abnormal labor and delivery

8/18/2019 Abnormal Labor and Delivery

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Abnormal Labor and Delivery Abnormal Labor and Delivery

(Fetal Factor)(Fetal Factor)

Irwan T RachmanIrwan T Rachman


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IntroductionIntroduction

Difficult laborDifficult labor dystocia (opposite:dystocia (opposite:

eutocia)eutocia)

haracteri!ed by abnormally slowharacteri!ed by abnormally slowpro"ress of labor pro"ress of labor

In "eneral# abnormal labor is commonIn "eneral# abnormal labor is common

whenever there is disproportion betweenwhenever there is disproportion between

the presentin" part of the fetus and birththe presentin" part of the fetus and birth

canalcanal


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$resentasi %anin$resentasi %anin


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Fetal &eadFetal &ead


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$arto"raph$arto"raph


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IntroductionIntroduction

Four distinct abnormalities:Four distinct abnormalities: Abnormalities of the e'pulsive forces Abnormalities of the e'pulsive forces

Abnormalities of the maternal bony pelvis Abnormalities of the maternal bony pelvis

Abnormalities of presentation# position or Abnormalities of presentation# position or

development of the fetusdevelopment of the fetus

Abnormalities of the soft tissues of the Abnormalities of the soft tissues of the

reproductive tractreproductive tract


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A (*++,) A (*++,)

-implified the factor abnormal labor:-implified the factor abnormal labor: Abnormalities of the $./R (uterine Abnormalities of the $./R (uterine

contractility and maternal e'pulsive effort)contractility and maternal e'pulsive effort)

Abnormalities involvin" the $A--/0/R (the Abnormalities involvin" the $A--/0/R (the

fetus)fetus)

Abnormalities of the $A--A/ (the pelvis) Abnormalities of the $A--A/ (the pelvis)


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0ormal Labor 0ormal Labor

+12 of pre"nancies#+12 of pre"nancies#

at the time of delivery#at the time of delivery#

the fetus is enterin"the fetus is enterin"

the pelvis as athe pelvis as acephalic presentationcephalic presentation


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Fetal $resentationFetal $resentation

$resentation$resentation $ercent$ercent IncidenceIncidence

ephalicephalic

3reech3reech

TransverseTransverse

ompoundompound

FaceFace3row3row

+456+456

751751

859859

85*85*

858,858,858*858*

*:94*:94

*:99,*:99,

*:*5888*:*5888

*:75888*:75888*:*85888*:*85888


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0ormal labor is a coordinated interplay0ormal labor is a coordinated interplaybetween maternal e'pulsive forcesbetween maternal e'pulsive forces(power)# fetal position (passen"er)# and(power)# fetal position (passen"er)# and

maternal pelvic shape and structurematernal pelvic shape and structure(passa"e);(passa"e);

3efore ma


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ommon clinical findin" in womenommon clinical findin" in women

with ineffective labor with ineffective labor Inade=uate cervical dilatation and fetal descent:Inade=uate cervical dilatation and fetal descent:$rotracted labor > slow pro"ress$rotracted labor > slow pro"ress

Arrested labor > no pro"ress Arrested labor > no pro"ress

Inade=uate e'pulsive effort > ineffective ?pushin")Inade=uate e'pulsive effort > ineffective ?pushin")Fetopelvic disproportion:Fetopelvic disproportion:/'cessive fetal si!e/'cessive fetal si!e

Inade=uate pelvic capacityInade=uate pelvic capacity

@alpresentation or malposition of the fetus@alpresentation or malposition of the fetus

Ruptured membranes without labor Ruptured membranes without labor


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Face presentationFace presentation

The head is hypere'tendedThe head is hypere'tended

The occiput is in contact with theThe occiput is in contact with the

fetal bac< and the chin (mentum)fetal bac< and the chin (mentum)

is presentin"is presentin"

