PERSALINAN PATOLOGIS

(DISTOSIA)

Marsianto, dr, SpOG(K)

Dept. / SMF Obstetri & Ginekologi
FK UNAIR / RSU Dr Soetomo
SURABAYA - 2008
 PENGERTIAN DISTOSIA
UMUM : - Difficult Labor
- Abnormally Slow Progress of Labor
GREEK :
EUTOCIA : NORMAL LAHIR
DYSTOCIA : ABNORMAL LAHIR
DIFFICULT CHILDBIRTH

MACAM DISTOSIA
(American College of Obstetricians and Gynecologist 1995)

I. Abnormalies of Powers
II. involving Passangers
III. of The Passage
KELAINAN
JALAN LAHIR
(PASSAGE)
 PANGGUL SEMPIT

BILA SALAH SATU ATAU LEBIH

UKURAN PANGGULNYA MENGECIL
1 CM ATAU LEBIH
PEMBAGIAN KELAINAN JALAN LAHIR

a. Jalan Lahir Keras

b. Jalan Lahir Lunak

 4. JALAN LAHIR KERAS

I. Caldwell Moloy (PAP)

II. Munro Ker ( Etiology)
III. Lokasi
IV. Kapasitas
 Causes of Contracted Pelvis

A. Genetic : 1. With deformity (e.g.

achondroplasia. Naegeles pelvis
absence of one sacral ala).

2. Without deformity (e.g.

justominor)

B. Nutritional : e.g. Rickets, Osteomalacia.

An extreme type of this
deformity is illustrated

C. Bony Disease e.g. tuberculosis, osteomyelitis

D. Trauma e.g. old fractures of pelvis

Ginekoid Platipelloid

Antropoid Android
 The Anthropoid pelvis can be considered
normal for clinical purposes as its
measurements are equivalent to a
gynaecoid pelvis turned through 90o

The anthropoid pelvis is frequently found in

association with a high assimilation of the
sacrum the fifth lumbar vertebra is
incorporated in the sacrum making a sixth
segment. The effect is to alter the angle of
the pelvic brim so that it is about 75o rather
than the normal 55o. This makes engagement
more difficult and delayed. The long sacrum
makes the pelvis deeper so that the head has
further to travel in the can fines of the pelvic High
cavity. Assimilation
The Android pelvis is a pelvis with
decreasing capacity the deeper the
descends. The greatest difficulty is
at the outlet. It is sometimes
called the funnel pelvis.

The flat pelvis is contracted at the

brim levels with a more capacious
cavity and outlet. The difficulty is
at the brim
III. LOKASI
I. Pintu Atas Panggul
Conjucata Vera
a. Kurang 6 cm Panggul Sempit
b. Antara 6 8 cm Absolut

c. Antara 8,5 10 cm Panggul Sempit

Ringan
 MANAJEMEN :

a. SC. Absolut (H / M)

b. SC. Primer (H)

c. SC. Sekunder / Partus Percobaan

 2. RONGGA PANGGUL

a. Diameter Interspinarum < 10,5 cm

(Spina Menonjol)

b. Sacrum Mendatar

Akibat :
- Gangguan Putar Paksi
- Gangguan Penurunan
3. PINTU BAWAH PANGGUL

a. Distansia Tuberum < 10,5 cm

b. Distansia Tuberum + Diameter

Sagitalis Posterior < 15 cm

1. The sub-pubic angle is estimated by
putting two fingers under the symphisis
and spreading them

2. The depth and thickness

of the symphisis is
assessed.

3. The angle of the pubis may also be

demonstrated by placing fingers and
thumb along the descending rami of
the pubis.
Even though the intertuberous diameter is quite narrow (5.5
cm), vaginal delivery is possible because of the long (10 cm)
posterior sagittal diameter. (Int. tub. Diam. = Intertuberous
diameter; Sym = symphysis pubis; S-5 = Fifth sacral vertebra).
Diagram of pelvic outlet in which the intertuberous diameter is
narrow (6.5 cm) and the posterior sagittal diameter is quaite
short (7 cm), precluding vaginal delivery of most term-size
fetuses (int. tub. Diam. = Intertuberous diameter; Sym =
symphysis pubis; S-5 = Fifth sacral vertebra).
 15 Cm < 20 Cm

A < B

Posterior sagittal diameter Adequate posterior

Too small head arrested Sagittal diamater

The bituberous diameter plus the posterior sagittal

diameter should be 20 cm (7.5 in.). If the sum is 15 cm
(6 in.) dystocia may result.
 JONGES
Melebarkan Arcus Pubis
 IV. KAPASITAS PANGGUL
1. PINTU ATAS PANGGUL
a. Penurunan Kepala
b. Osborn
c. Muller
d. Munro - Kerr

2. RONGGA PANGGUL & PINTU BAWAH

Trial of Labour
The assessment of disproportion may be made by
trying to push the head to the pelvic brim with one
hand and the fingers of the other gauge descent while
the thumb feels for overlap (Munro Kerrs method).
1. Head behind pubis
there should be no problem of disproportion
2. Head flush with pubis may or may not
mould and engage.
3. Head over riding pubis and will not enter
brim. Caesarean section method of choice
 B. JALAN LAHIR LUNAK

1. Dalam Jalan Lahir

a. Tumor Rahim Myoma
b. Pintu Rahim Stenosis / Rigiditis Serviks
c. Vagina Septum Vagina

2. Sekitar / Diluar Jalan Lahir

a. Buli Buli Batu
b. Ovarium Kistoma
c. Tulang Pelvis Sarkoma
Incarcerated Cyst Which will Obstruct Labour
 CERVICAL MYOMA

Fibroid Obstructing Labour

When the lowermost portion of the fetal head is above the
ischial spines, the biparietal diameter of the head is not likely
to have passed through the pelvic inlet and therefore is not
engaged. (P = Sacral promontory; Sym = symphysis pubis).
When the lowermost portion of the fetal head is at or below the
ischial spines, it is usually engaged. Exceptions occur when there is
considerable molding, caput formation, or both. (P = sacral
promontory; S = ischial spine; Sym = symphysis pubis.)
II. KELAINAN JANIN
( PASSENGER )
JENIS KELAINAN PASSANGER (ANAK)
I. LETAK
II. BESAR OVERWEIGHT BABY

