jurnal2 - distosia pd wanita nulipara

8/13/2019 Jurnal2 - Distosia Pd Wanita Nulipara

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Moderator :dr. Rimonta F. Gunanegara, SpOG

OBSTETRICS DAN GYNAECOLOGY DEPT.IMMANUEL HOSPITAL

MEDICAL FACULTY MARANATHA CHRISTIAN UNIVERSITY BANDUNG - 2007

Opponent: David Ong

Presentant : Irene Ranny K.Rani ManaluRudy ChandraNevin Chandra J.Ritsia Anindita W.Abram PratamaHendrik Sutopo L.Mirna PrimasariPrisilla Alvini S.

Shields SG, Ratcliffe SD, Fontaine P, Leman LAm Fam Physician 2007;75:1671-8


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Dystocia: prolonged or slowlyprogressing labor

a BIG challenge:Common in nulliparous women

augmentation, op. vag. delivery, CSAccounts for >50% 1 CS

optimal mgmt labor outcomes


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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidencerating References Comments

Amniotomy in the first stage of labor results in shorterlabor, but it also may be associated with variable fetalheart rate decelerations; therefore, it should be reservedfor slowly progressing labors.

A 13 Systematic review

High-dose oxytocin regimens result in shorter labors thanlow-dose regimens without adverse effects for the fetus. A 18, 19 -

Women who receive continuous labor support from alabor support companion use less analgesia, have lowerrates of operative vaginal and cesarean delivery, and areless likely to report dissatisfaction with their childbirthexperiences.

A 35 Systematic review; resultsfor each outcome werederived from atleast four trials including atleast 1,000 women

Epidural analgesia is associated with a prolongation of thesecond stage of labor and an increase in oxytocin use andoperative vaginal delivery.

A 46-49 Systematic reviews and ameta-analysis

It is important to follow systematic protocols fordiagnosing labor, assessing its progress, and usingoxytocin. Audit and feedback regarding operativedeliveries has been associated with lower institutionalcesarean delivery rates.

C 17, 57, 58 -

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented

evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1605 orhttp://www.aafp.org/afpsort.xml .
http://www.aafp.org/afpsort.xmlhttp://www.aafp.org/afpsort.xml


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Friedman, 1950:Table 1

Today:Values seems to be morethan those of the pastRoutine intervention forprogressive yetprotracted labor isquestionable

Table 1. Traditional Definitions of Abnormal Labor

Stage oflabor

Labor abnormalityProtracted Arrested

LatentNulliparous > 20 hours NAMultiparous > 14 hours NAFirst stageNulliparous < 1 cm per hour

dilation>= 2 hours of activelabor without cervicalchange

Multiparous < 1.2 to 1.5 cmper hour dilation

>= 2 hours of activelabor without cervicalchange

Second stageNulliparousor

multiparous

With no regionalanesthesia: > 2

hours durationor< 1 cm per hourdescent

No descent after 1hour of pushing

With regionalanesthesia: > 3hours duration

NA = not applicable.


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Consider four issuesContractions

MalpositionCephalopelvic disproportionOther coexisting clinical issues


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Options for latent phase: observation,sedation, augmentation; no CS

Active phase: amniotomy comes firstNot without risk!

IUPC (Fig.2)Augmentation: oxytocin

High dose regimens are more preferable


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Figure 2. Inadequate uterine contractions as measured by an intrauterinepressure catheter, with continuous tracing of the FHR (top) and contractions asindicated by uterine pressure (bottom). This representative 10-minute monitorstrip shows three contractions totaling 145 MVU. If MVU are less than 200 in 10minutes, oxytocin augmentation should be considered. (FHR = fetal heart rate;bpm = beats per minute; kPa = kilopascal; MVU = Montevideo units.)


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Confirm the cause: Phys. exam, USPOPP: manual rotation?

Options:Further augmentationUpright/lateral positionDelayed pushing


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Prolongation of the second stage oflabor beyond an arbitrary time limit isno longer an indication for operativevaginal or cesarean delivery.

Nonreassuring fetal heart tracingonly indicates a need to consider

those two.


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To decrease dystocia in nulliparouswomen:1. provision of labor support2. avoidance of hospital admission in latent

stage of labor3. avoidance of elective induction with an

unripe cervix4. cautious use of epidural analgesia


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Using trained labor support companionEspecially doulas and alike

Patient education:Not going to hospital in latent laborInstead, encourage adequate hydration,rest, and emotional and physical support


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Elective induction vs selective induction

Analgesia ? epiduralThe mother factor is the most important

Walk or stay upright during 1 st stage

Ultimately, permit adequate time topass before intervening for dystocia


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Physicians style caregiverHealthcare systems continuity

Encourage a pronatalistcultural attitude

Second opinion(Regular) feedbacks between physicians


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Given a good reason, the second stage of labor canbe permitted to continue for longer thantraditional time limits.Dont forget that to prevent is better than to cure.


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Given a good reason, the second stage of labor canbe permitted to continue for longer thantraditional time limits.Dont forget that to prevent is better than to cure.


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~ End of show ~

Thank you for your attention

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