The mentum can present in anyThe mentum can present in any

position relative to the maternalposition relative to the maternal

pelvis5pelvis5

If the mentum presents in the leftIf the mentum presents in the left

anterior =uadrant of the maternalanterior =uadrant of the maternal

pelvis# it is desi"nated as leftpelvis# it is desi"nated as left

mentum anterior (L@A)5mentum anterior (L@A)5


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Face presentationFace presentation


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/tiolo"y/tiolo"y

causes which may be :causes which may be : Anencephaly: due to absence of the bony vault of the Anencephaly: due to absence of the bony vault of the

s


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Dia"nosisDia"nosis

The dia"nosis of face presentation can beThe dia"nosis of face presentation can be

made clinically by:made clinically by:Leopold maneuvers: the cephalic prominenceLeopold maneuvers: the cephalic prominence

is on the same side as the fetal bac


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@echanism of labor @echanism of labor

Fetuses with face presentation probablyFetuses with face presentation probably

initially be"in labor in the brow position5initially be"in labor in the brow position5

Internal rotation:Internal rotation:hin rotates anteriorlyhin rotates anteriorly chin under thechin under the

symphysis pubis (48682)symphysis pubis (48682)

hin rotates posteriorlyhin rotates posteriorly the relatively shortthe relatively short

nec< cannot span the anterior surface of thenec< cannot span the anterior surface of thesacrumsacrum


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Labor @ana"ementLabor @ana"ement

Labor mana"ement should follow that of aLabor mana"ement should follow that of averte' mana"ement of labor5verte' mana"ement of labor5

Do not attempt to convert face presentation toDo not attempt to convert face presentation toverte'verte'

0ever apply vacuum e'tractor to face0ever apply vacuum e'tractor to facepresentationpresentation

onsider lar"e episiotomy if fetus deliversonsider lar"e episiotomy if fetus deliversva"inallyva"inally

$erform cesarean delivery when arrest of labor$erform cesarean delivery when arrest of laboroccurs despite an ade=uate contraction patternoccurs despite an ade=uate contraction pattern(avoid 'ytocin in most cases) andBor with a(avoid 'ytocin in most cases) andBor with anonreassurin" fetal heart rate patternnonreassurin" fetal heart rate pattern


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3row $resentation3row $resentation

The rarest presentationThe rarest presentation the fetal head is midwaythe fetal head is midway

between full fle'ionbetween full fle'ion(verte') and(verte') and

hypere'tension (face)hypere'tension (face)alon" a lon"itudinal a'isalon" a lon"itudinal a'is

The causes of aThe causes of apersistent browpersistent browpresentation arepresentation are"enerally similar to those"enerally similar to thosecausin" a facecausin" a facepresentationpresentation


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Dia"nosisDia"nosis

abdominal palpation can be made withabdominal palpation can be made with

Leopold maneuvers: A prominent occipitalLeopold maneuvers: A prominent occipital

prominence is encountered alon" the fetalprominence is encountered alon" the fetal

bac


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@echanism Labor @echanism Labor

Three labor courses are possible when theThree labor courses are possible when the

fetal head en"a"es in a brow presentation5fetal head en"a"es in a brow presentation5

The brow may convert to:The brow may convert to:a verte' presentation#a verte' presentation#

a face presentationa face presentation

remain as a persistent brow presentationremain as a persistent brow presentation

the occipitomental diameter# which is thethe occipitomental diameter# which is thelar"est diameter of the fetal headlar"est diameter of the fetal head


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Labor @ana"ementLabor @ana"ement

en"a"ement is usually impossible and arrested labour isen"a"ement is usually impossible and arrested labour iscommoncommon

If the fetus is alive# deliver by caesarean section5If the fetus is alive# deliver by caesarean section5 If the fetus is dead and:If the fetus is dead and: the cervi' is not fully dilated# deliver by caesareanthe cervi' is not fully dilated# deliver by caesarean

section;section; the cervi' is fully dilated:the cervi' is fully dilated:

Deliver by craniotomy;Deliver by craniotomy;

If the operator is not proficient in craniotomy# deliver byIf the operator is not proficient in craniotomy# deliver bycaesarean section5caesarean section5

Do not deliver brow presentation by vacuumDo not deliver brow presentation by vacuumextraction, outlet forceps or symphysiotomy.extraction, outlet forceps or symphysiotomy.


