MALPOSITION

AND
DYSTOCIA

Oleh :
Agung Pramartha Irawan

LABOR
Definition
Process fetus expelled from the uterus.
Mechanism of Labor :
Not passive processes
Depend on interactions of three variables
1. Uterine activity (Power)
2. Fetus (Passanger)
3. Maternal Pelvis (Passage)
Kilpatrick S & Etoi G, Normal Labor and Delivery .

FETUS
Course of labor and delivery :
1. Fetal size :
Estimated by palpation or USG
2. Lie
Longitudinal axis of the fetus relative to the longitudinal
axis of the uterus
3. Presentation
Fetal part which directly overlies the pelvic inlet
4. Attitude
Position of the head with regard to the fetal spine
(flexion or extension)
5. Position
Relationship fetal presenting part to maternal pelvis
6. Station
Estimated distances from the ischial spines
Kilpatrick S & Etoi G, Normal Labor and Delivery .

LABOR
Clinician must assess not only cervical
assessment and dilation but also fetal
station
and
position
with
vaginal
examination to judge labor progress.
It is critical to determined fetal head position
and
station
before
performing
an
operative vaginal delivery

Kilpatrick S & Etoi G, Normal Labor and Delivery .

Fetal Position
Relationship of an arbitrarily chosen
portion of the fetal presenting part to
the right or left side of the birth canal.
Accordingly, with each presentation
there may be two positionsright
or left.
Approximately 2/3 of all vertex
presentations are in the left occiput
position, and 1/3 in the right.
Cunningham, F.G. 2010, Preeclampsia, Obstetri williams, 23rd edn, The
McGraw-Hill Company, New York

DETERMINE FETAL HEAD

POSITION

FETAL POSITION

Mechanism of Labor
Normal mechanism (90%)
Deflexion is corrected and complete flexion occurs.
The occiput meets the pelvic floor first, long anterior rotation 3/8 circle occurs
bringing the occiput anteriorly Fetus is delivered normally
Abnormal mechanism (10%)
Deep transverse arrest (1%):
In mild deflexion, the occiput rotates 1/8 circle anteriorly and the head is
arrested in the transverse diameter.
Persistent occipito-posterior (3%):
In moderate deflexion, the occiput and sinciput meet the pelvic floor
simultaneously, no internal rotation and the head persists in the oblique
diameter.
Direct occipito-posterior (face to bubis) (6%):
-- In marked deflexion, the sinciput meets the pelvic floor first, rotates
1/8 circle anteriorly and the occiput becomes direct posterior.
In deep transverse arrest and persistent occipito-posterior no further progress occurs
and labour is obstructed as the head cannot be delivered spontaneously.
El-Mowafi , DM. Geneva Foundation for Medical Education and

Mechanisms of Labor with OA Presentation

The fetus enters the pelvis in theleft occiput
transverse (LOT)position in 40 % of labors and in
theright occiput transverse (ROT)position in
20 %.
Inocciput anterior positionsLOAorROAthe
headeither enters the pelvis with the occiput rotated
45 degrees anteriorly from the transverse position, or
subsequently does so.
The mechanism of labor in all these
presentations is usually similar.

Cunningham, F.G. 2010, Preeclampsia, Obstetri williams, 23rd edn, The

McGraw-Hill Company, New York

Deep Transverse Arrest

DEFINITON :
Mechanical obstruction of labour in
which the fetal head is unable to rotate
from occipitotransverse to
occipitoanterior position
(Concise Medical Dictionary)

In deep transverse arrest,

the head is deep into the
cavity;
the saggital suture is placed in the transverse
bispinous diameter &
there is no progress in descent of the head
even after -1 hour following full
dilatation of the cervix.
The pelvis should be assessed and
if,pelvis is adequately spacious &
fetus of normal size (not macrosomia) &
fetal conditions adequate for a vaginal
delivery, ventouse is ideal in these cases.

Deep Transverse Arrest

Occurs in 2nd stage.
Fetus maintain an OT position at low
pelvic station
Incident : 5-10% of entire labor
The head is deep in pelvic cavity at
level of ischial spine
Associated with abnormal maternal
pelvic architecture (android type)
Gibs, RS et al. Danforths Obstetric and

FRIEDMAN CURVE
DEEP TRANSVERSE
ARREST

Deep Transverse Arrest

Flexion is not maintained and
occipitofrontal diameter stucked at
bispinous diameter of the outlet.
Arrest may be due to :
- weak contractions
- a straight sacrum or
- narrowed outlet

Coates T, Malposition of the occiput and

Deep Transverse Arrest

Mode of delivery :
- Kielland forceps designed to address
the problem of deep transverse
arrest
- Ventouse
- Cesarean Section : not sufficiently
low

Gibs, RS et al. Danforths Obstetric and

DYSTOCIA
Dystocia :
Maternal
Bony Pelvis
Soft Tissue
Abnormalities

Cunningham, F.G. 2014, Preeclampsia, Obstetri williams, 24th edn, The

McGraw-Hill Company, New York

Maternal Pelvic Bone

Cunningham, F.G. 2014, Preeclampsia, Obstetri williams, 24th edn, The

McGraw-Hill Company, New York

SOFT TISSUE IN BIRTH

CANAL

Cunningham, F.G. 2014, Preeclampsia, Obstetri williams, 24th edn, The

McGraw-Hill Company, New York

ABNORMAL LABOR

Cunningham, F.G. 2014, Preeclampsia, Obstetri williams, 24th edn, The

McGraw-Hill Company, New York

THANK YOU
3P

POWER

SURATAN

PASSAGE

PASSANGER

LEKAD

NORMA
L

LIKAD

SC