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P ER S A LIN A N PATO LO G IS

A B N O R M A L LA B O R
D Y S TO C IA

TUJUAN =
M ahasisw a 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.

Abnorm allabour = dystocia


Dystocia means difficult labor and is
characterized by abnormally slow
progress of labor.
William obstetrics 24 ed.

KASU S # 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.

KASU S # 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

KASU S # 3 (cont)
Pemeriksaan dalam vagina

Pembukaan 5 cm.
Kulit ketuban (-)
Kepala H III
UUK kiri depan
Moulage ++

Buatlah partograf,
diagnosis klinis
dan sikap ?

KASU S # 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 ?

P ER S A LIN A N PATO LO G IS
A B N O R M A L LA B O R
D Y S TO C IA

Abnorm allabour = dystocia


Dystocia means difficult labor and is
characterized by abnormally slow
progress of labor.
William obstetrics 24 ed.

CO N TO H TEM U AN PARTO G RAF


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.

Progress in labor

Alarm course

Assessm ent oflabor


abnorm alities

William obstetrics 22 ed.

P O W ER S

Abnorm alities ofthe pow ers

Assessm ent ofuterine 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.

Assessm ent ofuterine 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.

Adequacy ofuterine activity

High risk pregnancy, 2006 and alarm cour

Reported causes ofuterine


dysfunction
Epidural analgesia
Chorioamnionitis
Maternal position during labor
William obstetrics 24 ed.

M anagem ent ofhypotonic


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 am niotom y


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


augm entation
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


augm entation
Initial dose

1 2 mU/min
Increase interval
every 30 minutes
Dosage increment
1 2 mU
Usual dose for good labor2 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 m anagem ent


for hyperstim ulation
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

PA SS A G ES

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

Alarm course

G enerally assum e
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

PA SS EN G ER S

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

Clinicalfeature ofCPD
Excessive moulding
Failure of presenting part to engage and
descent.
High risk pregnancy 2006

Tem uan sebagaiindikasiCPD


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


m anagem ent 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


ofdystocia
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


m anagem ent oflabor
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.

M aternaleff
ects ofdystocia
Intrapartum infection
Uterine rupture
Pathological retraction ring
Fistula formation
Pelvic floor injury
Postpartum lower extremity nerve

injury
Wiiliam obstetrics 24 ed

Fetaleff
ects ofdystocia
Caput succedaneum
Fetal head molding
Asfiksia
Wiiliam obstetrics 24 ed