III. BENTUK HIDROCEPHALUS

IV. JUMLAH KEMBAR

V. PERJALANAN PUTAR PAKSI

SEBAB :
1. AKOMODASI
2. FISIKA
 PENGERTIAN LETAK

Situs : Sumbu Janin - Sumbu Uterus

Habitus : Sikap Kedudukan Janin

Presentasi : Bagian terendah

Positio : Bagian Janin (Denominator) Ka Ki

Depan Belakang

Statiom : Penurunan Bidang Panggul

 FETAL PRESENTATION AT VARIOUS GESTATIONAL AGES
DETERMINED SONOGRAPHICALLY
GESTATION TOTAL PERCENT
( WK) NUMBER CEPHALIC BREECH OTHER
21 - 24 264 54,6 33,3 12,1
25 - 28 367 61,9 27,8 10,4
29 - 32 443 78,1 14,0 7,9
33 - 36 638 88,7 8,8 2,5
37 - 40 463 91,5 6,7 1,7
From Scheer and Nubar (1976)

FETAL PRESENTATION IN 49,156 SINGLETON

PREGNANCIES AT PARKLAND HOSPITAL, 1983 1986
PRESENTATION NUMBER PERCENT INCEDENCE
Cephalic 47.497 96.9 -
Breech 1.468 3.0 1 : 33
Tranverse 117 0.24 1 : 420
Face 41 0.08 1 : 1200
Compound 22 0.05 1 : 2235
Brow 11 0.02 1 : 4470
 POOR MODERATE

ADVANCED COMPLETE
Four degrees of head flexion. Infected by the solid line is the occipitomental
diameter; the broken line connects the center of the interior fontanel with
the posterior fontanel; A. Flexion poor, B. Flexion moderate. C. Flexion
advanced. D. Flexion complete

Note that with flexion complete, the chin is on the chest and the
suboccipitobregmatic diameter, the shortest anteroposterior diameter of the
fetal head, is passing through the pelvic inlet. (Modified from Rydberg, 1954)
 PENYEBAB :
I. PRIMER : TAK DAPAT DIKOREKSI
- Kelainan Lahir Bayi
- Struma Conginetal
- Ihgroma Coli
- Lilitan Tali Pusat di leher

II. SEKUNDER : DAPAT DI KOREKSI

- Panggul Sempit
- Prematuritas
- Multipara
- Hidramnion
JANIN DALAM AKHIR KEHAMILAN

Beberapa Sikap Badan Janin

 A. LETAK DEFLEKSI
PATOFISOLOGI LETAK DEFLEKSI
I. DI ATAS PAP
UNSTABLE LIE TERABA PENEMPATAN
U2 B BEL. KEP
U2 K PUNCAK
DAHI DAHI
MUKA MUKA

DESENSUS

FLEXI

TETAP / BERUBAH
 II. MELEWATI PAP
DALAM RONGGA PANGGUL
- LINGKARAN TERBESAR LEWAT PAP

STABLE LIE

LETAK
B. KEP, P, M, D.
Presentasi puncak kepala, presentasi dahi, presentasi muka
1. LETAK PUNCAK
 PENGERTIAN
1.LETAK PUNCAK
- Letak deflexi
- Diameter Ocipito Frontalis
- Ubun-ubn Besar

2.POSITIO OCCIPITALIS POSTERIOR (P.O.P)

- Letak Belakang Kepala
- Diameter SOB
- Ubun-ubun Kecil di Posterior
- Masih dapat berputar ke Anterior
3. POSITIO OCCIPITALIS
Posterior Persisten
- Bila Macet
- Dengan U2 K masih tetap di Posterior

4. POSITIO OCCIPITALIS
Posterior Directa Sacralis
- Bila lahir / Macet dengan U2 K
di depan Sacrum
5. DEEP TRANSVERSE ARREST
- Putar Paksi Tak Sempurna
- U2 K Transverse ( Kiri / Kanan)
- Macet
 PEMERIKSAAN DAN DIAGNOSA
1. Pola persalinan
Pada letak B bila terjadi kelambatan persalianan
- pikirkan pos. occ. Post

2. Bentuk perut
Seringkali terlihat adanya cekungan di bawah pusat

3. VT : 2 kali berturut Occiput pada pelvis post

- atau berputar ke post.
ETIOLOGI LETAK PUNCAK

1. JANIN : - PREMATUR
2. POWER : - INERTIA UTERI
- GRANDEMULTI
- PENDULAR ABDOMEN

3. PASSAGE : - ANTROPOID
- ANDROID
Pendulous Abdomen - This is found in multiparae.

Anthropoid pelvic brim - This favours direct O.P.

or direct O. A.

Android pelvic brim - The transverse diameter of

the brim being near the sacrum encourages the
biparietal diameter to accommodate posteriorly

A flat sacrum with a poorly flexed head leads

to further deflexion and O.P.
The placenta on the anterior uterine wall tends
to encourage the foetus to flex round it.

R.O.L. position of the head and the normal right

obliquity and dextro - rotation of the uterus
favours deflexion of the head and R. O. P.
descent. There is some assistance from the pelvic
colon in the left posterior pelvic quadrant.
 PATOFISIOLOGI LETAK PUNCAK
I. DI ATAS PAP
- Unstable (U2B, U, K, M, D)
- Obliq Desensus

II. LEWAT PAP MASUK RONGGA PANGGUL

Tidak FLEXI Ya
U2B : Let. P U2K : Let. B. Kep

Internal Rotasi Internal Rotasi

U2B U2B U2K U2K Di Tengah

Anterior Posterior Anterior Posterior

Mudah Lebih Let. B. Kep Gangguan DTA

(= L.B. Kep) Sulit
Putar Paksi
Deflexi Sulit
Ruptur Pirenium
 O. P. POSITION MECHANISM
Two types of occipito - posterior ( O. P ) are described

A Flexed O. P. with suboccipito -

frontal and biparietal diameter
engaging 10 cm ( 4in. ) X 9.5 cm (
3 3/4 in.
B Deflexed O. P. with occipito - frontal
and biparietal diameters engaging
11.5cm (41/2in.) X 9.5 cm ( 3 3/4 in.).
FURTHER PROGRESS DEPENDS ON FLEXION OF HEAD

A. If flexion of the head increases in descent then the occiput strikes

pelvic floor first and rotates anteriorly through the right occipito -
lateral (R. O. L.). position - and then to the R. O. A. position and to
the direct O. A. position.
 R.O.P 0.A

The occiput has thus rotated through the angle of 1350 to bring the
occiput to the symphysis pubis. This is known as LONG rotation.
The mechanism is thereafter the same as for the occipito -
anterior position.

DELIVERY
Two thirds of the cases will
delivery spontaneously as O.A
The mechanism now is difficult for flexion of the head is
restricted by the foetal chest though the brow is pressed
to the pubis and some flexion occurs. The soft tissues are
stretched more than in O. A. and the foetus is delivered
face to pubis.

12% will deliver spontaneously face

to pubis. The perineum is
distended by the occipito frontal
diameter; an episiotomy is made.
B If flexion of head remains incomplete in descent then rotation of the
occiput anteriorly on the pelvic floor may not occur; but rotation of
the occiput posteriorly may occur bringing the occiput into the hollow
of the sacrum. This is known as SHORT rotation ( 450 ) and gives the
persistent occipito - posterior ( P. O. P ) position or direct O. P.
position.
R. O. P P. O. P

Engagement occurs in the transverse or the right

oblique diameter of the brim. Descent occurs in
the right oblique diameter of pelvis giving the
right occipito - posterior position ( R. O. P. ).
Descent continues to pelvic floor
Mechanism of labor for right occiput posterior
position, posterior rotation (From Steele and
javert.Surg Gynec Obstet 75:477,1942.).
Soft tissues

If this does not occur then an impasse is

reached and labour becomes obstructed.
 JALANNYA PERSALINAN
PADA LETAK PUNCAK

Persalinan lebih sulit lama

70% akan terjadi perputaran spontan
OCC Anterior

Sebagian Partus Spontan Pervaginam

Dengan OCC Posterior Trauma
Robekan Perineum Luas

Sebagian Tejadi Kemacetan

Persalinan dengan OCC Posterior
O.P. POSITION MANAGEMENT
Occipito posterior position may lead to disorganised
labour especially in the primigravida. Initial the
contractions are sustained and irregular, accompanied
by marked backache. Analgesia with morphine 15 mg
is advisable to ease pain and induce sleep. Pethidine
and pentazocine act similarly but with less hypnotic
effect.
Engagement of the head is thought to be encouraged if
the patient lies on the side which the foetus faces.
Walking about after rest also helps

Labour tends to be long and though contractions become

more normal as it progresses severe backache may
demoralise the patient. Much analgesia and comforting
are needed. Epidual anaesthesia gives great relief and
accelerating offers a shortened labour
Retention of urine is common in O. P. labour and
catheteriation may be required.

The patient may feel the need to bear down before

the second stage is reached, probably due to pressure
on the sacrum and rectum. Dilatation must be known
before she is encouraged to push
 PERSISTANT OCCIPUT
POSTERIOR POSITION

1. PENYEBAB : PENYEMPITAN MIDPELVIS

2. PERJALANAN : (GARDBERG DKK 1998)
KEHAMILAN ATERM
N = 408 100%

AWAL PERSALINAN

OCCIPUT ANTERIOR OCCIPUT POSTERIOR

N = 347 85,0% N = 61 15,0%

KELAHIRAN
n=53 n=53 n=334 n=53
13,0% 13,0% 81,9% 13,0%

OCCIPUT POSTERIOR OCCIPUT ANTERIOR

n = 21 5,1% n = 387 94,9 %
PERSALINAN LEBIH LAMA

MORBIDITAS IBU & ANAK MENINGKAT

PERLU EPISIOTOMI LEBIH LEBAR

TINDAKAN PERVAGINAM LEBIH SULIT

DAN SERING GAGAL

BILA SULIT, DAPAT DILAKUKAN S.C

 PERSISTENT OCCIPUT TRANSVERSE POSITION
A. Penyebab 1. Kegagalan Putar Paksi karena Power

2. Kesempitan Panggul
- Platypeloid
- Android

B. Perjalanan & Manajemen

1. Power Tanpa Disproporsi
- Oxytosin Drip
Dengan Monitor Ketat
- Forceps
Kielland
Standar
2. Disproporsi SC
MANUAL ROTATION
First determine the exact position by palpating the anterior
fontanelle. This may be extremely difficult to detect if there
haas been much moulding or caput formation

An ear maybe palpable. The root of the pinna must be identified

to distinguish left from right
Internal rotation may be disturbed

by prominent ischial spines or

by cavity restriction as in android pelvis.

In such cases delivery must be completed

by manipulation or caesarean section

The right hand then grasps the head, while the left
hand throughthe abdominal wall pushes the soulder
forward.The head may have to be dislodged slightly to
achieve this, and once round it must be held in position
until the forceps blades are applied.
 COMPLICATIONS OF MANUAL ROTATION

1. Like all vaginal manipulations it increases the risk

of infection

2. The cord may prolapse during rotation, but

delivery is usually possible at once.

3. There is an increased risk to the foetus, and on that

account delivery without rotation is preferable.
However unless the head is low in the pelvis, it is
usually impossible to delivery it in the OP position
without the use of excessive and traumatic force.
LETAK MUKA
The face is ill fitting at first, so contractions are poor
and irregular and early rupture of membranes occurs
with risk of prolapse cord.

Labour may proceed normally thereafter when caput has

formed. Engagement of biparietal diameter occurs only
when mentum is deep in the pelvis.
If the chin rotates anteriorly spontaneous delivery can
occur. Rotation occurs very deep in pelvis.

If the chin rotates posteriorly interference is required

to procure delivery unless in exceptional circumstances
( the head very small or anencephaly ).

The head may be arrested in the transverse position.

 Uterine obliquity is commonly to the right
A head presenting R. O. T. with some deflexion may also
convert to aface presentation if for example in a flat
pelvis there is partial arrest of the biparietal diameter
but an easier passage for the bitemporal diameter
[ Note that the brow is an intermediate presentation
in these conversions to face.]

If the foetus has its back to the

opposite side the same forces
would cause compaction and
further flexion.
In complete flexion with occipito posterior vertex and
marked uterine obliquity can promote Extension

Parietal Bitemporal
Eminence Diamater
The action of the uterine forces, which normally tends to
cause compaction, is in fact promoting extension of the head
at the atlanto occipital joint because the back of the foetus
is in same direction as the uterine obliquity
Right Mento - Anterior
Right Mento - Posterior
Left Mento - Anterior
AUSCULTATION
Foetal heart best heard at front of foetus

VAGINAL EXAMINATION
Malar processes
Nose rubbery saddle shaped

Mouth hard areolar ridges

Supra-orbital ridges

Frontal suture and

anterior fontanelle
 PALPATION
Longitudinal lie.
1. Head in lower pole
2. Groove between head and back (best
felt after membranes rupture ).
3. Lack of head prominence on ventral
side

Diagnosis is difficult by palpation.

