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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 1 - 2 mU /


min
Interval every 30 min.
Dosis kenaikan 1 - 2 mU
Optimal dose 8 - 10 mU / min.
Side Effects Oxytocin

Side effect Mecanism Prophylacis


Hypoxia fetal Hiperstimulasi Optima
dose
Ruptur Utery Hiperstimulasi Optimal dose
Water intoxycation ADH effect Batasi cairan
Hypotensi Vasodilatation 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 LOA

ROT
LOT

ROP LOP
OP
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
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
part feet foot
DELIVERY SHOULD BE CONSTRAINTLESS
Hospital Primi : BW > 3500 gram C-Section
Caesarean Section
BW < 3500 & Multipara Spontaneous : Bracht
Manual A i d C-Section
Forcep Piper
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 Empty

LEOPOLD II Large parts left & right side

Heart sound Around the umbilicus

Int.Ex : Membrane ( - ) Shoulder


Dilatation >>>

PROFILAXIS External Version :


1.Single
2.Second twin
DELIVERY 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 Mother restlessness
Fetal distress / IUFD
Urine bloody
THANK YOU FOR YOUR
ATTENTION

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