DYSTOCIA

Dini Pusianawati
PART - 1
Ref : 1. Williams Obstetrics
2. OBSTETRI PATOLOGI 3. PROTAP BAG .OB.GYN RSHS

DYSTOCIA
A difficult labor

3-P
1. POWER

2. PASSENGER
3. PASSAGE

A BABY IS DELIVERED UPON A CERTAIN POWER

THROUGH A CERTAIN ROUTE

PHYSIOLOGIC LABOR

SPONTANEOUS LABOR

3-P

1. POWER :

( Kekuatan ibu )
H i s / Labor pain

Tenaga mengejan /
Pushing power

2. PASSENGER :
2.1. PATHOLOGIC PRESENTATION/POSITION : 2.1.1 : POPP 2.1.2 : DEFLECTION: FACE/BROW 2.1.3 : BREECH PRESENTATION

2.1.4 : TRANVERSE LIE

2.1.5 : COMPOUND PRESENTATION 2.2 FOETAL ABNORMALITY : 2.2.1 : LARGE BABY 2.2.2 : HYDROCEPHALUS/LARGE ABDOMEN

3. PASSAGE
( Jalan lahir )
3.1. PELVIC ABNORMALITIES 3.2. PELVIC TUMOR

3.3. NARROWNESS OF VAGINA/VULVA

3.4. EXOSTOSIS

POWER ABNORMALITIES :
Labor pain abnormalities :

1. How does labor pain start ?.

2. What may disturb labor pain and

why ?
3. Type of labor pain abnormalities ?

4. How could we diagnose them ?

5. What is the therapeutic measure ?.

LABOR PHASES AND STAGES

1. PHASE - 1 : PREPARATORY 2. PHASE - 2 : ACTIVE LABOR

STAGE : I - II - III - IV
3. PHASE - 3 : PUERPERIUM AND

UTERINE INVOLUTION

PREPARATORY PHASE
1. UTEROTROPIN Prostaglandin Cervix soft & mature Junction gap

Oxytocin receptors
Contractility

2. UTEROTONIN

A collection of substances that provokes myometrial contraction

OXYTOCIN PROSTAGLANDIN

ETIOLOGY OF HIS ABNORMALITY

Overuse of analgesics

Contracted pelvis Malpresentation Over extended uterus Psychological factor

TYPE OF LABOR PAIN ABNORMALITIES

1. Hypertonic uterine inertia 2. Hypotonic uterine inertia Primary uterine inertia

Secondary uterine inertia

Differences of uterine inertia

Hypotonic Hypertonic Uterine Inertia Uterine Inertia 4 % 1% Stage I - Active None Slow onset Oxytocin Stage I Latent Exagerated Rapid onset Sedative

Incidence Phase Pain Fetal distress Therapy

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

Foetal distress Prolonged labor

MANAGEMENT

1.Hypertonic uterine Inertia Morphine 10 mg ( Inj ) Pethidine 50 mg ( Inj )

Caesarean Section

2. Hypotonic uterine inertia

OXYTOCIN INFUSION : Membrane ruptured Oxytocin 5 IU/500 cc Dextrose 5% Fail : Sectio Caesarea

MODE OF ADMINISTRATION :

Starting dose 20 gtt / min Increased 5 gtt / 15 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 dissappeared > FHB ( - )

> Fetal parts are easily palpable

> Shock : BP PULSE : unpalpable

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 [forceps extraction]

THREATENED UTERINE RUPTURE

SYMPTOMS AND SIGNS : Contraction strong / Tetanic

RING OF BANDL
Round ligament tense & hard

Painful

Mother restlessness

Fetal distress / IUFD Urine bloody (red color in catheter)

MANAGEMENT :

PREGNANCY TERMINATION
1. CAESAREAN SECTION

2. FORCIPAL EXTRACTION
3. EMBRYOTOMY

4. DOUBLE SET UP

Constriction ring Locally thickness Thicknes at the ring site Lower uteine segment normal Stage I II III Stationary Palpable through internal examination Good general cond Prem rup membran / operative delivery

Bandl ring Border of Upper and Lower Ut.segment Upper segment thick lower part thin Lower uterine segment stretched Stage II Getting higher Palpable through Abdominal wall Bad gen.condition CPD

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

DYSTOCIA

PART - 2

PASSENGER ABNORMALITIES

MALPOSITION MALPRESENTATION PHYSICAL ABNORMALITIES

MALPOSITION :

Persistent Occiput Posterior Position

Await spontaneous delivery : 15% delivery 7% POPP

Forceps/vacuum delivery berhasil

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

DEFLECTION
Leopold II
Auscultation Int.Exam Large dilatation Delivery Forcipal Extraction Manuvers Etiology for dystocia

FACE Pr
Fabre angle
Small part Orbital nose , mouth , chin Chin ant : SP Chin post : CS Chin anterior

BROW Pr
Fabre angle
Small part Large fontanel , frontal suture orbital edge CS Never

ABANDONED Maximally Diameter >>> head deflection

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

HS Hospital

BW > 3500 gram Caesarean Section Spontaneous : Bracht Manual A i d Forcep Piper

BW < 3500 & Multipara

Sectio C

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

PROFILAXIS :

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

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/ VcE / 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 / 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 : Suficient : CS Small : Perforation Complication :Uterine Rupture

PASSAGE ABNORMALITIES

Diameter

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

CV Transver + Sagit Post Transver

< 9 cm

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

COMPLICATIONS : Incarceratous Retroflected 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 : Occiput 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 Uncomplete 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 tumours Diagnosis during a terme pregnancy / delivery : CS

DISTOSIA BAHU
Terjebaknya bahu pada pintu atas panggul setelah kepala anak lahir.

Etiologi : Anak besar Ibu menderita DM Genetik (orang tua) Serotinus CPD Anenchephalus Pada ekstraksi forseps/ vakum, melahirkan terlalu cepat

Evidence level III B Evidence level IV

Evidence level III

Evidence level III

THANK YOU FOR YOUR ATTENTION