DISTOSIA

M.THAMRIN TANJUNG
 DEFINISI
• Distosia adalah persalinan yang : abnormal,
sulit,lama
• Tanda karakteristik adalah kemajuan
persalinan yang lambat
• Umumnya disebabkan disproporsi antara anak
dan jalan lahir
 Penyebab

1. Kelainan powers : his

2. Kelainan passage: jalan lahir
3. Kelainan passenger: anak
 KELAINAN HIS
• His normal: tiap 3-4 mnt, 40-50 mmHg, fundal
dominan, ada fase latent dan aktif
• His lemah : inersia uteri
• His yang hipertonik (His terlalu kuat)
• His yang incoordinate
GENERALISED FOETAL ENLARGEMENT
( MACROSOMIA)
• Definition:
A foetal weight of more than 4 kg.
• Causes :
1. Genetic or constitutional : large women tend to give
birth to large babies.
2. Diabetes and prediabetes.
3. Post-date ( postmaturity).
4. Multiparity: The first baby is about 100 gm smaller
than the next.
• 5. Hydrops foetalis.
• Diagnosis:
• 1. Clinical palpation : can give a rough idea.
• 2. Ultrasonography: can calculate the foetal
weight.
• Management:
1. Proper antenatal care: to prevent
macrosomia and diagnose it before labour
commences.
2. Caesarean section : is the safest for both
mother and foetus .
 HYDROCEPHALUS
• Definition:
It is an enlargement of the foetal head due to
accumulation of excessive cerebro-spinal fluid
(C.S.F) within the ventricles.
• Incidence:
0.5-1.8 per 1000 births. Incidence of
recurrence in subsequent pregnancy is about
3%.
• Aetiology:
Obstruction of aqueduct of sylvius which may
be due to :
– 1. Genetic aberration as trisomies.
– 2. Infections: as cytomegalovirus, toxopalsmosis
and rubella.
– 3. No detected cause.
• Complications:
1. Obstructed labour : with its sequel as
rupture uterus . This is more common in mild
degrees of hydrocephalus which cannot be
detected before or during labour.
• 2. Foetus : Still birth or live birth with
neurological manifestations and low growth
rate.
• Management:
• (I) Antepartum:
(1) Ventriculo-amniotic shunt:
(2) Induction of preterm labour: after draining of the
fluid through a transabdominal needle
puncture.
• (II) Intrapartum:
• (1) Cephalic presentation:
i) If the cervix is dilated : transcervical aspiration by a
needle or perforation through a gaping suture or
fontanelle is done.
• ii) If the cervix is not dilated: transabdominal
aspiration by a needle is done.
• Traction on the collapsed head can then applied
by Willet’s scalp forceps.

• (2) Breech presentation:

• CSF is drained through:
– 1. perforation in the roof of the mouth , foramen
magnum or behind the mastoid process.
– 2. Spinal tapping which is easier through spina bifida if
present.
• (III) Postpartum:
– The living newborn should be referred for shunt
operation to drain the cerebral ventricles into the
jugular vein or right atrium.
 SHOULDER DYSTOCIA
• Definition:
– It is a difficulty in shoulder delivery.
• Incidence:
– about 0.5% of deliveries.
• Causes:
1. Large shoulders which may be due to :
- Maternal obesity.
- Diabetic mothers.
- Post-term pregnancy.
- Anencephaly.
2. Failure of shoulder rotation.
3. Contracted and platypelloid pelvis.
• Prediction:
• Prediction:
1. Presence of risk factors of macrosomia (see
before).
2. Ultrasonographic assessment of foetal weight.

• Clinical Picture:
- The head is delivered and the chin is applied
firmly against the perineum.
- There is no further progress in spite of gentle
traction on the head.
• Management:
• (A) Prophylaxis:
1. Proper antenatal care particularly for high risk
mothers as diabetics.
2. Antepartum assessment of foetal weight----
macrosomic babies should be delivered by
caesarean section.
• (B) of shoulder dystocia:
Calling urgently an anaesthetist and
paediatrician.
The following methods are used in a rapid succession when the
previous one failed:
• (1) Rotation of the anterior shoulder : if unrotated by fingers
transvaginally to bring it in the antero -posterior diameter.
• (2) Generous episiotomy + gentle downward traction + suprapubic
pressure by an assistant obliquely to flex the anterior shoulder
against the foetal chest.
• (3) Mc Roberts' manoeuvre: It is sharp flexion of the maternal thighs
against her abdomen. This can free the shoulders by:
– i- backward displacement of the sacral promontory.
– ii- upward displacement of the symphysis pubis.
– iii- Decrease the inclination of the pelvic inlet.
– iv- Decrease in lumbar lordosis.
• (4) Woods screw manoeuvre:
• (5) Extraction of the posterior arm: by pressing
with 2 fingers against the cubital fossa to sweep
the posterior arm in front of the chest and deliver
it giving space for the anterior shoulder to escape
from below the symphysis.This is aided by
suprapubic pressure.
• (6) Zavanelli manoeuvre (cephalic replacement)
• (7) Clavicular fracture:
was described to reduce the diameter of the shoulders.
It is done by upward pressure against its midportion to
avoid injury of the subclavian vessels.
• (8) Cleidotomy:
It is cutting of the clavicle and usually reserved for a
dead foetus.
• (9) Symphysiotomy:
It is advocated by some authors to overcome
contracted pelvis in women living in uncivilised areas.
Complications:
• (I) Foetal :
– 1. Asphyxia and death.
– 2. Brachial plexus injury causing Erb's palsy.
– 3. Fracture clavicle or humerus.
• (II) Maternal :
Injuries from manoeuvres which may extend
up to rupture uterus.
 PRIMARY POSTPARTUM
HAEMORRHAGE
• Aetiology:
• (A) Placental site haemorrhage:
• (I) Atony of the uterus: