PERSALINAN PATOLOGIS

ABNORMAL LABOR
DYSTOCIA
TUJUAN =
Mahasiswa kedokteran klinik
Mampu menginterpretasikan temuan atau
informasi yang ditampilkan oleh Partograf.
Mampu mengklasifikasikan persalinan normal
dan abnormal berdasarkan temuan dari
partograf.
Mampu menilai penyebab persalinan abnormal.
Mampu menjelaskan keputusan klinik sebagai
upaya penyelesaian persalinan berdasarkan
diagnosis klinis.
Abnormal labour = dystocia

Dystocia means difficult labor and is characterized

by abnormally slow progress of labor.

William obstetrics 24 ed.

KASUS #1

Ny S, 30 tahun, hamil G2 P1 A0 hamil aterm,

dirujuk oleh bidan dengan alasan belum
partus dari 12 jam yang lalu.
Anak pertama laki laki, usia 2 tahun, BB
3600, lahir dengan ekstraksi vakum.
Tinggi badan ibu 155 cm, berat badan 65 kg
dan kenaikan bera badan selama hamil 20 kg.
KASUS #2 (cont)

Kondisi ibu baik, TD = 120/80 mmHg,

pernafasan 20 x/mnt, nadi 80 x/mnt, tidak
anemis, tidak edem.
Pemeriksaan obs =
TFU 38 cm
L I-IV presentasi kepala, punggung kiri,
penurunan kepala 2/5
djj = 140 x/mnt
his = 3 x dalam 10 menit, lama 45 detik
KASUS #3 (cont)

Pemeriksaan dalam vagina

Pembukaan 5 cm.
Kulit ketuban (-)
Kepala H III
UUK kiri depan
Moulage ++
Buatlah partograf,
diagnosis klinis dan
sikap ?
KASUS #4 (cont)

4 jam kemudian =
his 5x dalam 10 menit, lama 50 detik, djj
150x/mnt
penurunan kepala 2/5
periksa dalam vagina =
pembukaan 8 cm, portio edem
kepala turun HIII
moulage sulit dinilai, caput +
Gambaran apa yang
ditunjukkan oleh
partograf?
Kesimpulan apa yang
anda buat
berdasarkan temuan
partograf tersebut ?
Dari kesimpulan yang
anda buat, apakah
persalinan ini
termasuk normal ?
Apakah penyebab dari
kelainan ini ?
Bagaimana jika
dilakukan augmentasi
pada kasus ini ? Apa
resikonya ?
Tindakan apa yang
paling rasional untuk
menyelesaikan
persalinan ini ?
PERSALINAN PATOLOGIS
ABNORMAL LABOR
DYSTOCIA
Abnormal labour = dystocia

Dystocia means difficult labor and is characterized

by abnormally slow progress of labor.

William obstetrics 24 ed.

CONTOH TEMUAN PARTOGRAF

Pembukaan serviks tidak mengalami kemajuan.

Pembukaan serviks maju tetapi tidak disertai penurunan
kepala.
Pembukaan serviks tidak maju tetapi terdapat kemajuan
dalam penurunan kepala.
Grafik garis pembukaan menyilang ke arah kanan garis
waspada.
Kontraksi tidak membaik dan diikuti dengan tidak
majunya pembukaan dan penurunan kepala.

PONEK
Progress in labor

POWER PROGRESS
PASSAGES PASSENGER
IN LABOR

Alarm course
Assessment of labor
abnormalities

Abnomalities of the powers

Abnormalities involving the passanger

Abnormalities of the passage

William obstetrics 22 ed.

POWERS
Abnormalities of the powers

Hypotonic uterine
dysfunction

Hypertonic uterine
dysfunction

Incoordinate uterine
dysfunction
Assessment of uterine
activity
Ideally = Uterine activity can be quantified by
measurement of intrauterine pressure (IUP).
High risk pregnancy, 2006

The lower limit of contraction pressure required

to dilate the cervix is 15 mmHg.
William obstetrics 24 ed.
Assessment of uterine
activity
For clinical purpose =
Most contraction only become palpable when the
IUP exceeds baseline tone by
more than 15 mmHg.

