CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.
-
Upload
ann-harmon -
Category
Documents
-
view
220 -
download
2
Transcript of CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.
![Page 1: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/1.jpg)
CPD & Dystocia
Adly NandaAndreas KurniawanGregorius Tanamas
![Page 2: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/2.jpg)
Anatomy of Pelvic
![Page 3: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/3.jpg)
Types of Pelvic
![Page 4: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/4.jpg)
Pelvic Inlet
Konjugata Diagonal(Oblique)
Konjugata AP(Obstetric/Vera)
Konjugata Transversal
![Page 5: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/5.jpg)
Anteroposterior Diameter of Pelvic Inlet
Obstetrical conj = diagonal conj -1.5/2 cm• Depends on the height and inclination of
the symphysis pubis. • diagonal conjugate >11.5 cm adequate
size for vaginal delivery of a normal-sized fetus.
![Page 6: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/6.jpg)
Variation in Length of diagonal conjugate
![Page 7: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/7.jpg)
Pelvic Outlet
Sacrum To Pubic
Distansia Tuberum(10,5 cm)
![Page 8: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/8.jpg)
Pelvic (Ligament)
![Page 9: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/9.jpg)
Normal Delivey
![Page 10: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/10.jpg)
![Page 11: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/11.jpg)
Maharaj et.al OBSTETRICAL AND GYNECOLOGICAL SURVEY Volume 65, Number 6
![Page 12: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/12.jpg)
Obstruction
Chaabra S, et al, Journal of Obstetrics and Gynaecology (2000) Vol. 20, No. 2, 151± 153
![Page 13: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/13.jpg)
Pelvimetry
• Bimanual examination (clinical pelvimetry)• X-ray• CT Scan• MRI– radiologic pelvimetry:
• there is poor correlation with the clinical outcome of labor, skill-depended (Maharaj et,a.l, 2010)
• The role of pelvimetry in current obstetric practice is controversial. It has been widely used without adequate RCT (Morrison et al., 1995).
![Page 14: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/14.jpg)
What is adequate pelvis?
Maharaj et.al OBSTETRICAL AND GYNECOLOGICAL SURVEY Volume 65, Number 6, 2010
![Page 15: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/15.jpg)
Conventional Radiologic Measurement
![Page 16: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/16.jpg)
Dystocia - classification
![Page 17: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/17.jpg)
Dystocia
• ‘difficult labor’• characterized by abnormally slow progress of labor. • common if there is disproportion between the
presenting part of the fetus and the birth canal. • American College of Obstetricians and
Gynecologists : – 1. Abnormalities of the powers (uterine contractility and
maternal expulsive effort). – 2. Abnormalities involving the passenger (the fetus). – 3. Abnormalities of the passage (the pelvis).
![Page 18: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/18.jpg)
Common Clinical Findings in Women with Ineffective Labor
• Inadequate cervical dilation or fetal descent• Protracted labor—slow progress • Arrested labor—no progress • Inadequate expulsive effort—ineffective "pushing"• Fetopelvic disproportion• Excessive fetal size • Inadequate pelvic capacity • Malpresentation or position of the fetus• Ruptured membranes without labor
![Page 19: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/19.jpg)
Nulipara
Taken from http://emedicine.medscape.com/article/273053-media
![Page 20: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/20.jpg)
Multipara
Taken from http://emedicine.medscape.com/article/273053-media
![Page 21: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/21.jpg)
Abnormal Labor Indicators
Taken from http://emedicine.medscape.com/article/273053-overview
![Page 22: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/22.jpg)
Patophysiology
Dystocia
Passenger
PassagePower
mechanical dystociaPassenger
• produce abnormal labor because of the infant's size or from malpresentation.
Passage/pelvis• abnormal labor because
its contours may be too small or narrow to allow passage of the infant.
![Page 23: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/23.jpg)
Patophysiology
Dystocia
Passenger
PassagePower
functional dystociapower
• the frequency and intensity of contractions.
• Disruption of communication between adjacent segments of the uterus resulting from surgical scarring, fibroids, or other conduction disruption.
• fails to result in cervical effacement and dilation. This is called
• Uterine contractile force quantified by the use of an intra-uterine pressure catheter in Montevideo units (MVUs).
• Adequate force >200 MVUs during a 10-minute contraction period.
![Page 24: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/24.jpg)
Intrauterine pressure catheter
Taken from http://www.umm.edu/pregnancy/000138.htm
The ACCU-TRACE™ Intrauterine Pressure Catheter
![Page 25: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/25.jpg)
frequency
• Of all cephalic deliveries, 8-11% are complicated by an abnormal first stage of labor. Dystocia occurs in 12% of deliveries in women without a history of prior cesarean delivery
![Page 26: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/26.jpg)
CauseProlonged latent phase
• Prolonged: >20 hours in nulliparas ; >14 hours in multiparas.
• The most common reason entering labor without substantial cervical effacement.
