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DYSTOCIA

Ref : 1. Williams Obstetrics 23rd Ed

2. OBSTETRI PATOLOGI

3. PROTAP BAG .OB.GYN RSHS

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Persalinan normal

Suatu keadaan fisiologis, normal dapat berlangsung sendiri tanpaintervensi penolong.

Kelancaran persalinan tergantung 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.

Kelambatan atau kesulitan persalinan inidisebut DISTOSIA.

Gangguan

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A BABY IS DELIVERED UPON A CERTAIN POWER

IN A PHYSIOLOGICAL MANNER

THROUGH A CERTAIN ROUTE

PHYSIOLOGIC LABOR

SPONTANEOUS LABOR

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PROBABILITY OF

AN OBSTETRIC COURSE

INPUT(Pregnant woman)

PROCESS(Labor)

OUTCOMEMother Survive

Foetus Death

Sequellae

PHYSIOLOGIC

PATHOLOGIC

DIAGNOSIS

PHYSIOLOGIC

PATHOLOGIC

PHYSIOLOGIC

PATHOLOGIC

PROGNOSIS PROGNOSIS

Intervention

- Promotive

- Preventive

- Curative

Promotive

Preventive

Curative

Rehabilitative

- Promotive

- Preventive

- Curative

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EUTOCIA ?

DYSTOCIA ?

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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.

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DYSTOCIA

Abnormal labor

3 - P Abnormalities :

1. POWER

2. PASSENGER

3. PASSAGE

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H i s / Labor pain

Tenaga mengejan / Pushingpower

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PATHOLOGIC PRESENTATION

POSITION :

POPP DEFLECTION

BREECH PRESENTATION

TRANVERSE LIE

COMPOUND PRESENTATION

FOETAL ABNORMALITY :

LARGE BABY

HYDROCEPHALUS

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PELVIC ABNORMALITIES

PELVIC IN LETMID PELVIC

PELVIC OUTLET

PELVIC TUMOR

NARROWNESS OF VAGINA/VULVA

EXOSTOSIS

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ETIOLOGY

Overuse of analgesics

Contracted pelvis

Malpresentation

Over extended uterus

Psychological factor

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TYPE OF LABOR PAIN

ABNORMALITIES

1. Hypertonic uterine inertia

2. Hypotonic uterine inertiahis lemah dan frekuensinya jarang.

- anemia

-uterus yang terlalu teregang misalnya akibat hidramnion atau

kehamilan kembar atau makrosomia, grandemultipara atau primipara

-keadaan emosi kurang baik.

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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

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Hypotonic

Uterine Inertia

Hypertonic

Uterine Inertia

Incidence 4 % 1 %

Phase Stage I - Active Stage I Latent

Pain None Exagerated

Fetal

distress

Slow onset Rapid onset

Therapy Oxytocin Sedative

Differences of uterine

inertia

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Criteria for detecting abnormal

uterine contraction :

No / slow progress of labor :

Tool : PARTOGRAPH ( WHO )

Clinical values :

DilatationDescend of the presenting part

Internal rotation

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Complications

Prolonged labor :

Fetal morbidity

Maternal morbidity

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MANAGEMENT

1.Hypertonic uterine Inertia

Morphine 10 mg ( Inj )

Pethidine 50 mg ( Inj )

Caesarean Section

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OXYTOCIN INFUSION :

RSHS : TRIPLE PROCEDURE

Membrane ruptured

Oxytocin 5 IU/500 cc Dextrose 5%

Pethidine 50 mg + Phenergan 50 mg

Fail : Caesarean section

2. Hypotonic uterine inertia

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MODE OF ADMINISTRATION :

Starting dose 20 gtt / min

Increased 10 gtt / 30 min

Maintained if adequatecontraction has achieved.

Maximum 60 gtt / min

Tool for observation CTG

MAXIMUM 2 BOTLES

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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

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MANAGEMENT OF COMPLICATIONS

Fetal distress detected :

Stop oxytocin infusion or

Decreased number of drops

Intrauterine resuscitationRe evaluation

Fetal distress ( + ) CS

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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

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THREATENED UTERINE RUPTURE

SYMPTOMS AND SIGNS :

Contraction strong / Tetanic

RING OF BANDLRound ligament tense & hard

Painful Mother restlessness

Fetal distress / IUFD

Urine bloody

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MANAGEMENT :

PREGNANCY TERMINATION

1. CAESAREAN SECTION2. FORCIPAL EXTRACTION

3. EMBRYOTOMY

4.DOUBLE SET UP

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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

internal examination

Palpable through

Abdominal wall

Good general cond Bad gen condition

Prem rup membran /

operative delivery

CPD

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DYSTOCIA

PART - 2

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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

