DYSTOCIA

Dr. Erick Caesar, SpOG

PART - 1

Ref : 1. Williams Obstetrics 21th Ed

2. OBSTETRI PATOLOGI
3. PROTAP BAG .OB.GYN RSHS
 OBTETRICS SECOND PART
1. Pathologic condition during pregnancy
 First trimester
 Second trimester
 Third trimester
2. Pathologic condition during delivery
 First stage ) Dystocia ) Abnormality of
) Power
) Passenger and or
 Second stage ) Dystocia ) Passage.
 Third stage ) bleeding due to bad uterine
) contraction , retained
 Fourth stage) placenta , coagulation defect.
3.Pathologic condition during puerperal stage
 Delivery process ?

 Delivery process is actually a process of

accommodations between the fetal parts
diameters and the pelvic spaces width .
Enhanced by physiological natural delivery
forces ( Labor pain and bearing down)

Cardinal Movements ?
A BABY IS DELIVERED UPON A CERTAIN POWER
IN A PHYSIOLOGICAL MANNER
THROUGH A CERTAIN ROUTE

PHYSIOLOGIC LABOR

SPONTANEOUS LABOR
EUTOCIA ?

DYSTOCIA ?
 EUTOCIA

A SUCCESFULL DELIVERY PROCESS DUE TO

THE WOMAN’S 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.
 DYSTOCIA

“ Abnormal labor “

3 - P Abnormalities :
1. POWER
2. PASSENGER
3. PASSAGE
 WHICH ONE ?

FETAL PARTS DIAMETERS ?

PELVIC SPACE WIDTH ?

LIE , PRESENTATION ,POSITION ?

FETAL PARTS DIAMETERS
( PASSENGER )

FETAL’S LIE

FETAL PRESENTATION

FETAL ( PARTS ) POSITION

PELVIC SPACE WIDTH
( PASSAGE )

PELVIC IN LET
MID PELVIC
PELVIC OUTLET
 PROBABILITY OF
AN OBSTETRIC COURSE
INPUT PROCESS OUTCOME
(Pregnant woman) (Labor) Mother Survive
Foetus Death
Sequellae

PHYSIOLOGIC PHYSIOLOGIC PHYSIOLOGIC

PATHOLOGIC PATHOLOGIC PATHOLOGIC

DIAGNOSIS PROGNOSIS PROGNOSIS

Intervention Promotive
- Promotive - Promotive Preventive
- Preventive - Preventive Curative
- Curative - Curative Rehabilitative
 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
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
 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 ( 0 )
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
Incidence 4 % 1%

Phase Stage I - Active Stage I –Latent

Pain None Exagerated

Fetal Slow onset Rapid onset

distress
Therapy Oxytocin Sedative
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

 Prolonged labor :
Fetal morbidity
Maternal morbidity
 MANAGEMENT

1.Hypertonic uterine Inertia

 Morphine 10 mg ( Inj )
 Pethidine 50 mg ( Inj )
 Caesarean Section
 2. Hypotonic uterine inertia

OXYTOCIN INFUSION :
 UNPAD : TRIPLE PROCEDURE
 Membrane ruptured
 Oxytocin 5 IU/500 cc Dextrose 5%
 Pethidine 50 mg + Phenergan 50 mg
 Fail : Caesarean section
 MODE OF ADMINISTRATION :

 Starting dose 20 gtt / min

 Increased 10 gtt / 30 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 disappeared
> FHB ( - )
> Fetal parts are easily palpable
> Shock : BP PULSE : impalpable
 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
 THREATENED UTERINE RUPTURE

SYMPTOMS AND SIGNS :

 Contraction strong / Tetanic
 RING OF BANDL
 Round ligament tense & hard
 Painful Mother restlessness
 Fetal distress / IUFD
 Urine bloody
 MANAGEMENT :