( X- ray will confirm )
 FACE PRESENTATION MECHANISM
The engaging diameters in a face presentation are the
submento bregmatic followed by the biparietal

Suboccipito
bregmatic diameter

Submento
bregmatic diameter
The submento bregmatic and suboccipito bregmatic
diameter are the same size ( 9 cm, 3 in. ).
Therefore the engaging diameters are the same size as
in a normal vertex presentation
In a face presentation the submento bregmatic
diameter enters the plane of the brim and is
followed by the other engaging diameter.

Pelvic brim

Submento
bregmatic
diameter engaged
 In a face presentation the submento bregmatic and
the biparietal diameters are in different planes. The
submento bregmatic and bitemporal diameters
engage together

Biparietal diameter

Bitemporal diameter Pelvic brim.

Engagement is usually in the transverse

diameter of the brim giving a right or left

mento transverse position. Left mento

transverse (L.M.T) is the more common

When the lowermost portion of the fetal head is above the
ischial spines, the biparietal diameter of the head is not likely
to have passed through the pelvic inlet and therefore is not
engaged. (P = Sacral promontory; Sym = symphysis pubis).
When the lowermost portion of the fetal head is at or below the
ischial spines, it is usually engaged. Exceptions occur when there
is considerable molding, caput formation, or both. (P = sacral
promontory; S = ischial spine; Sym = symphysis pubis.)
 FACE PRESENTATION - MECHANISM

Descent continues till the pelvic floor is reached and rotation occurs.
Most commonly the mentum leads and rotates forward ( Internal
rotation) to The oblique diameter left mento anterior (L.M.A)

With further descent the

Rotation is completed to
Bring the mentum to the
Symphysis. This is the
Mechanism in 75% of
Face presentations.
Descent continues and chin escapes from under pubis
And progressive flexion allows the birth of the head
 135

Mechanism of labour for right mentosposterior position

There after restitution and external rotation take place
and further descent delivers the baby as in a persistent
occipito posterior delivery
 FACE PRESENTATION MECHANISM

If the sinciput leads and rotates forward the mentum is carried

to the hollow of the sacrum

This is now a dfficult

mechanism because
further extension of the
head is necessary to
negotiate the lower birth
canal - and the shoulders
must engage too.
A normal pelvis cannot accommodate a normal foetus because
the bregmatic - sternal diameter is 18cm ( 7 inches ) Obtruction
therefore occurs
A small foetus in a roomy pelvis MAY permit birth
Face presentation. The occiput is on the longer end
of the head lever. The chin is directly posterior.
Vaginal delivery is impossible unless the chin rotates
anteriorly
 A.

Descent continues and the occiput crushes into

the shouldera till the occipital bone is behind me
pubis, the peritoneum slips beneath the chin, the
head starts to flex and the occiput is free.

The mechanism is then the as occipito anterior

Caput Formation
In face presentations the caput succedaneum is
formed from the soft tissues covering the facial
bones, and bruishing is the rule. The mother should
be assured that her babys face will be normal in a
few days.
Face presentation. The occiput is on the longer end
of the head lever. The chin is directly posterior.
Vaginal delivery is impossible unless the chin rotates
anteriorly
Manual rotation of mento posterior

When chin is posterior the face and chin are gripped and displaced
upwards to free the shoulders from the pelvis and then the head is
rotated in the cavity, the other hand used to apply presusure to
the shoulders. The mentum is thus brought to the front and
forceps are then applied or, alternatively, manual rotation may be
only to the transverse and Kiellands forceps applied
- BROW
- PARIETAL
3. LETAK DAHI
 3. LETAK DAHI
Sering merupakan Penempatan
Deflexi Max letak Muka
Pemeriksaan dalam : Dagu Tak Teraba
Bila teraba letak Muka
Pada keadaan Normal
Letak dahi tak dapat lahir pervaginam

30 40 % Partus Spontan sebagai

Letak Muka atau B
Brow posterior Brow anterior
Presentation Presentation
 PALPATION
This feels like normal vertex except
that the head feels unduly large, due
to palpation across the mento-
vertical diameter. Head appears
disproportionate.

AUSCULTATION Foetal heart site not significant

VAGINAL EXAMINATION Head is high because of disproportion.

Membranes rupture early in labour. Brow is palpated through
cervix and is identified by :
1. Anterior fontanelle and frontal suture leading to
2. Supra orbital ridge and root of nose
 BROW PRESENTATION

A. brow presentation is unstable

and tends to convert to an occipital
or face presentation

The Aetiology is similar to that of face

 If the presentation is seen and
recognised in early labour an attempt
by vaginal and abdominal manipulation
to correct it should be made
somewhat as in face under general
anaesthesia. One or two fingers
through the cervix displace the head
and encourage flexion while the other
hand applies pressure on the foetal
chest towards its back an assistant
pressing on the breech will help

The brow may be altered to a face presentation

 There is no mechanism for brow
presentation given a normal sized
foetus and pelvis, because the
engaging diameter are the mento
vertical and biparietal.

The mento vertical diameter is 14

cm ( 51/2 inches) and the largest
pelvic diameter is 12,5 cm ( 5
inches).

If the head is small or the pelvis roomy moulding takes

place and engagement occurs with descent
The brow is ill fitting so membranes rupture early and
labour is poor at the beginning. There is risk of cord
prolapse. With a normal baby and pelvis labour is
impossible. Brow is an unstable presentation and may
convert to vertex or face, but moulding and caput
formation help to stabilise the malpresentation.
Caesarean section is the treatment of choice, but
bipolar version to breech may be attempted where the
facilities are limited
If he foetus is small in relation to the pelvis then a
normal type of labour and delivery will ensue

A BROW PRESENTATION SHOULD BE

SUSPECTED WHEN A PAROUS WOMAN
HAS UNEXPECTED DYSTOCIA
If the presentation is seen and recognised in early
labour an attempt by vaginal and abdominal
manipulation to correct it should be made
somewhat as in face under general anaesthesia.
One or two fingers through the cervix displace the
head and encourage flexion while the other hand
applies pressure on the foetal chest towards its
back an assistant pressing on the breech will help

The brow may be altered to a face presentation

The uterine forces thrust down. The head is roughly

equal in size front of and behind the brow. Thus the
leverage to encourage flexion or extension is equal
Unequal resistance of the pelvic parts or oblique
direction of thrust will tend to create flexion or
extension of the head
 BROW PRESENTATION MECHANISM
This is only possible when the baby is small for the pelvis

Moulding Occipito-frontal
Diameter Increases

CERVIX

Occipito-mental
Diameter decreases
The brow slowly descends to pelvic floor and
turns forward under the symphysis
Flexion then follows and the brow, vault of
the skull and occiput are born
The head drops back over the peritoneum and
the face and chin are born
The mechanism there after is the same as O. P.
LETAK PARIETAL
 PARIETAL PRESENTATION
True parietal presentation is rare and only found in flat pelvis.
The head is partly flexed bringing anterior and posterior
fontanelles to the same level and is in the transverse diameter
of the brim.