Power• uterine contractility x frequency
Montevideo units (MVUs) • Adequate uterine contractile
force : >200 MVUs/10 min
Passage• The shape of the bony pelvis (eg,
anthropoid or platypelloid) • extremely short or obese patient• Patients with history of prior
severe trauma to the bony pelvis
Passenger • the size & presentation• Fetal macrosomia and other
anomalies (including hydrocephalus, encephalocele, or any other abnormality that increases the size of the infant)
![Page 27: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/27.jpg)
malfunction of uterine muscle
![Page 28: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/28.jpg)
Uterine muscle dysfunction
• Cause: overdistention due to excessive fetal size and/or uterine fatigue when labor is obstructed by inadequate pelvic capacity, excessive fetal size, or both.
• uterine dysfunction VS fetopelvic disproportion interlinked– uterine dysfunction corrected with oxytocin vaginal
delivery• “clinicians must rely on a trial of labor to determine if
labor can be successful in effecting vaginal delivery” (Williams Obstetrics, 21st ed)
![Page 29: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/29.jpg)
hypotonic uterine dysfunction• More common there is no basal hypertonus and
uterine contractions have a normal gradient pattern – the slight rise in pressure during a contraction is insufficient to
dilate the cervix.• Weak his, frequency ↓• Cause: anemia, dilated uterus (hydramnion, gemelli,
makrosomia, etc)• Divided into
– Primary uterine inertia (early laten phase)– Secondary uterine inertia (active 1st stage 2nd stage of labor)
• Treatment: monitor general condition, oxytocin (no CPD exist)– CPD SC
![Page 30: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/30.jpg)
hypertonic uterine dysfunction
• hypertonic (incoordinate) uterine dysfunction either basal tone is elevated or the pressure gradient is distorted– contraction of the midsegment uterus > fundus – complete asynchronism of the impulses.
• Strong his, continuing patient feels pain; hypoxia on fetus
• Cause: excess oxytocin• treatment: tocolytic agent, SC
![Page 31: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/31.jpg)
Shoulder dystocia
![Page 32: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/32.jpg)
Shoulder Dystocia
• diagnosed as such when maneuvers were required to deliver the shoulders in addition to downward traction and episiotomy
• Risk Factor– Several maternal risk factors, including obesity, multiparity,
and diabetes, all exert their effects because of associated increased birthweight
– postterm pregnancy – Intrapartum complications associated with shoulder
dystocia include midforceps delivery and prolonged first- and second-stage labor (still controversial)
![Page 33: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/33.jpg)
• The American College of Obstetricians and Gynecologists (2002) has concluded that performing cesarean deliveries for all women suspected of carrying a macrosomic fetus is not appropriate, except possibly for estimated fetal weights over 5000 g in nondiabetic women and over 4500 g in those with diabetes.
![Page 34: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/34.jpg)
Consequences
• Mother– Postpartum hemorrhage, usually from uterine atony,
but also from vaginal and cervical lacerations, is the major maternal risk
• Fetus – fetal morbidity and even mortality– 2/3 Transient Erb or Duchenne brachial plexus palsies
were the most common injury– clavicular fractures– humeral fractures
![Page 35: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/35.jpg)
Managementdiagnosis
Stop the head traction, immediately call for help
McRobert Maneuver (episiotomy if necessary , suprapubic pressure, head traction
Maneuver Rubin ( McRobert position, shoulder rotation, suprapubic pressure, head traction)
Bear the posterior shoulder, or crawling position or Wood manuever
![Page 36: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/36.jpg)
![Page 37: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/37.jpg)
CEPHALOPELVIC DISPROPORTION
![Page 38: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/38.jpg)
Cephalopelvic Disproportion
• Mismatch between the size of the fetal head and size of the maternal pelvis, resulting in “failure to progress” in labor for mechanical reasons. (Maharaj, D, 2010)
• Fetal head : hydrocephalus, Occipito-Posterior malposition
• Maternal pelvis : abnormally small / unusual shape. – childhood rickets – Orthopaedic disorders
![Page 39: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/39.jpg)
• In such cases the fetal and pelvic dimensions are not abnormal but the presenting diameter of a deflexed O.P. malposition is greater than an occipito-anterior position and labour may become obstructed.
• In such cases the term Relative Disproportion is used and in subsequent pregnancies vaginal delivery might reasonably be allowed.
![Page 40: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/40.jpg)
Diagnosis
• CPD may only be reliably diagnosed during labour. • Typically the first stage of labour will be
prolonged. • Sign– failure of descent of the head VT/abdominal exam– Moulding fetal skull bones override each other.
– The parietal bones override each other commonly and both overlie the frontal bones, irreducible
– Caput formation oedematous is a feature of the duration of labour rather than CPD.
![Page 41: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/41.jpg)
Occipito Posterior Position
• Occipito-posterior position is a malposition of the head and occurs in 13% of vertex presentations.
• The presenting part is the vertex and the denominator is the occiput.
![Page 42: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/42.jpg)
causes
![Page 43: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/43.jpg)
Source: www.icsi.org
![Page 44: CPD & Dystocia Adly Nanda Andreas Kurniawan Gregorius Tanamas.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649f0d5503460f94c21551/html5/thumbnails/44.jpg)
references
• Cunningham F.G. (Editor), et.al. Williams Obstetrics 21st ed. New York: McGraw-Hill Professional. 2001
• Hanretty KP. Obstetric Illustrated ed.6th. New York: Churcill Livingstone: 2003. p268
• Joy S. Abnormal Labor. 2009. Downloaded from http://emedicine.medscape.com/article/273053-overview