Palpation of frequency and duration of contraction

can give an adequate, semiquantitative
assessment of uterine activity, including
oxytocin augmentation.
High risk pregnancy, 2006
Adequacy of uterine activity

3 or 4 contraction every 10
Frequency minutes

Minimum 40 seconds
Duration

Good progress
Result
High risk pregnancy, 2006 and alarm course
Reported causes of uterine
dysfunction

Epidural analgesia
Chorioamnionitis
Maternal position during labor
William obstetrics 24 ed.
Management of hypotonic
dysfunction
Check maternal condition
Informed consent
Assess maternal pelvis and fetal presentation.
Remember =ineffective labor is generally
accepted as apossible warning sign of CPD
Amniotomy in case of intact membrane.
Oxytocin augmentation

High risk pregnancy, 2006

Alarm guideline for amniotomy

Effective if dilatation > 3 cm.

Mostly amniotomy continue with oxytocin
augmentation.
Be careful if the lowest presenting part of
fetus still high.
Alarm guideline for oxytocin
augmentation
Check maternal hydration.
Consideration amniotomy before augmentation.
Experience care givers.
Ready for CS immediately.
Must be prepared to manage uterine
hyperstimulation.
Alarm guideline for oxytocin
augmentation
Initial dose 1 2 mU/min
Increase interval every 30 minutes
Dosage increment 1 2 mU
Usual dose for good labor 2 12 mU/min
Conversion 1 mU = 2 drops
Precipitatous labor and
delivery
Definition = expulsion of the fetus in less than 3
hours
Effect on maternal :
rupture cerix, vagina, vulva or perineum
amnionic fluid embolism
PPH because hypotonic after delivery
Effect on fetus and neonate :
Hypoxia fetus
Erb or duchenne brachial palsy
William obstetrics 22 ed.
Alarm guideline for management
for hyperstimulation
Stop oxytocin
Rehydration intravenous
Termination of labor immediately
Check fetal hypoxia intrauterine resucitation
Consider tocolytic
Oral ISDN 5 mg
Terbutaline 2,5 mg oral
IV Betamimetic 250 500 ug/min
nitroglycerin 50 ug max 200 ug
PASSAGES
try it and see

Because of
1. Clinical and x ray pelvimetry have poor
predictive values.
2. the mechanism of labor that relies on
flexion, rotation, molding and even pelvic
compliance.
High risk pregnancy, 2006
Caused by

Contracted bony pelvis

Pelvis Deformed bony pelvis

Soft Uterine fibroids

Ovarian tumors
tissue Rectal tumors

Alarm course
Generally assume

Pelvic capacity is adequate if a woman has a

delivered vaginally before.

Indonesia assume that 2500 gr as a cut of point.

High risk pregnancy, 2006

PASSENGERS
Caused by

Malpresentation
Face, brow, shoulder/arm, breech, compound
presentation
Malposition
Persistent occipito transverse
Malformations
Hydrocephalus, abdominal tumors, cystic higroma,
conjoined twins
Alarm course
Macrosomia
Shoulder dystocia
William obstetrics 24 ed
Clinical feature of CPD

Excessive moulding
Failure of presenting part to engage and descent.
High risk pregnancy 2006
Temuan sebagai indikasi CPD

Pemeriksaan abdomen
- ukuran janin besar ( > 4 kg )
- kepala janin diatas PAP
Pemeriksaan panggul
- serviks mengecil setelah amniotomi
- edema serviks
- caput
- molase bera
- defleksi kepala (fontanella anterior mudah dipalpasi.
- asinklitismus (sutura sagitalis tidak tepat di tengah panggul)

PONEK
Alarm guideline for
management dystocia
Arrest without CPD = amniotomy and
oxytocin augmentation.
Arrest withCPD = CS
Remember
A lack of descent in the absence of moulding
or caput is likely due to inadequate
contractions.
Alarm guideline for
prevention of dystocia
Accurate diagnosis of labor
Management of prolonged latent phase (PLP)
Deff PLP = time > 20 hours
Labor preparation (prenatal education)
Birth companion (continuous support)
Not only health discipline
Ambulation
Choice of labor position
Active management of labor
Analgesia
Alarm guideline for active
management of labor
Correct diagnosis of labor.
Close surveillance of progress of labor by
partogram.
Continuous support in labor.
Early intervention to correct inadequate progress
of labor with appropriate intervention = such as
amniotomy, oxytocin augmentation.
Maternal effects of dystocia

Intrapartum infection
Uterine rupture
Pathological retraction ring
Fistula formation
Pelvic floor injury
Postpartum lower extremity nerve injury
Wiiliam obstetrics 24 ed
Fetal effects of dystocia

Caput succedaneum
Fetal head molding
Asfiksia

Wiiliam obstetrics 24 ed