The presentation is described as (1 ) an anterior parietal

presentation (anterior asynclitism ) or (2) a posterior
parietal presentation ( posterior asynclitism)
Sinklitismus.

Asinklitismus Anterior

Asinklitismus Posterior
PARIETAL PRESENTATION MECHANISM

Anterior asynclitism is more favourable as the

anterior parietal bone has passed the depth of
the pubis and the posterior parietal bone has to
pass the shallow promomtory of the sacrum. In
posterior asynclitism the posterior parietal bone
has passed the sacral promontory but the anterior
parietal bone has still to descend past the
symphysis pubis.
The head also rolls adopting the attitude of asynclitism with
advantage too, as the biparietal diameter is substituted by the
subparietal supraparietal diameter ( 8. 25 cm, 3 inches ).

Compaction of the foetus occurs and lateral displacement of the

head towards the occiput brings the bitemporal diameter (
8.25cm, 3 inches ) nearer the conjugate of the brim and the
biperietal diameter ( 9.5cm, 3 inches ) into the bay thus
gaining advantage.
Anterior asynclitism the head engages (1) and then the
anterior parietal bone descends into the pelvis increasing
the asynclitism (2) till the anterior parietal eminence is
behind and just below the pubis and the sagittal suture is
close to the sacrum; then the head descends further by
decreasing the asynclitism (3) and pushing the posterior
parietal eminence past the sacral promontory (4). The
pelvic cavity and outlet are relatively roomy and further
descent causes flexion of the head and the final
mechanism is that O. A. or O. P.
The mechanism of posterior asynclitism is
similar but the position are reversed. Difficulty
is found, and thus delay, in pushing the parietal
eminence past the pubis

In these circumstances caesarean section is

advisable because the head is not engaged
V
 BREECH PRESENTATION MECHANISM
The breech is a mal presentation and occurs once in about 40 cases of
labour

The presenting part is the breech and the denominator is the sacrum

Aetiology : The breech is the presenting part in 25% of cases before 30

weeks therefore prematurity is an important factor

The legs of the foetus may be extended and interfere with flexion of
the body so breech with extended legs is common especially in
primigravida.

Multiple pregnancy will interfere with spontaneous version.

Other related factors are : - Foetal malformation, hydramnios,lax
uterus and pendulous abdomen, abnormal shape of pelvic brim or
uterus, placenta praevia
 Fully flexed foetus

A. Complete or Full breech

Not fully flexed foetus With legs extended

B. Frank breech
One or both thighs extended

Footling or
Incomplete breech
 BREECH PRESENTATION MANAGEMENT

RECOGNITION

PALPATION
Longitudinal lie.
Firm lower pole.
Limbs to oneside.
Hard head at fundus.
Frank Breech Full Breech
( Head may not be palpable at fundus because it is
under the ribs always confirm by pelvic
examination )
AUSCULATATION
The foetal heart ( F.H ) is best heard above the umbilicus
 MEKANISME PERSALINAN SUNGSANG
BOKONG : Diameter intertrochanterica P. A. P
Putar paksi dalam : sacrum ke ka - ki
Hipomochlion : Troch.mayor depan

Lateroflexi BO lahir P. P. L
BAHU : Diameter Bacromial P. A. P
P. P. D Hipomochlion : Acromion dep
Latero flexi / lordose bahu belakang lahir
KEPALA : Diameter Suboccip Bregmatica
Sut. Sagitalis Melintang
Flexi Kepala Putar paksi dalam
Hipomochlion : Subocciput
Gerakan Flexi ( Hiperlordose )
Lahir seluruh kepala
 MECHANISM
The denominator is the sacrum; the leading part the
anterior buttock.
The bittrochanteric diameter ( transverse diameter
between the great trochanters of the foetus ) is 10 cm (
4in. ). The most common position is the left sacro-
anterior ( L.S.A. ). With labour there is compaction,
descent and engagement of the breech (bisiliac
diameter )
Descent continues until breech reaches pelvic floor.
The anterior buttock rotates Forward under the pubis
( internal rotation ).
Lateral flexion of the foetal body round the pubis
allows the anterior buttock to slip forward under the
pubis and the posterior buttock to slip over the
peritoneum. The breech is delivered followed by the
legs. A movement of restitution of the hips takes place
The shoulders now engage in the same pelvic
diameter as the hips - the left oblique. ( The
bisacromial diameter of the shoulders is 11
cm. 4 in. )
As descent continues internal rotation of the shoulders
occurs in the pelvic cavity bringing one shoulder
beneath the pubis and the other into the hollow of the
sacrum. The anterior shoulder and arm are born first
As the shoulders are being born the head enters the pelvic
brim either, in the transverse or left oblique of the brim.