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Transverse LieTransverse Lie

Lon" a'is of the fetus is appro'imatelyLon" a'is of the fetus is appro'imately

perpendicular to that of the motherperpendicular to that of the mother

bli=uebli=ue when the lon" a'is forms acutewhen the lon" a'is forms acute

an"lean"le


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/tiolo"y/tiolo"y

$rematurity$rematurity

$lacenta $revia$lacenta $revia

Abnormal uterus Abnormal uterus ontracted pelvis or rela'ed abdominalontracted pelvis or rela'ed abdominal

wallwall

$olyhydramnios$olyhydramnios multiparitymultiparity


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@ana"ement@ana"ement

eserean section re=uired in most caseseserean section re=uired in most cases

(in labor)(in labor)

Indications to consider /'ternal ephalicIndications to consider /'ternal ephalic

CersionCersion Intact membranes and no laborIntact membranes and no labor

3ac


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Procedure External CephalicProcedure External Cephalic

VersionVersion

@obilisasi@obilisasi/


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Procedure External CephalicProcedure External Cephalic

VersionVersion

Fi


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Knee chest positionKnee chest position


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COMPOUND P!"!N#$#%ONCOMPOUND P!"!N#$#%ON

ompound presentations are rareompound presentations are rare

obstetric eventsobstetric events

ompound presentations may beompound presentations may be

observed more commonly after prematureobserved more commonly after premature

rupture of membranes# with preterm labor#rupture of membranes# with preterm labor#

with pelvic masses displacin" the mainwith pelvic masses displacin" the main

fetal pole# or after inductions of laborfetal pole# or after inductions of laborinvolvin" floatin" presentin" partsinvolvin" floatin" presentin" parts


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@ana"ement@ana"ement

eplacement of the prolapsed arm iseplacement of the prolapsed arm is

sometimes possible&sometimes possible& $ssist the woman to assume the 'nee(chest$ssist the woman to assume the 'nee(chest

positionposition Push the arm above the pelvic brim and hold itPush the arm above the pelvic brim and hold it

there until a contraction pushes the head into thethere until a contraction pushes the head into the

pelvis.pelvis.

Proceed with mana)ement for normal childbirth.Proceed with mana)ement for normal childbirth. %f the procedure fails or if the cord prolapses,%f the procedure fails or if the cord prolapses,

deliver by caesarean section.deliver by caesarean section.


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$ersistent cciput $osterior$ersistent cciput $osterior

$osition$osition@ost often posterior position under"o@ost often posterior position under"o

spontaneous anterior rotationspontaneous anterior rotation


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$ersistent cciput Transverse$ersistent cciput Transverse

$osition$osition In absence of abnormal pelvic architectureIn absence of abnormal pelvic architecture

usually transitoryusually transitory


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&idrocephalus&idrocephalus

Delivery fetus with a hydrocephalic head isDelivery fetus with a hydrocephalic head is

problematicproblematic

-i!e fetal head must usually be reduced-i!e fetal head must usually be reduced


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-houlder Dystocia-houlder Dystocia

DefinisiDefinisi

E #ertahannya bahu depan diatas simfisis#ertahannya bahu depan diatas simfisis

E *etida'mampuan melahir'an bahu pada persalinan normal*etida'mampuan melahir'an bahu pada persalinan normal

%nsidens%nsidens

E + ( per +--- 'elahiran+ ( per +--- 'elahiran

E + per +--- 'elahiran bayi / 0--- )+ per +--- 'elahiran bayi / 0--- )

E -.(+.01-.(+.01

E Depend on criteria usedDepend on criteria used


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ompli


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Fa


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$rediction and $revention of -houlder$rediction and $revention of -houlder

