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DYSTOCIA Dini PusianawatiPART - 1Ref : 1. Williams Obstetrics 2. OBSTETRI PATOLOGI 3. PROTAP BAG .OB.GYN RSHSDYSTOCIA A difficult labor 3 - P 1. POWER2. PASSENGER3. PASSAGEPHYSIOLOGIC LABOR SPONTANEOUS LABORA BABY IS DELIVERED UPON A CERTAIN POWER

THROUGH A CERTAIN ROUTE1. POWER :( Kekuatan ibu ) H i s / Labor pain Tenaga mengejan / Pushing power 3 - P2. 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 ABDOMENPPOP: Persistance occipital posterior presentation53. PASSAGE( Jalan lahir )3.1. PELVIC ABNORMALITIES3.2. PELVIC TUMOR 3.3. NARROWNESS OF VAGINA/VULVA3.4. 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 STAGES1. PHASE - 1 : PREPARATORY 2. PHASE - 2 : ACTIVE LABOR STAGE : I - II - III - IV3. PHASE - 3 : PUERPERIUM AND UTERINE INVOLUTIONPREPARATORY PHASE1. UTEROTROPIN Cervix soft & mature Junction gap Oxytocin receptors Contractility Prostaglandin 2. UTEROTONINA collection of substancesthat provokes myometrialcontraction OXYTOCIN PROSTAGLANDINETIOLOGY OF HIS ABNORMALITY Overuse of analgesics Contracted pelvis Malpresentation Over extended uterus Psychological factorTYPE OF LABOR PAIN ABNORMALITIES1. Hypertonic uterine inertia2. Hypotonic uterine inertia Primary uterine inertia Secondary uterine inertia

Differences of uterine inertiaCriteria for detecting abnormal uterine contraction :No / slow progress of labor :Tool : PARTOGRAPH ( WHO )Clinical values : Dilatation Descend of the presenting part Internal rotationComplications Foetal distress

Prolonged laborMANAGEMENT1.Hypertonic uterine Inertia Morphine 10 mg ( Inj ) Pethidine 50 mg ( Inj ) Caesarean SectionOXYTOCIN INFUSION : Membrane ruptured Oxytocin 5 IU/500 cc Dextrose 5%

Fail : Sectio Caesarea2. Hypotonic uterine inertiaMODE 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 BOTLESComplications :1. Fetal distress /Tetanic contraction > Fetal heart beat : Irregular / > 160 > CTG : Late deceleration/Var.decel2. UTERINE RUPTURE : > Contraction dissappeared > FHB ( - ) > Fetal parts are easily palpable > Shock : BP PULSE : unpalpable MANAGEMENT OF COMPLICATIONSFetal distress detected : Stop oxytocin infusion or Decreased number of drops Intrauterine resuscitation Re evaluation Fetal distress ( + ) CSUTERINE RUPTURE : Stop oxytocin drip Prepare blood transfusion Laparotomy Hysteroraphy + Sterilization HysterectomyINADEQUATE PUSHING POWER :Most frequent causes :MOTHER FATIGUENESS : Rapid pulse Rapid respirationMANAGEMENT :1.Dextrose 5 % Infusion2.Damp Oxygen 3 L/minute3.F.E [forceps extraction] THREATENED UTERINE RUPTURESYMPTOMS 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

CERVICAL DYSTOCIA As long as the labor pain is physiologic a full cervical dilatation should be achieved , except in case of :1. CERVICAL DYSTOCIA2. Contracted pelvisDYSTOCIAPART - 2 PASSENGER ABNORMALITIES MALPOSITION MALPRESENTATION PHYSICAL ABNORMALITIESMALPOSITION :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 FACE Pr BROW PrLeopold II Fabre angle Fabre angleAuscultation Small part Small part Int.Exam Orbital nose , Large fontanel Large dilatation mouth , chin , frontal suture orbital edge Delivery Chin ant : SP CS Chin post : CSForcipal Extraction Chin anterior NeverManuvers ABANDONEDEtiology for dystocia Maximally Diameter >>> head deflection Frank Compl Incompl Footling Breech Breech Breech LEOPOLD I Head Head Head HeadLEOPOLD III Breech Breech Breech Breech Auscultation Umb Umb Umb Umbilical Presenting Foot (-) Both One Feet part feet foot DELIVERY SHOULD BE CONSTRAINTLESSHS Hospital BW > 3500 gram C a e s a r e a n S e c t i o n BW < 3500 & Multipara Spontaneous : Bracht Manual A i d Forcep PiperBREECH PRESENTATIONSectio CKhusus untuk footling lakukan operasi sesar.. Karena 33PROGNOSIS :BAD , Fetal death3-4 X vertex presentationPROFILAXIS :External version Condition : Dilatation < 2-3 Cm Membrane : intact Presenting part : above inletContra indication of Ext.Version : Contracted pelvis Hypertension Ante partum bleeding Uterine ( Myometrial ) scarConstraints for External Version : Abdominal wall hardness Placenta lies Anteriorly Uterine malformation Short umbilical cord Frank breechComplications : Rupture of the membrane prolaps of umbilical cord Foetal distress Solutio placentae Uterine ruptureTRANSVERSE LIEUterine congenital malformationUTERUS ARCUATUS