The engaging diameters of the head are the biparietal and

the suboccipito - bregmatic or suboccipito - frontal
The head descends into the pelvic cavity and rotates
to bring the occiput under the pubis
The occiput is arrested at the pubis and the head is
born by flexion. The chin, face and brow are born
first, and then the occiput
Sometimes the occiput rotates posteriorly
If the head is flexed the root of the nose is arrested behind
the pubis and the occiput and vertex are born first followed
by the face

If the head is extended the chin is arrested above the pubis

and the occiput and vertex are delivered and the face
follows
 FACE TO PUBIS
Suprapubis Traction
Pressure on jaw

The head may rotate to bring the occiput to the sacrum. Delivery is
completed by traction on jaw to maintain head flexion and supra pubic
pressure to encourage descent. if the chin is above the pubis the foetal
body is rotated up over the maternal abdomen as in the prague seizure
to allow the head to rotated around the pubis and so deliver.
 JALAN PERSALINAN
BO / Kaki Lunak Kurang Efektif
Lahirnya BO tak menjamin Lahirnya
Bahu + Kepala
Penilaian Disproporsi F P Sulit
Persalinan Lebih Lama
Kemacetan Bokong
Bahu
Kepala
Letak BO + Kaki diameter sama dengan Kepala

Letak BO : Dilatator yang Baik

Letak Kaki : Paling Jelek
 PROGNOSA PERSALINAN
Ibu :
Persalinan lama ( Bo / Kaki lunak )
Robekan cervix ( Bo - kaki lahir pembukaan belum lengkap )
Akibat tindakan pertolongan

Anak
Kemacetan persalinan kepala ( after coming head )
Asphyxia, kematian, perdarahan, Intracranial, robekan
otot leher, trauma columna ver, plexus brachialis
Kemacetan bahu
Fraktur humerus
Kerusakan organ viscera
Persalinan bokong
Fraktur os femoris
Kematian perinatal 3 kali
Paralysa
( Kematian prematur : 5 kali )
 BREECH PRESENTATION - RISKS TO FOETUS
Breech delivery is associated with risk of injuries to the child
Intra-cranial haemorrhage Dislocation of shoulder, Fracture
From rupture of tentorium Of clavicie, fracture of humerus
Cerebral or falx cerebni-due On delivery of arms
To rapid moulding
Prolapsed crd.
Dislocation of neck, Commoner in footing
Erb-Duchenne Paralysis, Than incomplete breech
Damege to sternomastoid Disiocation of hip joint by
Nuscies Traction.
Due to Traction Fracture of femur in flexing
Extended legs
Rupture of viscus
Uusaly liver or kidney Genital oedema and Disruption of knee joint.
Due to pressures or Ecchymoses due to Hyperextension instead of
Faulty handling caput formation Flexion when delivering legs
The placenta separates frequently in the second stage of labour as the active uterus
contracts and the foetal head is in the pelvis. Asphyxia is therefore a danger.
Manual assistance to complete delivery of baby is essential and may be a sudden
need. Episiotomy is desirable to permit sudden interference, or complete perineal
tear may result.
Breech presentation, like all malpresentations holds greater risk for
the baby than a normal vertex presentation. The corrected perinatal
mortality rate is about 2.5% under the best conditions. Death is
associated with atelactasis and cerebral injury and prematurity and
foetal subnormality are common
When a breech presentation is found then X - ray of the foetus for
abnormality should be undertaken

There is greater risk of injury to the baby and also of trauma

and infection for mother. ( Many complete tears are caused by
breech delivery ). Breech presentation therefore should be
avioded if possible antenatally by caesarean section.
If there is any abnormal factor which may handicap easy delivery
then caesarean section is the method of choice. THERE IS NO
PLACE FOR TRIAL OF LABOUR
Unfortunately vaginal delivery of a breech presentation may be
forced on the least experienced or in wholly unsuitable conditios
because of unexpected labour or an undiagnosed breech.
Manual breech extraction ( operative delivery with the breech in
high cavity or not engaged ) should not be used
 CARA PERSALINAN SUNGSANG
Versi luar ke Letak Kepala
Persalinan Pervaginam
Panggul + B. B. Normal
Kepala Flexi
Pembukaan + Penurunan Lancar
Spontan Bracht
Manual Aid ( Partial Extr. )
Extr. Bo / Kaki ( Total Extr. )

Sectio caesarea.
 MANAGEMENT OF DELIVERY OF BREECH
WITH EXTENDED LEGS

Ihis breech forms a well fitting presenting part and

labour proceeds normally till the pelvic floor is reched

Delivery will only progress if there is lateral flexion of

the trunk. This may not occur despite perineal
distention as the legs splint the body

An episiotomy may allow delivery of the buttocks but progress may

be only slight because of limitation of flexion. Groin traction with
pains may help descent. Delivery of afoot will relieve the splint
effect

The delivery in a breech presentation is conducted in the lithotomy

position at the end or side of the bed to allow the foetus to hang
over the peritoneum. An anaesthetist should be at hand in case of
sudden need for general anaesthesia but pudendal block or perineal
in filtration is usually sufficient
 INCOMPLETE DILATATION OF CERVIX
The breech in footling or full breech presentation and especially in
prematurity may slip throug an incompletely on this and cause
extension of the head. A hand is passed up the foetal abdomen and a
finger inserted into the mouth. Traction on the jaw promotes flexion
and passage through the cervix
VI
1. Fundal height is less than expected
2. Uterine breadth is greater than expected.
3. Head in one flank and breech in opposite side.

4. Lie may be transverse or obliq

AUSCULTATION
Site of foetal heart not significant ( best heard
through foetal back )

VAGINAL EXAMINATION

Prior to labour and in early labour, pelvis is empty,

Hand, arm or elbow may be in pelvis, or ribs may
be felt or tip of shoulder or iliac crest or
trochanter of foetus. Placenta praevia may be
cause of transverse lie
 First maneuver Second maneuver

Third maneuver Fourth maneuver

Palpation in right acromiodorsoanterior position
The lie is transverse or oblique.
The head may be to right of left and the back may be
anterior or posterior.
The Denominator the shoulder.
Vaginal examination reveals an empty pelvis, and an unusual
presenting part. The shoulder might be mistaken for the
breech but the ribs have a characteristic feel.
When the foetus and pelvis are of normal size there is
obstruction and no mechanism
 JALAN PERSALINAN LETAK LINTANG UMUMNYA
Pembukaan lamban tak lengkap
Ketuban pecah lebih awal
Prolapsus Extr Funic. Lebih sering
Pada anak hidup, Aterm dan panggul normal anak tak dapat
lahir spontan pervaginam pembukaan hampir lengkap bahu
turun

dalam panggul - SBR meningkat.

