mother’s physic and psychologyare
mature enough in dealing with pregnancy and childbirth. Maternal deaths in pregnancy
and childbirth at the age below 20 years turned out to be 2-5 times higher than in
maternal deaths occur at age 20-29 years. Maternal death increased again after the age
of 30-35 years.

Age under 20 years old, a mother’s reproductive organs as a whole hasn’t been
perfect yet and immature psychological development that’s not ready to be a mother
and accept her pregnancy. Under 16 or over 35 years old predispose women to a
number of complications. Under 16 years of age the incidence of preeclampsia
whereas over 35 years, mother’s reproductive organs undergo changes which occurs
due to the aging process and the birth canal gynecologic becomes rigid or not flexible
again. Moreover,the increase of mother’s age will affect vital organssuch as the
cardiovascular system, kidneys, etc. (at this age, disease easily occur in women that
would aggravate the task of these organs so that will increase the risk of complications
in the mother and fetus). This age of 35 years old also increases incidence of chronic
hypertension and a long labor in nulliparous.
 12. Explain why pain felt through to the back ?
Pain caused by uterine muscle contraction, muscle contraction hypoxia, stretch the
cervix, ischemia of uterine corpus , and stretching of the lower uterine segment.This
pain is transferred to the dermatome which supplied by the same spinal cord segment
to the segment that receives nociceptive input from the uterus and cervix. Dermatome
is an area of the body supplied by the special spinal nerves. Pain is felt as a dull pain
which is long in the early stage 1 and limited to the thoracic dermatomes 11 and 12.
Then the first stage of labor, T11 and T12 dermatomes pain becomes more severe,
sharp, and spread to the lumbar dermatomes 1 (L1).

13. Why there is difficulty in pregnancy first child ?

The present study examined the association between maternal anthropometric
measurements, neonates, and labor characteristics with dystocia in order to identify
the risk factors related to this problem. According to logistic regression analysis, a
moderate to high anxiety score at admission was the most important risk factor for
dystocia in nulliparous women.
Women with moderate to high anxiety score experienced dystocia 10.5 times
more than other women. Researchers have concluded that anxiety and fear lead to the
production of stress hormones in the body that can interfere with normal delivery and
conduct dystocia. Anxiety causes the release of catecholamines. Catecholamines,
particularly epinephrine, interrupt the coordination of uterine contractions by binding
to beta-adrenergic receptors located on the myometrium which slows the progression
of labor. A study by Laursen et al. reported that the cesarean section rate in women
who experienced fear of delivery during the third trimester was 1.3 times higher. In
this research, mothers exhibited symptoms of increased fear as the time to delivery
became nearer.
According to the results of this study the most important risk factor for dystocia
in nulliparous women were moderate to high anxiety scores, occipito-posterior fetal
head position, fetal head swelling during the second phase, Michaelis sacral transverse
diameter ≤9.6 cm, and height to fundal height ratio <4.7. Measuring these parameters
in addition to special care during labor and delivery in high risk women might
effectively prevent dystocia and its complications

14. How the interpretation of the physical examination of the scenario ?

INTERPRETATION OF THE RESULTS OF A PHYSICAL EXAMINATION

RESULTS OF A PHYSICAL
NUMB. INTERPRETATION
EXAMINATION
Fundus height 3 fingers below
1 ± 36 weeks pregnant
Xyphoideusprocessuss
2 Fetus spine was on the left side Left occiput anterior
3 The most lower part was head Head presentation
Sinciput felt and Occiput
4 1/5 engaged
not felt
Distance between Simphysis pubis and
Predicting birth weight
5 height of fundus was 40 cm and abdominal
3.920 gram
circumference 98 cm
6 Fetal heart rate 130 x/menit Normal
His 4 times within 10 minutes with Adequancy His and Sign
7
duration of 40 – 45 seconds ofInpartu
Complete dilation of
Cervix opening 10 cm and membranes not cervix and the
8
palpable membranes already
ruptured

15. Mention the Islamic perspective with regard to the scenario ?

AL-Baqarah 233
Mothers may breastfeed their children two complete years for whoever wishes to
complete the nursing [period]

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