DystociaDystocia @ost cases of shoulder dystocia cannot be predicted or@ost cases of shoulder dystocia cannot be predicted or

prevented because there are no accurate methods toprevented because there are no accurate methods to

identify which fetuses will develop this complicationidentify which fetuses will develop this complication

Gltrasonic measurements to estimate macrosomia haveGltrasonic measurements to estimate macrosomia havelimited accuracylimited accuracy

/lective induction of labor or planned - delivery based/lective induction of labor or planned - delivery based

on suspected macrosomia is not reasonable strate"yon suspected macrosomia is not reasonable strate"y

$lanned - delivery may be reasonable for the diabetic$lanned - delivery may be reasonable for the diabeticwoman with estimated fetal wei"ht e'ceedin" ,88 "woman with estimated fetal wei"ht e'ceedin" ,88 "


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Incidence of Shoulder DystociaIncidence of Shoulder Dystocia

according to BW grouping in singletonaccording to BW grouping in singleton

infantsinfants

3irthwei"ht3irthwei"htrouproup

3irths3irths-houlder-houlderdystociadystocia(percent)(percent)

9888 " 9888 " 7+,97+,9 88

988*9,88 "988*9,88 " 98+98+ * (859)* (859)

9,8*888 "9,8*888 " 769+769+ 76 (*58)76 (*58)

88*,88 "88*,88 " 1818 96 (,5)96 (,5)

H ,88 "H ,88 " +*+* *1 (*+58)*1 (*+58)

All wei"ht All wei"ht *856+4*856+4 +1 (85+)+1 (85+)


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epala bayi mele


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Ask for help

Lift - bokong - kaki

Anterior disimpaction of shoulder - rotate to oblique - suprapubic pressure

Rotation of the posterior shoulder – manuver Wood

Manual removal of posterior arm

} Manuver McRobert


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LLift - McRobert’s Manoeuverift - McRobert’s Manoeuver


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Lifting the legs andbuttocks

• Manuver McRobert

• Fleksikan paha ke arah

abdomen

• Membutuhkan asisten

• 7! kasus dapat

diselesaikan oleh manuver


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AAnterior Disimpaction -nterior Disimpaction -

1) Suprapubic1) Suprapubic

PressurePressure

(Manuver(Manuver

Massanti )Massanti )

E Tida< boleh mene


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nterior Disi!paction "

#$ %anu&er 'ubin

• "emeriksaan vagina

• adduksi bahu depan dengan

menekan bagian belakang

bahu #bahu didorong ke arah

dada$

• "ikirkan tindakan episiotomi

• %idak boleh menekan fundus


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'otation of Posterior Shoulder "Langkah (

• "enekanan pada

bagian depan bahu

belakang

• &isa dikombinasi

dengan anterior

disimpactionmanoeuvers

• %idak boleh

menekan fundus


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'otation of Posterior Shoulder "

Langkah #

Wood's scre(

manoeuvre

• &isa dilakukan

secara simultan

dengan anterior

dissimpaction


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'otation of Posterior Shoulder "

Langkah )

• &isa diulang bila proses

persalinan

tidak tercapai

pada langkah )dan *+


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Rotation of Posterior Shoulder -Lan!ah "


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%%anual re!o&al ofanual re!o&al ofposterior ar!posterior ar!E Fle


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Manual removal of the posterior arm


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#pisiotomi#pisiotomi

E Dapat membantu manuver .ood atauDapat membantu manuver .ood atau

memberi ruan" untu< men"eluar


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$inda!an tera!hir %$inda!an tera!hir %

E Fra


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Setelah selesai tindakan *Setelah selesai tindakan *E Antisipasi &$$ Antisipasi &$$

E

e


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S'MPLA

• ,ntisipasi dan persiapan #kebanakan kasus

tidak dapat diprediksikan$• .elalu ingat dengan /,0,RM1R2• %etap tenang3 tidak panik3 menarik3 mendorong

atau memutar+


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abnormal labor and delivery

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