Abnormal Labor and Delivery
-
Upload
anon55864979 -
Category
Documents
-
view
250 -
download
0
Transcript of Abnormal Labor and Delivery
-
8/18/2019 Abnormal Labor and Delivery
1/56
Abnormal Labor and Delivery Abnormal Labor and Delivery
(Fetal Factor)(Fetal Factor)
Irwan T RachmanIrwan T Rachman
-
8/18/2019 Abnormal Labor and Delivery
2/56
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
-
8/18/2019 Abnormal Labor and Delivery
3/56
$resentasi %anin$resentasi %anin
-
8/18/2019 Abnormal Labor and Delivery
4/56
Fetal &eadFetal &ead
-
8/18/2019 Abnormal Labor and Delivery
5/56
-
8/18/2019 Abnormal Labor and Delivery
6/56
$arto"raph$arto"raph
-
8/18/2019 Abnormal Labor and Delivery
7/56
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
-
8/18/2019 Abnormal Labor and Delivery
8/56
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)
-
8/18/2019 Abnormal Labor and Delivery
9/56
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
-
8/18/2019 Abnormal Labor and Delivery
10/56
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
-
8/18/2019 Abnormal Labor and Delivery
11/56
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
-
8/18/2019 Abnormal Labor and Delivery
12/56
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
-
8/18/2019 Abnormal Labor and Delivery
13/56
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
-
8/18/2019 Abnormal Labor and Delivery
14/56
Face presentationFace presentation
-
8/18/2019 Abnormal Labor and Delivery
15/56
/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
-
8/18/2019 Abnormal Labor and Delivery
16/56
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
-
8/18/2019 Abnormal Labor and Delivery
17/56
@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
-
8/18/2019 Abnormal Labor and Delivery
18/56
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
-
8/18/2019 Abnormal Labor and Delivery
19/56
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
-
8/18/2019 Abnormal Labor and Delivery
20/56
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
-
8/18/2019 Abnormal Labor and Delivery
21/56
@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
-
8/18/2019 Abnormal Labor and Delivery
22/56
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.
-
8/18/2019 Abnormal Labor and Delivery
23/56
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
-
8/18/2019 Abnormal Labor and Delivery
24/56
/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
-
8/18/2019 Abnormal Labor and Delivery
25/56
@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
-
8/18/2019 Abnormal Labor and Delivery
26/56
Procedure External CephalicProcedure External Cephalic
VersionVersion
@obilisasi@obilisasi/
-
8/18/2019 Abnormal Labor and Delivery
27/56
Procedure External CephalicProcedure External Cephalic
VersionVersion
Fi
-
8/18/2019 Abnormal Labor and Delivery
28/56
Knee chest positionKnee chest position
-
8/18/2019 Abnormal Labor and Delivery
29/56
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
-
8/18/2019 Abnormal Labor and Delivery
30/56
@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.
-
8/18/2019 Abnormal Labor and Delivery
31/56
$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
-
8/18/2019 Abnormal Labor and Delivery
32/56
$ersistent cciput Transverse$ersistent cciput Transverse
$osition$osition In absence of abnormal pelvic architectureIn absence of abnormal pelvic architecture
usually transitoryusually transitory
-
8/18/2019 Abnormal Labor and Delivery
33/56
-
8/18/2019 Abnormal Labor and Delivery
34/56
&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
-
8/18/2019 Abnormal Labor and Delivery
35/56
-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
-
8/18/2019 Abnormal Labor and Delivery
36/56
ompli
-
8/18/2019 Abnormal Labor and Delivery
37/56
Fa
-
8/18/2019 Abnormal Labor and Delivery
38/56
$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 "
-
8/18/2019 Abnormal Labor and Delivery
39/56
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+)
-
8/18/2019 Abnormal Labor and Delivery
40/56
epala bayi mele
-
8/18/2019 Abnormal Labor and Delivery
41/56
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
-
8/18/2019 Abnormal Labor and Delivery
42/56
LLift - McRobert’s Manoeuverift - McRobert’s Manoeuver
-
8/18/2019 Abnormal Labor and Delivery
43/56
Lifting the legs andbuttocks
• Manuver McRobert
• Fleksikan paha ke arah
abdomen
• Membutuhkan asisten
• 7! kasus dapat
diselesaikan oleh manuver
-
8/18/2019 Abnormal Labor and Delivery
44/56
AAnterior Disimpaction -nterior Disimpaction -
1) Suprapubic1) Suprapubic
PressurePressure
(Manuver(Manuver
Massanti )Massanti )
E Tida< boleh mene
-
8/18/2019 Abnormal Labor and Delivery
45/56
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
-
8/18/2019 Abnormal Labor and Delivery
46/56
'otation of Posterior Shoulder "Langkah (
• "enekanan pada
bagian depan bahu
belakang
• &isa dikombinasi
dengan anterior
disimpactionmanoeuvers
• %idak boleh
menekan fundus
-
8/18/2019 Abnormal Labor and Delivery
47/56
'otation of Posterior Shoulder "
Langkah #
Wood's scre(
manoeuvre
• &isa dilakukan
secara simultan
dengan anterior
dissimpaction
-
8/18/2019 Abnormal Labor and Delivery
48/56
'otation of Posterior Shoulder "
Langkah )
• &isa diulang bila proses
persalinan
tidak tercapai
pada langkah )dan *+
-
8/18/2019 Abnormal Labor and Delivery
49/56
Rotation of Posterior Shoulder -Lan!ah "
-
8/18/2019 Abnormal Labor and Delivery
50/56
%%anual re!o&al ofanual re!o&al ofposterior ar!posterior ar!E Fle
-
8/18/2019 Abnormal Labor and Delivery
51/56
Manual removal of the posterior arm
-
8/18/2019 Abnormal Labor and Delivery
52/56
#pisiotomi#pisiotomi
E Dapat membantu manuver .ood atauDapat membantu manuver .ood atau
memberi ruan" untu< men"eluar
-
8/18/2019 Abnormal Labor and Delivery
53/56
$inda!an tera!hir %$inda!an tera!hir %
E Fra
-
8/18/2019 Abnormal Labor and Delivery
54/56
Setelah selesai tindakan *Setelah selesai tindakan *E Antisipasi &$$ Antisipasi &$$
E
e
-
8/18/2019 Abnormal Labor and Delivery
55/56
S'MPLA
• ,ntisipasi dan persiapan #kebanakan kasus
tidak dapat diprediksikan$• .elalu ingat dengan /,0,RM1R2• %etap tenang3 tidak panik3 menarik3 mendorong
atau memutar+
-
8/18/2019 Abnormal Labor and Delivery
56/56
Terima