jurnal2 - distosia pd wanita nulipara
TRANSCRIPT
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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