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PASSENGER ABNORMALITIES

MALPOSITION

MALPRESENTATION

PHYSICAL ABNORMALITIES

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MALPOSITION :

oPOPP : Persistent Occipital

Posterior

Position

oTransverse Arrest

oDeep Transverse Arrest

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MALPRESENTATION

DEFLECTION :

1. Face presentation

2. Brow presentation

BREECH PRESENTATION

TRANVERSE LIE


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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 CSChin post : CS

Forcipal Extraction Chin anterior Never

Maneuvers ABANDONED

Etiology for dystocia Maximally Diameter >>>

head

deflection

BREECH PRESENTATION

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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

HS Hospital Primi : BW > 3500 gram Caesarean

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

Manual A i d

Forceps Piper

BREECH PRESENTATION

Caesarean

BW > 1800

PROGNOSIS :

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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

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Contra indication of Ext.Version :Contracted pelvis

Hypertension

Ante partum bleeding

Uterine ( Myometrial ) scar

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Constraints for External Version :

Abdominal wall hardness

Placenta lies Anteriorly

Uterine malformation

Short umbilical cord

Frank breech

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Complications :

Rupture of the membrane

prolapsed of umbilical cord

Fetal distress

Solutio placentae

Uterine rupture

TRANSVERSE LIE

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TRANSVERSE LIE

Uterine congenital malformation

UTERUS ARCUATUS

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TRANSVERSE LIE

LEOPOLD I , III Empty

LEOPOLD II Large parts left & right side

Heart sound Around the umbilicus

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

Shoulder

PROFILAXIS External Version :1.Single2.Second twin

DELIVERY Foetus alive aterme CSDeath foetus a termeEmbryotomi / Double set up

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COMPLICATIONS :

Umbilical cord prolapsed

Arm / hand prolapsed

Neglected transverse lie

Uterine rupture

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Diagnosis during 1

st

stage of laboractive phase / Second Stage .

Hand / arm /was felt beside the

head

MANAGEMENT :

Hand prolapsed : Spontaneous /FE

Arm prolapsed : Reposition/FE/CS

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CORD PROLAPS

DIAGNOSIS :

Membrane ( - ), cord was felt

beside the presenting part.

TYPES :

Occult Prolapsed

True Prolapsed

CTG : Variable deceleration

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MANAGEMENT :

Prompt pregnancy termination :

Fetus alive : FE/ VcE / CS

Fetus dead : Vaginal delivery

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LARGE BABY :

Birth weight > 4000 gram

DIAGNOSIS :

Fundal height > 42 cmUSG

COMPLICATIONS :CPD

Shoulder Dystocia

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MANAGEMENT :

Fetus alive:Breech presentation : CS

Occipital presentation :

Spontaneous /Considerpelvic cavity wideness

Woods maneuver

FE / Vc E

CS

Fetus dead : Embriotomy/FE/CS

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HYDROCEPHALUS

Diagnosis :

Leopold III : Large bulky head ;

undescended.

Leopold IV : Both hand //

or Diverge.USG : Brain Ventricles >>>

Face

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Diagnosis : ( continued )During delivery :

Head presentation : high

Sutures >>>

Large fontanel >>> and bulging

Ping pong phenomenon

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PASSAGE ABNORMALITIES

Pelvic inletDiameter

ABSOLUT RELATIVE Mid Pelvic Pelvic

out let

CV < 8,5 cm 8,5 - 10cm

Transver

+Sagit Post

< 13,5 cm < 15 cm

Transver < 9 cm

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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

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COMPLICATIONS :

Incarceratous Retroflexed uterus

Malpresentation

Pendulous abdomen

Prolonged labor

Uterine Rupture

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MANAGEMENT :

Type of pelvic Mode of delivery

abnormalitiesAbsolute : CS

Relative :

Trial of labor

Succeed Spontaneous/FE/VcE

Failed CS

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TRIAL OF LABOR :

Conditions :

Occipital presentation

Mother and fetus in good conditionStart : at the beginning of labor

End :

Improbability of vaginal deliverySuccessful vaginal delivery

( Spontaneous / FE /VcE)

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Successful trial of labor :

Vaginal delivery ; mother and childsurvive in good condition ( Sp / FE /Vc E )

Complete failed trail of labor :

Dilatation full ;CS due to unengagement or failed of FE /Vc EIncomplete failed trial of labor :

CS was performed before fullydilatation was achieved , due toother indications.

Management during next pregnancy :

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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

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THANK YOU FOR YOUR ATTENTION

Good Luck with your examinations !!

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