Anak terjepit dalam SBR Mati
( Letak lintang kasep )
Akhirnya SBR robek
( Ruptura uteri )
 JALAN PERSALINAN LETAK LINTANG UMUMNYA
Pembukaan lamban tak lengkap
Ketuban pecah lebih awal
Prolapsus Extr Funic. Lebih sering
Pada anak hidup, Aterm dan panggul normal anak tak
dapat lahir spontan pervaginam pembukaan hampir
lengkap bahu turun
dalam panggul - SBR meningkat.
Anak terjepit dalam SBR Mati
( Letak lintang kasep )
Akhirnya SBR robek
( Ruptura uteri )
 SAAT SAAT KEADAAN BAHAYA
PADA LETAK LINTANG
1. Saat ketuban pecah
Prolapsus funiculi / extremitas
Janin sulit diubah tertekan
2. Pembukaan Lengkap
Penurunan janin
Saat terbaik melakukan terminasi
3. Letak lintang kasep
Anak terjepit dalam S.B.R
4. Ruptura uteri
 KOMPLIKASI BAHAYA PERSALINAN LINTANG

Ibu : Persalinan lama dan akibatnya

Ketuban pecah awal
Ruptura Uteri
Akibat Operasi Obstetrik

Anak : Asphixia Instrauterin Mati

Trauma Persalinan
Versi + Extraksi

Kematian Perinatal
Persalianan Pervaginam Tinggi
Kecenderungan S.C
Pathologic
Retraction Ring P.R.R.

Lower
Segment

Neglected shoulder presentation. A thick muscular band to form a

pathological ring has developed just above the very thin lower
uterine segment. The force generated during a uterine contraction
is directed centripetally at and above the level of the pathological
retraction ring. This serves ti stretch further and possibly to rupture
the very thin lower segment below the retraction ring. ( P.R.R. =
pathological retraction ring )
If the feotus is alive and viable caesarean
section is the method of choice, but if it is
dead then embryotomy may be carried out.

Shoulder presentation is an impossible labour

unless the foetus is very small.

The membranes rupture early in labour and

the cord frequently is prolapsed.
 MEKANISME PERSALINAN

Rectificatio spontanae Letak kepala

Versio Spontanea Letak sungsang
Conduplicatio Corpore Tubuh terlipat bahu lahir
Disusul kepala bersamaan dengan perut
Evolutio spontanea

Modus denmam :
Tubuh Terlipat pada pinggang lahir
BO + Kaki disusul bahu kepala

Modus Douglas : Bahu lahir disusul dada, perut,

Bo+kaki, baru kemudian disusul kepala.
 A B
Douglas method of spontaneous Denmans method of spontaneous
evolution in transverse lie. evolution in transverse lie.
Extreme lateral flexion of vertebral Same extreme lateral flexion of
column with birth of lateral aspect vertebral column as in Figure A
of thorax before buttocks. but in opposite direction, so that
buttocks are born before thorax
Occasionally, when the child is dead, it may
be expelled with shoulder leading and the
rest of the baby double up and following (
corpore conduplicato ). This is spontaneous
expulsion.
If the pelvis is large and the
foetus small then the
machanism of spontaneous
evolution takes place.

The head remains above

the pubis and the arm and
shoulder descend behind
the symphysis

The chest then descends

into the pelvis
SHOULDER PRESENTATION MECHANISM

The breech follows

The birth is then

that of breech with
one arm extended.
Prolapse of an arm in transverse lie
 PRESENTATION RANGKAP

Compound Presentation
Bila Extremitas turun Bersama bagian terendah

Macam : Kepala + Tangan

Kepala + Lengan
Kepala + Kaki ( jarang )
BO + Tangan / Lengan.
Predisposing Causes
It occurs wiyh an ill-fitting presenting - malposition,
malpresentation, disproporting, small infants are
therefore its associated conditions. It is also seen in the
multipara whose lax abdomen allows the head to remain
high; and cord may prolapse as well.

Treatment
Usually nothing need be done. If the hand is palpated in
front of the head and appears to be causing delay, it should
be pushed up out of the way
It is important to distinguish hand from foot by identifying
the presence or absence of the heel
 COMPOUND PRESENTATION

This means the prolapse of a limb alongside the

presenting part. It is a rare complication and head -
and - arm are most often seen although head - and -
foot and breech - and - hand have been described
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
 NUCHAL DISPLACEMENT OF THE ARM

This will prevent delivery and should be looked for when

forceps delivery is unsuccessful for some unrecognised
reason. When the arm is palpated, an attempt can be made
to restore it to the front of the foetus after dislodging the
head; but section may well be necessary
 PENGELOLAAN
Kepala + Tangan
- Expectatif : Spontan / Tangan
- Tertarik ke atas

Kepala + Lengan / Tangan macet

- Reposisi tangan lengan
- Versi extraksi
- Forceps
- Sectio Caesarea.
 ETIOLOGI :
Gangguan Fixasi - Akomodasi
Panggul Sempit, Kel. Letak
Plac. Letak Rendah, Gemelli
Hidramnion
Tali Pusat Panjang
Ketuban Pecah - Dipecah dengan bagian
Terendah tinggi
Keluarnya Cairan Ketuban yang cepat - mendadak
 PROLAPSE AND PRESENTATION OF THE CORD

Prolapse occurs after rupture of the

membranes when the presenting part is
ill fitting or abnormal. It is associated
with multiparity and prematurity, Prolapse cord
at the vulva
disproportion and malpresentation,
foetal abnormality and hydramnios

Once the cord is out of the uterus, and

especially when out of the vagina, the foetal
blood supply is obstructed, either because of
the drop in temperature, or spasm of the
vessels, or compression between the pelvic
brim and the presenting part. If delivery is
not effected within about 40 minutes, foetal
death is likely
 The presence of prolapse may not be recognised until cord
appears at the vulva; or cord may be palpated on vaginal
examination done to assess progress of the labour or because of
the sudden onset of acute foetal distress. It is essential to make a
vaginal examination as soon as the membranes rupture in all
patients who display an ill fitting or non - engaged presenting part

Occult
Presentation
presentation
of the cord
of the cord

Presentation of the cord means that the cord is palpable at the

cervix through intact membranes. Occult presentation means that
the cord is lying alongside the presenting part but will not be
palpable on vaginal examination. It is a particularly dangerous
condition and may be a cause of unexpected foetal distress.
 Sims position

Genu - pectoral
position
 PENGERTIAN
SPONG DKK (1995)

DISTOSIA BAHU APABILA WAKTU LAHIR

KEPALA KE BADAN LEBIH DARI 60 DETIK

ANGKA KEJADIAN
- 0,6 1,4 % Persalinan (ACOG 2000)

- Cenderung meningkat karena berat lahir bayi

Bertambah meningkat
MASALAH
IBU HRP ATONIA
- ROBEKAN VAGINA
- CERVIX
- INFEKSI
- MORBIDITAS MENINGKAT
- Kerusakan Plexus Brachlalis
- Fraktura Clavicula
- Fraktura Humeri
- Merupakan Salah Satu Kedaruratan Persalinan
- Bila Tidak Ditangani Dengan Benar Akan Meningkatkan
Morbiditas dan Mortalitas
 4. PREDIKSI DAN PREVENSI

