Download - Dis Tosia
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DISTOSIA
Dr. Kusuma Andriana SpOG
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Definisi
• Difficult labor• Kemajuan persalinan yang lambat
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Common Clinical Findings in Women with Ineffective Labor
• Inadequate cervical dilatation or fetal descent• Protracted labor—slow progress• Arrested labor—no progress• Inadequate expulsive effort—ineffective "pushing"• Fetopelvic disproportion• Excessive fetal size• Inadequate pelvic capacity• Malpresentation or position of fetus• Ruptured membranes without labor
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Etiologi1. Kelainan tenaga (power) . His . Merejan2. Kelainan jalan lahir (Passage) . Bagian keras (maternal bony pelvis = pelvic
contraction) . Bagian lunak (selain bagian keras)3. Kelainan janin (Passenger) . Kelainan posisi, presentasi, bentuk dan besar janin 4. Kelainan kejiwaan (Psyche)
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Kelainan kontraksi (his)
Macam- Prolonged latent phase- Protracted active phase- Arrest of delatation- Protracted of descent- Arrest of descent
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Perbedaan True Labor dan False Labor
Factors True labor False labor
Contractions Regular intervals Irregular intervals
Interval between contractions
Gradually shortens Remains long
Intensity of contractions Gradually increases Remains same
Location of pain In back and abdomen Mostly in lower abdomen
Effect of analgesia Not terminated by sedation
Frequently abolished by sedation
Cervical change Progressive effacement and dilation
No change
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Prolonged latent phase • Def : - > 8 jam (BPPPK-MN) - > 14 jam pd Po, 20 jam pd Pm
(Will.)• Sebab
analgesia rigide cervix False labor
• Tx : Istirahat InduksiSedatif kuat (tramadol. Pethidin) 85% masuk fase aktif10% tetap – false labor5% tetap prolonged & perlu indulksi
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Protracted active phaseArrest of dilatation
Sebab . Disproporsi sefalopelvik (CPD) . Malposisi, malpresentasi . Rahim overdistensi . Kelainan otot rahim . Sedatif, analgesik kuat . Kelainan rangsangan his
Tx ssuai dg Ex
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Criteria for Diagnosis of Abnormal Labor Due to Arrest or Protraction Disorders
Labor Pattern Nullipara Multipara
Protraction disorder
Dilatation < 1.2 cm/hr < 1.5 cm/hr
Descent < 1.0 cm/hr < 2.0 cm/hr
Arrest disorder
No dilatation > 2 hr > 2 hr
No descent > 1 hr > 1 hr
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• Before the diagnosis of arrest during first-stage labor is made, both of these criteria should be met:– The latent phase has been completed, with the
cervix dilated 4 cm or more.– A uterine contraction pattern of 200 Montevideo
units or more in a 10-minute period has been present for 2 hours without cervical change.
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Labor Pattern Nulliparas Multiparas Preferred Treatment
Exceptional Treatment
Prolongation Disorder (Prolonged latent phase)
> 20 hr > 14 hr Bed rest Oxytocin or cesarean delivery for urgent problems
Protraction Disorders
1. Protracted active-phase dilatation
< 1.2 cm/hr < 1.5 cm/hr Expectant and support
Cesarean delivery for CPD
2. Protracted descent
< 1.0 cm/hr < 2 cm/hr
Arrest Disorders
1. Prolonged deceleration phase
> 3 hr > 1 hr Oxytocin without CPD
Rest if exhausted
2. Secondary arrest of dilatation
Diagnostic Criteria
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Kurva Friedman
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Normal , protracted, arrest 10
9
8
7
6
5
4
3
2
1 1 2 3 4 5 6 7 8 9 10
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Prolonged 2nd stageArrest of descent
* Prolonged 2nd stage: . > 2 jam utk nulli & 1 jam utk multi* Arrest of descent : . > 1 jam tidak ada pnurunan * Sebab . CPD . Merejan kurang kuat . His berkurang krn analgesik, sedatif
yg kuat* Tx . tgantung penyebab
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Duration of Second Stage
Clinical Outcome < 2 hr n=6259)
2–4 hr n=384)
> 4 hr (n = 148)
Cesarean delivery 1.2 9.2 34.5Instrumental delivery
3.4 16.0 35.1
Perineal trauma 3.6 13.4 26.7Postpartum hemorrhage
2.3 5.0 9.1
Chorioamnionitis 2.3 8.9 14.2
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Kelainan jalan lahir (Passage)
Pengukuran panggul bagian keras . UPD . PelvimetriMacam . Panggul sempit ringan . Panggul sempit absolut . Tx . Penting adalah ada/tidaknya CPD
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Kelainan pd janin
Macam. Bentuk atau besar janin. Malpresentasi, malposisiTx. Tgantung ada/tidaknya CPD dan
kmungkinannya utk koreksi pd malpresentasi/malposisi
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Kelainan bentuk dan besar janin
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Kelainan letak
• Letak bujur• Letak lintang
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Kelainan presentasi
• Presentasi kepala
. Blkang kep . Dahi
. Puncak . Muka
. Tlg ubun2
• Presentasi bokong
. Bokong kaki . Pres kaki
. Bokong sempurna
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Kelainan posisi
• Adanya perubahan denominator (uuk, uub, dagu, sakrum) dan menetap
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Kelainan Presentasi dan Posisi
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Presentasi Kepala
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Derajat Fleksi Kepala
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Face presentation, (a) Mento-anterior - delivery possible. CD) Mento-posterior – delivery impossible.