TRANSVERSE LIE

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 headMANAGEMENT : Hand prolaps : Spontaneous /FE Arm prolaps : Reposition/FE/CSCORD PROLAPSDIAGNOSIS :Membrane ( - ), cord was feltbeside the presenting part.TYPES : Occult Prolapse True ProlapseCTG : Variable deceleration MANAGEMENT :Prompt pregnancy termination :Foetus alive : FE/ VcE / CSFoetus dead : Vaginal delivery LARGE BABY :Birth weight > 4000 gramDIAGNOSIS : Fundal height > 42 cm USGCOMPLICATIONS : CPD Shoulder DystociaMANAGEMENT :Fetus alive: Breech presentation : CS Occiput presentation : Spontaneous /Consider pelvic cavity wideness Woods manuver FE / Vc E CSFetus dead : Embriotomy/FE/CSHYDROCEPHALUSDiagnosis : Leopold III : Large bulky head ; undescended. Leopold IV : Both hand // or Diverge. USG : Brain Ventricles >>> Face > Large fontanel >>> and bulging Ping pong phenomenonMANAGEMENT :USG Brain tissue : Suficient : CS Small : PerforationComplication :Uterine RupturePASSAGE ABNORMALITIES

DIAGNOSIS :

Leopold : Primi : 36 Weeks + ; undescended head Malpresentation PELVIC MEASUREMENT :Clinic : Promontorium - InnLin - Isch Spine - Pub Arch - Sacrum - Side walls Rontgen Pelvimetri / CT Scan /MRICOMPLICATIONS : Incarceratous Retroflected uterus Malpresentation Pendulous abdomen Prolonged labor Uterine Rupture

MANAGEMENT :Type of pelvic Mode of deliveryabnormalitiesAbsolute : CSRelative :Trial of labor Succeed Spontaneous/FE/VcE Failed CSTRIAL 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 EUncomplete 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 laborPELVIC TUMOURS : Fibroid Ovarian cyst Large bowel tumoursDiagnosis during a terme pregnancy/ delivery : CSDISTOSIA BAHUTerjebaknya bahu pada pintu atas panggul setelah kepala anak lahir.Etiologi :Anak besarIbu menderita DMGenetik (orang tua)SerotinusCPDAnenchephalusPada ekstraksi forseps/ vakum, melahirkan terlalu cepat

Evidence level III BEvidence level III Evidence level IVEvidence level III

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Hypotonic

Uterine InertiaHypertonic

Uterine Inertia

Incidence4 %1 %

PhaseStage I - ActiveStage I Latent

PainNoneExagerated

Fetal distressSlow onsetRapid onset

TherapyOxytocinSedative

Constriction ring Bandl ring

Locally thicknessBorder of Upper and Lower Ut.segment

Thicknes at the ring site Upper segment thick lower part thin

Lower uteine segment

normalLower uterine segment

stretched

Stage I II IIIStage II

StationaryGetting higher

Palpable through internal examinationPalpable through

Abdominal wall

Good general condBad gen.condition

Prem rup membran / operative delivery CPD

LEOPOLD I , IIIEmpty

LEOPOLD IILarge parts left & right side

Heart soundAround the umbilicus

Int.Ex : Membrane ( - )

Dilatation >>>

Shoulder

PROFILAXISExternal Version :

1.Single

2.Second twin

DELIVERYFoetus alive aterme CS

Death foetus a terme

Embryotomi / Double set up

DiameterPelvic inlet

ABSOLUTRELATIVEMid Pelvic Pelvic out let

CV< 8,5 cm8,5 - 10 cm

Transver

+

Sagit Post

< 13,5 cm< 15 cm

Transver

< 9 cm