FAKTOR RISIKO
- Diabetes
- Obesitas
- Multiparity
- Postdate

Rekomendasi untuk Prophylactic cesarean

- Non Diabetic : 5000 Gram
- Diabetic : 4500 Gram
 PENGELOLAAN

1. Penekanan Supra Pubis

2. Mc. Roberts Maneuver
3. Woods Corkscrew Maneuver
4. Mematahkan Clavicula
 B

Shoulder dystocia with impacted anterior shoulder of the fetus

A. The Operators hand is introduced into the vagina along the
fetal posterior humerus, which is splinted as the arm is swept
across the chest, keeping the arm flexed at the elbow.
B. The fetal hand is grasped and the arm extended along the side
of the face
C. The Posterior arm is delivered from the vagina
 WOODS MANEUVER

The hand is placed behind the posterior shoulder of the fetus.

The shoulder of the fetus. The shoulder is then rotated
progressively 180 degrees in a corkscrew manner so that the
impacted anterior shoulder is released
 THE Mc ROBERTS MANEUVER

A B

The maneuver consists of

A. Removing the legs from the stirrups and
B. Sharply flexing them upon the abdomen
 KELAINAN BAWAAN
PENYEBAB DISTOCIA
Kelainan tanpa menyebabkan kesukaran Partus
Kelainan Penyebab Distocia
Hidrocephalus
Anencephalus
Tumor Abdomen
Asites
Kembar Siam
Hidrops Foetalis
 ANENCEPHALUS

Otak + calvarium
tak terbentuk
Bahu besar

Akibat : Postdatisme
Kelainan Letak ( M - SU )
Distocia bahu

TX : Expectatif ( tak mungkin hidup ).

Severe dystocia from hydrocephalus, cephalic
presentation. Note the disparity between the small
size of the face and the rest of the cranium.
 MULTIPLE PREGNANCY
Twins may present in various ways

45 % 37 % 10 %

Vertex and Vertex Vertex and Breech Breech and Breech

5% 2% 0,5 %

Vertex and Transverse Breech and Transverse Transverse and Transverse

 KEHAMILAN GANDA
INSIDEN Bertambah karena
1. Penggunaan Obat Induksi Ovulasi
2. Peningkatan In Vitro Fertilisasi

MASALAH
1. Kebutuhan 2. Zygosity 3. Kelainan
Makanan (Mono) Plasenta
Lebih Banyak
a. BBLR
Perinatal & Neonatal b. Preterm
Morbiditas & Mortalitas c. Kel. Comigenal
Meningkat d. Distosia
 MULTIPLE PREGNANCY

Locked twins is a very rare

condition in which parts of one
interlock with the other causing
an impasse. It most commonly
occurs with the first as breech and
the second as a vertex. The head
of the second slips down with the
shoulders of the first and prevents
the engagement of the head of the
first in the pelvis

Locked Twins
 DISTOSIA - TENAGA
KALA I PEMBUKAAN
- Fase Laten
- Aktif
H I S

Hypertonic Uterine Hypotonic Uterine

Contraction Contraction
( Inertia Uteri )
Coordinated U.C Incoordinated UC
Primary I.U Secondary I.U
KALA II :
1. HIS
2. Tenaga Mengejan
( Kontraksi otot perut dan diafragma Pelvis )
 SAKIT
Involuntary
Ritmis
Intermiten
Makin Kuat = Sering
Peristaltik

Fundal Dominance
Relaksasi yang cukup
Frekuensi 2-4 menit
Intensitas cukup 50-60 mmHg
Lama Kontraksi cukup 40-50 sec.
KALA I HYPERTONIC HYPOTONIC
MACAM COORD. INCOORD PRIMER SEKUNDER
Faktor Tak Jelas - Primigrav. - Multigrav. - Primigrav.
- Psikis ? - Keadaan - Kel. Letak
Umum jelek - Kel. Panggul
- Multipel Preg
- Hidramnion
- Myoma
Tanda - Kuat & Sinkron Kuat tapi tidak HIS lemah dari HIS mula-mula
Tanda Sinkron Awal kuat
DD : False lalu lemah
Relaksasi Ada Tonus tetap Labour
meningkat
Nyeri Normal Nyeri keras
dan lama
Akibat Persalinan Dilatasi lambat Prolonged - Protacted
pada Cepat Partus Lama Latent Phase Active Phase
Persalinan ( < 3 jam) - Secondary
Arrest
 KALA I HYPERTONIC HYPOTONIC
HIS COORD. INCOORD PRIMER SEKUNDER
Akibat Spasme Otot lokal
pada
Persalinan Lingkaran Konsriksi Dystocia Dystocia

Partus Macet

Ibu Robekan Nyeri Tegang Lelah Lelah

Luas Lemah Lemah
Lelah Lemah Asidosis Asidosis
Asidosis
Bayi Perdarahan - Hipoksia - Gawat Gawat
Otak - Gawat Janin Janin Janin
(Kuat -
Cepat)
KALA I HYPERTONIC HYPOTONIC
HIS COORD. INCOORD PRIMER SEKUNDER

Pencegahan 1. Riwayat 1. Faktor-2 1. Faktor-2 1. Faktor-2

2. Pengawasan 2. Pengawasan 2. Pengawasan 2. Pengawasan
Persalinan Persalinan Persalinan Persalinan

Pengelolaan Pencegahan - Psikis - Perbaikan KV S.C

- Sedativa - Uterotonika
- S.C ( Bila tak ada
Indikasi )
- S.C
KALA II - KELAINAN TENAGA
1. HIS 2. Otot Perut dan Diafragma
Faktor 2. C.P.D Ringan a. Ibu tak dapat b. Lemah
Inertia Uteri mengejan
Sekunder
Pencegahan 1. Evaluasi Faktor-2 Senam Senam
Persalinan Hamil Hamil
2. Trial of Labour
Tinggi Rendah Pimpinan
Tinggi Rendah
persalinan
- S.C Forceps - Dagu - Dada
Pengelolaan - Vaccum - Badan Fleksi
Vaccum Forceps
- Tarik Paha
- Waktu HIS
Partus Bantuan Partus Bantuan Vaginal