Physiology and

Management of
Labor
(An Overview)
Dr.dr.J.M.Seno Adjie
SpOG(K)
Departemen Obstetri dan Ginekologi
Fakultas Kedokteran Universitas Indonesia

Objectives
Definition and diagnosis of labor
Definition and diagnosis of dystocia
Causes of dystocia
Prevention and management of dystocia
Appropriate use of oxytocin

First Stage
Latent Phase
Active Phase

Second Stage
Passive
Active

Third Stage
Fourth Stage

 Labor
is
regular frequent uterine contractions
and
cervical change (dilatation and effacement)

Philpotts Partogram

Cervical dilatation (cm)

10
8

in
l
t
r
e
Al

e
n
o
i
t
c
A

lin

4
2
0
0

Time (hours)

10

Source: WHO/UNFPA/UNICEF/WORLD BANK. IMPAC-Managing Complications in Pregnancy and Childbirth: A

Guide for Midwives and Doctors. WHO 2000 (WHO/RHR/ 00.7)

Etiology of Dystocia

Power

Passenger

Passage

Adequate Powers
Contractions that
last 60 seconds
reach 50 - 60 mm Hg of pressure
occur every 2 - 3 minutes
or
result in good progress

Preventing Dystocia
Accurate diagnosis of labor
Management of prolonged latent phase
Labor preparation
Birth companion

Preventing Dystocia
(cont.)
Ambulation
Analgesia
Amniotomy (ARM)
Fetal size

Management of Dystocia
Arrest without CPD
- amniotomy
- consider oxytocin augmentation if contractions
are inadequate
Arrest with true CPD
- C-Section

Active Management of Labor

Rigorous diagnosis of labor
Close surveillance of progress of labor by partogram
Continuous support in labor

Active Management of Labor (cont.)

Early intervention to correct inadequate progress
of labor
- ARM
- Oxytocin

Augmentation of Labor
Initial dose of oxytocin

1 - 2 mU / min

Increase interval

every 30 min.

Dosage increment

1 - 2 mU

Usual dose for good labor

8 - 10 mU / min.

Contraction Strength with Oxytocin

Depends on:
the dose of oxytocin
and
the uterine sensitivity to oxytocin

Adverse Effects of Oxytocin

Adverse Effect

Mechanism

Fetal compromiseHyperstimulation

Prevention
Correct dose

Uterine rupture

Hyperstimulation

Correct dose

Water intoxication

ADH effect

Limit free
water

Hypotension

Vasodilatation

Low dose

Summary - Prevention of Dystocia

Avoid unnecessary induction
Admit women in active labor
Encourage ambulation / upright posture
Encourage the use of prenatal education
Continuous support of laboring women
Use of appropriate analgesia

Summary - Management of
Dystocia
Appropriate assessment of adequate progress in
labor

Appropriate intervention when necessary

- Amniotomy
- Analgesia
- Rest

- Ambulation
- Augmentation
- C-sections

Obstructed Labor

Definition and Incidence

Failure of descent of the fetus in the
birth canal for mechanical reasons in
spite of good uterine contractions.
(Philpott, 1982)
Incidence: 1-3%

Risks Associated with

neglected obstructed labor
Fetal:
Asphyxia, sepsis, death
Maternal:
Sepsis, uterine rupture, hemorrhage,
fistula, death

Etiology of Obstructed Labor

Fetal: Pelvic disproportion:

Malpresentations, malposition,
malformations
Maternal: Small pelvis, soft tissue tumors
of the pelvis

Clinical Presentation of a Patient with

Obstructed Labor
Dehydration
Oliguria
Keto-acidosis
Sepsis

Clinical Presentation of a Patient with Obstructed

Labor

State of the Uterus:

Ruptured Uterus
State of the Bladder:

Vaginal Findings

Cervical Findings

Complications of Obstructed Labor

Maternal:

Ruptured uterus
Vsico-Vaginal Fistulae
Recto-vaginal Fistulae
Pueperal Sepsis

Fetal:
Asphyxia/ cerebral palsy
Neonatal sepsis
Death

Treatment
Prevention

- Good nutrition in childhood

- Promotion of antenatal care

- Use of partogram in the health unit
- Development of appropriate and timely referral systems

Cesarean section

 Prolonged or neglected obstructed labor

Ruptured Uterus

1
Pa sien m engalami
Pe rsalinan abnorm al

Lakukan anam nesis

Lakukan pemeriksaan fisik
Instruksikan investigasi

3
Ap akah ada indikasi
Untuk sesar?

Ya

Lak ukan operasi sesar

Tidak

Apakah janin
sungsang?

Ya

Apakah pasien dalam

proses persalinan?

Ya

Tidak
5
Pa ntau proses persalinan
dengan Partograf

Apakah kem ajuan persalinan

berada atau di kiri
Garis W aspada?

Apakah pasien
Menunjukkan kriteria
Persalinan sungsang
Per vaginam

Ya

Lanjutkan sebagai
Persalinan norm al

Tidak

7
Nilai ulang oleh dokter

Apakah ada CPD

Ya

9
Lakuk an sesar

Tidak
10

N ilai H is dan posisi, sikap

aktif

Apakah kem ajuan persalinan

mengarah ke kanan
Garis Tindakan?

Ya

Ya

Lakukan persalinan
S ungsang dengan bantuan

Tidak
9
Lanjutkan dengan asuhan
persalinan normal selama kala dua

1
0
Apakah kala dua memanjang
atau ada gawat j anin?

Tidak

Lanjutkan sebagai
persalinan normal

Ya
4

Ya

Apakah posisi kepala lebih

tinggi dari 0?

Lakukan operasi
sesar

Tidak
1
2
Apakah kepala melakukan
paksi?

13

Tidak

Lakukan ekstraksi
vakum

Ya
14
Melakukan persalinan
dengan forsep atau
vakum

15

16

Lahirkan neonatus
Dan berikan
asuhan
Selama kala tiga

Plasenta tidak lahir dalam

waktu 30 menit

Ya

PENATALAKSANAANPERTAM
A:
Pasang infus (ukuran 16 atau 18)
Segera mulai infus kristaloid
(Ringers atau Saline) IV guyur
(1L/jam)
Berikan O2 100% dengan masker
dan hangatkan pasien
Pasang kateter Foley
Lakukan masase uterus
Berikan uterotonika, ergometrin +
misoprostol, manual plasenta

Tidak
1
8 Asuhan selama
kala empat

Apakah:
Perdarahan banyak
TD < 90/60 mmHg
Nadi 100/mnt

Tidak
1
8

Edukasi dan konseling:

Asuhan dan kunjungan
nifas
ASI
Keluarga berencana
Vaksinasi

Perbolehkan ibu dan

neonatus pulang

Ya

17
Lakukan penatalaksanaan
Seperti diagram alur PPH