DYSTOCIA

Efendi Lukas
Bagian / UP Obgin FK.UNHAS
/RS.Dr.Wahidin Sudirohusodo
Makassar
 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 :
 Pushing power
 H i s / Labor pain
 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

3.1. PELVIC ABNORMALITIES

3.2. PELVIC TUMOR
3.3. NARROWNESS OF VAGINA/VULVA
3.4. EXOSTOSIS
 PASSENGER ABNORMALITIES

 MALPOSITION
 MALPRESENTATION
 PHYSICAL
ABNORMALITIES
 MALPOSITION :

 POPP : Persistent Occiput

Posterior Position
 Transverse Arrest
 Deep Transverse Arrest
 OA
ROA LOA

ROT LOT

ROP LOP
OP
 MALPRESENTATION

 DEFLECTION :
1. Face presentation
2. Brow presentation
 BREECH PRESENTATION
 TRANVERSE LIE
 COMPOUND
PRESENTATION
 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
Hospital Primi : BW > 3500 gram C-Section
Caesarean Section
BW < 3500 & Multipara Spontaneous : Bracht
Manual A i d C-Section
Forcep Piper
 PROGNOSIS :
BAD , Fetal death
3-4 X vertex presentation

PROFILAXIS :
External version
Condition :
 Dilatation < 2-3 Cm
 Membrane : intact
 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
prolaps of umbilical cord
 Foetal 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 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/ VE / 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
Wood’s manuver
FE / VE
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

 THREATENED UTERINE RUPTURE

SYMPTOMS AND SIGNS :

Contraction strong / Tetanic
RING OF BANDL
Round ligament tense & hard
Painful Mother restlessness
Fetal distress / IUFD
Urine bloody
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 uteine segment Lower uterine segment
normal 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
 Shoulder dystocia

o Definition :
 Impaction of anterior shoulder above symphysis
 Inability to deliver shoulders by usual methods
o Turtle sign
o Incidence :
 1 : 1000 for baby weighing < 3500 g
 > 16 : 1000 for baby weighing > 4000 g
o > 50% cases occur in the absence of any identified
risk factor
 Complication

o Fetal / neonatal
 Death
 Hypoxia / asphyxia and sequelae
 Birth injuries : fracture clavicle and humerus, brachial
plexus palsy
o Maternal
 Post partum hemorrhage : uterine atony, maternal
laceration
 Uterine rupture
 Risk factors

 Post-term pregnancy
 Maternal obesity
 Fetal macrosomia
 Previous shoulder dystocia
 Operative vaginal delivery
 Prolonged labor
 Poorly controlled diabetes
Diagnosis

o Head recoils against perineum, “turtle”

sign
o Spontaneous restitution does not occur
o Failure to deliver with expulsive effort and
usual gentle downward direction
o Identified risk factors are present in less
than 50% of cases
 Management

o Ask for help

o Lift / hyperflex legs
o Anterior shoulder disimpaction
o Rotation of the posterior shoulder
o Manual removal posterior arm

o Episiotomy
o Roll over onto “all fours”
Ask for help

o Set up for obstetric emergencies

o Get the co-operation of the mother, partner,
coach, etc
o Establish and practise a nursing protocol
o Notify your physician backup, and enlist
other appropriate personel
 Lift the legs

o Hyperflex both legs (McRobert’s manoeuver)

o Shoulder dystocia is resolved in 70% of cases
by this manoeuver alone
Anterior disimpaction

o Suprapubic pressure applied with the heel of

clasped hands from the posterior aspect of
the anterior shoulder to dislodge it (Mazzanti
manouever)
o Adduction of the anterior shoulder by
pressure applied to the posterior aspect of
the shoulder (shoulder is pushed towards the
chest) (Rubin manouever)
Mazzanti manouever
Rubin manouever
Rotation of the posterior shoulder

o Wood’s screw manouever : pressure

applied to the anterior aspect of the
posterior shoulder and an attempt is made
to rotate that shoulder 180° to the posterior
position
o In practise, the anterior disimpaction
manouever and Wood’s manouever may be
done simulataneously
Wood’s screw manouever
Manual removal of the posterior
arm
o The arm is usually flexed at the elbow. If it
is not, pressure in the anteccubital fossa
can assist with flexion. The hand is
grasped, swept across the chest and
delivered
Manual removal of the posterior arm
 Episiotomy is an option that may facilitate
the Wood’s manouever or manual removal
of the posterior arm
 Roll over to knee chest position
 Avoid the 4 P’s

DO NOT :
 Pull
 Push
 Panic
 Pivot ( severely angulating the head, using
coccyx as a fulcrum)
If nothing has worked to this point :

 Deliberate fracture of the clavicle or

humerus
 Symphysiotomy
 Zavanelli manouever (cephalic replacement)
 Rotate head to OA
 Flex
 Push up
 Rotate to transverse, disengage
 Perform C-section
THANK YOU FOR YOUR
ATTENTION