 PREGNANCY TERMINATION
1. CAESAREAN SECTION
2. FORCIPAL EXTRACTION
3. EMBRYOTOMY
4. DOUBLE SET UP
Constriction ring Bandl ring
Locally thickness Border of Upper and
Lower Ut.segment
Thicknes at the ring Upper segment thick
site lower part thin
Lower uterine Lower uterine
segment normal segment
stretched
Stage I – II – III Stage II
Stationary Getting higher
Palpable through Palpable through
internal examination Abdominal wall
Good general cond Bad gen.condition
Prem rup membran / CPD
operative delivery
DYSTOCIA

PART - 2
 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
 PASSENGER ABNORMALITIES

 MALPOSITION
 MALPRESENTATION
 PHYSICAL ABNORMALITIES
 MALPOSITION :

o POPP : Persistent Occipital

Posterior
Position
o Transverse Arrest
o Deep Transverse Arrest
 MALPRESENTATION

 DEFLECTION :
1. Face presentation
2. Brow presentation
 BREECH PRESENTATION
 TRANVERSE LIE
 COMPOUND PRESENTATION
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 CS
Chin post : CS
Forcipal Extraction Chin anterior Never
Maneuvers ABANDONED
Etiology for dystocia Maximally Diameter >>>
head
deflection
 BREECH PRESENTATION
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 >1800
BW < 3500 & Multipara Spontaneous : Bracht
Manual A i d Caesarean
Forceps Piper BW > 1800
 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
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
prolapsed of umbilical cord
 Fetal distress
 Solutio placentae
 Uterine rupture
 TRANSVERSE LIE
Uterine congenital malformation

UTERUS ARCUATUS
 TRANSVERSE LIE
LEOPOLD I , III Empty

LEOPOLD II Large parts left & right side

Heart sound Around the umbilicus

Int.Ex : Membrane ( - ) Shoulder

Dilatation >>>

PROFILAXIS External Version :

1.Single
2.Second twin
DELIVERY Foetus alive aterme CS
Death foetus a terme
Embryotomi / Double set up
 COMPLICATIONS :
 Umbilical cord prolapsed
 Arm / hand prolapsed
 Neglected transverse lie
 Uterine rupture
 COMPOUND PRESENTATION

 Diagnosis during 1st stage of labor

active phase / Second Stage .
 Hand / arm /was felt beside the
head

MANAGEMENT :
 Hand prolapsed : Spontaneous /FE
 Arm prolapsed : Reposition/FE/CS
 CORD PROLAPS
TYPES :
 Occult Prolapsed
 True Prolapsed

DIAGNOSIS :
Membrane ( - ), cord was felt
beside the presenting part.

CTG : Variable deceleration

 MANAGEMENT :

Prompt pregnancy termination :

Fetus alive : FE/ VcE / CS
Fetus 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
 Occipital presentation :
Spontaneous /Consider
pelvic cavity wideness
Wood’s maneuver
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 :
 Sufficient : CS
 Small : Perforation

Complication :Uterine Rupture

 PASSAGE ABNORMALITIES

Diameter Pelvic inlet

ABSOLUT RELATIVE Mid Pelvic Pelvic

out let
CV < 8,5 cm 8,5 - 10
cm
Transver < 13,5 cm < 15 cm
+
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
Roentgen Pelvimetri / CT Scan /MRI
COMPLICATIONS :
 Incarceratous Retroflexed uterus
 Malpresentation
 Pendulous abdomen
 Prolonged labor
 Uterine Rupture
 MANAGEMENT :

Type of pelvic Mode of delivery

abnormalities
Absolute : CS
Relative :
Trial of labor
 Succeed Spontaneous/FE/VcE
 Failed CS
 TRIAL OF LABOR :

Conditions :
 Occipital 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
Incomplete 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 tumors
Diagnosis during at term pregnancy
/ delivery : CS
THANK YOU FOR YOUR ATTENTION

Good Luck with your examinations !!