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Presentasi Puncak (Brow presentation)
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TIPE SUNGSANG
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Mekanisme Lahir Sungsang
DESCENT
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Mekanisme Lahir Sungsang
Engagement Internal Rotation
Latero flexi
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Mekanisme Lahir Sungsang
Ext rotasi Restitution Bahu dpn lahir
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LETAK LINTANG
• Etiology– Abdominal wall relaxation from high parity.– Preterm fetus.– Placenta previa.– Abnormal uterine anatomy.– Excessive amnionic fluid.– Contracted pelvis.
• P4 atau lebih insiden let li 10 x
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LETAK LINTANG
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Letak Lintang Kasep
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COMPOUND PRES.
Compound presentation. The left hand is lying in
front of the vertex. With further labor, the hand
and arm may retract from the birth canal and
the head may then descend normally.
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Kelainankejiwaan (Psyche)
• Fakta2 pnelitian
Faktor kjiwaan ibu yg baik akan mpcepat/mplancar persalinan
• Sayang ibu
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DISTOSIA BAHU
Distosia bahu adalah kegawat daruratan obstetrik
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Definisi• Tertahannya bahu depan diatas simfisis• Ketidakmampuan melahirkan bahu pada persalinan
normal
Insidens• 1 - 2 per 1000 kelahiran• 16 per 1000 kelahiran bayi > 4000 g
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Komplikasi Distosia bahu• Bayi
- kematian- Asfiksia dan komplikasinya- Fraktur - klavikula, humerus- Kelumpuhan pleksus brachialis
• Ibu- Perdarahan postpartum- Ruptur uteri
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Faktor resiko
• Kehamilan lewat waktu• Obesitas pada ibu• Bayi makrosomia • Riwayat distosia bahu sebelumnya• Kelahiran lewat operasi• Persalinan lama• Diabetes yang tidak terkontrol
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• Faktor risiko terdapat pada < 50% kasus
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Diagnosis•Kepala bayi melekat pada
perineum, (‘turtle’ sign)•Kala II persalinan yang
memanjang•Gagal untuk lahir walau dengan
usaha maksimal dan gerakan yang benar
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SYARAT
• Kondisi vital ibu cukup memadai , bisa bekerja sama
• Masih punya kemampuan mengedan• Jalan lahir dan PBP cukup luas• Bayi masih hidup / mampu bertahan hidup• Bukan monstrum atau kelainan kongenital
yang menghalangi keluarnya bayi
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• Ask for help
• Lift - bokong• - kaki
• Anterior disimpaction of shoulder• - rotate to oblique• - suprapubic pressure
• Rotation of the posterior shoulder – manuver Wood
• Manual removal of posterior arm
Manuver McRobert
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Hindari 4 “P” :•Panic•Pulling (pada kepala)•Pushing (pada fundus)•Pivoting (memutar kepala secara
tajam, dengan koksigis sebagai tumpuan)
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Ask for HELP•Ibunya disamping pasien•Suami/orang terdekat•Perawat• Dokter pengganti atau tim
paramedis lainnya
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Lift - McRobert’s Manoeuver
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Lifting the legs and buttocks
• Manuver McRobert
• Fleksikan paha ke arah abdomen
• Membutuhkan asisten
• 70% kasus dapat diselesaikan oleh manuver ini
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Anterior Disimpaction - 1) Suprapubic Pressure (Manuver Massanti )
• Tidak boleh menekan fundus
• Penanganan abdomen : Penekanan suprapubik dengan ujung genggaman tangan pada bagian belakang bahu depan untuk membebaskannya.
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• Anterior Disimpaction -
• 2) Manuver Rubin
• Pemeriksaan vagina
• adduksi bahu depan dengan menekan bagian belakang bahu (bahu didorong ke arah dada)
• Pikirkan tindakan episiotomi• Tidak boleh menekan fundus
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Rotation of Posterior Shoulder - Langkah 1
• Penekanan pada bagian depan bahu belakang
• Bisa dikombinasi dengan anterior disimpaction manoeuvers
• Tidak boleh menekan fundus
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Rotation of Posterior Shoulder - Langkah 2
• Wood’s screw manoeuvre
• Bisa dilakukan secara simultan dengan anterior dissimpaction
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Rotation of Posterior Shoulder - Langkah 3
Bisa diulang bila proses persalinan tidak tercapai pada langkah 1 dan 2.
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Rotation of Posterior Shoulder - Langkah 4
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Manual removal of posterior arm
• Fleksikan tangan pada siku
• (menekan fosa antecubital untuk memfleksikan tangan)
• Usapkan tangan sepanjang dada.
• raih lengan depan atau jari-jari tangan
• Keluarkan tangan.
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Manual removal of the posterior arm
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Episiotomi
• Dapat membantu manuver Wood atau memberi ruang untuk mengeluarkan pergelangan tangan belakang,
• memutar lutut dan dada : memudahkan menggapai bahu belakang
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Tindakan terakhir :• Fraktur klavikula• cephalic replacement (manuver Zavenelli)• simfisiotomi
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Setelah selesai tindakan :• Antisipasi HPP• eksplorasi laserasi dan trauma• Pemeriksaan fisik bayi untuk melihat adanya perlukaan.• Menjelaskan proses persalinan dan manuver yang
dilakukan.• Catat tindakan yang dilakukan
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• KESIMPULAN• Antisipasi dan persiapan (kebanyakan kasus
tidak dapat diprediksikan)• Selalu ingat dengan “ALARMER”• Tetap tenang, tidak panik, menarik,
mendorong atau memutar.
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• Ask for help
• Lift - bokong• - kaki
• Anterior disimpaction of shoulder• - rotate to oblique• - suprapubic pressure
• Rotation of the posterior shoulder – manuver Wood
• Manual removal of posterior arm
Manuver McRobert
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• PERSALINAN KEPALA PADA DISTOSIA BAHU