PERSALINAN PATOLOGIS (DISTOSIA)

Dr. MARSIANTO, SpOG BAGIAN. / SMF. OBSTETRI - GINEKOLOGI FK. UNAIR / RSU Dr. SOETOMO SURABAYA

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 III. Lokasi IV. Kapasitas ( Etiology)

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 cavity.

High 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 b. Antara 6 8 cm c. Antara 8,5 10 cm
Panggul Sempit Absolut Panggul Sempit Ringan

MANAJEMEN :
a. SC. Absolut (H / M) b. SC. Primer (H) c. SC. Sekunder / Partus Percobaan

MOULDING OF THE HEAD

The base of the skull and face are rigid with firm sutures. The vault of the skull is flexible and jointed by open sutures. This allows a certain amount of malleability to the skull vaul. The bones may override each other and alter their contour This moulding is often characteristic for a presentation. In the normal vertex presentation the anterior parietal overlaps the posterior parietal bone and both overlap the occipital and frontal bones

The skull is now asymmetrical and the occipito frontal diameter is diminished but the mento vertical diameter is increased. The shape is altered and the volume is slightly diminished

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 Too small head arrested

Adequate posterior 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 b. Pintu Rahim c. Vagina Myoma Stenosis / Rigiditis Serviks Septum Vagina

2. Sekitar / Diluar Jalan Lahir a. Buli Buli b. Ovarium c. Tulang Pelvis Batu Kistoma 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 III. BENTUK IV. JUMLAH V. PERJALANAN
OVERWEIGHT BABY HIDROCEPHALUS KEMBAR PUTAR PAKSI

SEBAB : 1. AKOMODASI 2. FISIKA

PENGERTIAN LETAK
Situs Habitus : Sumbu Janin - Sumbu Uterus : Sikap Kedudukan Janin

Presentasi : Bagian terendah Positio : Bagian Janin (Denominator) Ka Ki Depan Belakang Bidang Panggul

Statiom

: Penurunan

FETAL PRESENTATION AT VARIOUS GESTATIONAL AGES DETERMINED SONOGRAPHICALLY

GESTATION ( WK) 21 - 24 25 - 28 29 - 32 33 - 36 37 - 40 TOTAL NUMBER 264 367 443 638 463 PERCENT CEPHALIC 54,6 61,9 78,1 88,7 91,5 BREECH 33,3 27,8 14,0 8,8 6,7 OTHER 12,1 10,4 7,9 2,5 1,7

From Scheer and Nubar (1976)

FETAL PRESENTATION IN 49,156 SINGLETON PREGNANCIES AT PARKLAND HOSPITAL, 1983 1986 PRESENTATION
Cephalic Breech Tranverse Face Compound Brow

NUMBER
47.497 1.468 117 41 22 11

PERCENT
96.9 3.0 0.24 0.08 0.05 0.02

INCEDENCE
1: 1: 1: 1: 1: 33 420 1200 2235 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 U2 B U2 K DAHI MUKA DESENSUS FLEXI TETAP / BERUBAH PENEMPATAN BEL. KEP PUNCAK DAHI MUKA

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 2. POWER : - PREMATUR : - 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 U2B : Let. P Internal Rotasi U2B Anterior Mudah (= L.B. Kep) Putar Paksi U2B Posterior FLEXI Ya U2K : Let. B. Kep Internal Rotasi U2K Anterior Let. B. Kep U2K Posterior Di Tengah

Lebih Sulit Ruptur Pirenium

Gangguan Deflexi Sulit

DTA

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.

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 N = 347 85,0% KELAHIRAN n=53 13,0% n=53 13,0%

OCCIPUT POSTERIOR N = 61 15,0% n=334 81,9% n=53 13,0%

OCCIPUT POSTERIOR n = 21 5,1%

OCCIPUT ANTERIOR 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 Eminence

Bitemporal 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 Presentation

Brow anterior Presentation

PALPATION
This feels like normal vertex except that the head feels unduly large, due to palpation across the mentovertical 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

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

C

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

P. A. P BOKONG : Diameter intertrochanterica 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 sacroanterior ( 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 Pressure Traction 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 Letak Kaki : Dilatator yang Baik : 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 Paralysa

Kematian perinatal 3 kali ( Kematian prematur : 5 kali )

BREECH PRESENTATION - RISKS TO FOETUS

Breech delivery is associated with risk of injuries to the child
Intra-cranial haemorrhage From rupture of tentorium Cerebral or falx cerebni-due To rapid moulding Dislocation of neck, Erb-Duchenne Paralysis, Damege to sternomastoid Nuscies Due to Traction Dislocation of shoulder, Fracture Of clavicie, fracture of humerus On delivery of arms Prolapsed crd. Commoner in footing Than incomplete breech Disiocation of hip joint by 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 caput formation Flexion when delivering legs Faulty handling
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 Extr. Bo / Kaki ( Partial Extr. ) ( 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 ( Letak lintang kasep ) Akhirnya SBR robek
( Ruptura uteri )

Mati

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 ( Letak lintang kasep ) Akhirnya SBR robek ( Ruptura uteri ) Mati

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

Trauma Persalinan Versi + Extraksi

Mati

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 BO + Kaki disusul bahu

lahir kepala

Modus Douglas : Bahu lahir disusul dada, perut, Bo+kaki, baru kemudian disusul kepala.

Douglas method of spontaneous evolution in transverse lie. Extreme lateral flexion of vertebral column with birth of lateral aspect of thorax before buttocks.

Denmans method of spontaneous evolution in transverse lie. Same extreme lateral flexion of vertebral column as in Figure A 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, disproportion and malpresentation, foetal abnormality and hydramnios

Prolapse cord at the vulva

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

Presentation of the cord

Occult presentation 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 - 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 CERVIX

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

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

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 % Vertex and Vertex

37 %

10 %

Vertex and Breech

Breech and Breech

5%

2%

0,5 %
Transverse and Transverse

Vertex and Transverse Breech and Transverse

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

MASALAH
1. Kebutuhan Makanan Lebih Banyak 2. Zygosity (Mono) 3. Kelainan Plasenta

Perinatal & Neonatal Morbiditas & Mortalitas Meningkat

a. BBLR b. Preterm c. Kel. Comigenal 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 Contraction
Coordinated U.C Incoordinated UC Primary I.U Secondary I.U

Hypotonic Uterine Contraction ( Inertia Uteri )

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
MACAM
Faktor

HYPERTONIC
COORD.
Tak Jelas

HYPOTONIC
PRIMER
- Multigrav. - Keadaan Umum jelek - Multipel Preg - Hidramnion - Myoma HIS lemah dari Awal DD : False Labour

INCOORD
- Primigrav. - Psikis ?

SEKUNDER
- Primigrav. - Kel. Letak - Kel. Panggul

Tanda Tanda

Kuat & Sinkron Relaksasi Ada Nyeri Normal

Kuat tapi tidak Sinkron Tonus tetap meningkat Nyeri keras dan lama Dilatasi lambat Partus Lama

HIS mula-mula kuat lalu lemah

Akibat pada Persalinan

Persalinan Cepat ( < 3 jam)

Prolonged Latent Phase

- Protacted Active Phase - Secondary Arrest

KALA I
HIS Akibat pada Persalinan

HYPERTONIC
COORD. INCOORD Spasme Otot lokal

HYPOTONIC
PRIMER SEKUNDER

Lingkaran Konsriksi Dystocia Partus Macet

Dystocia

Ibu

Robekan Luas

Nyeri Tegang Lelah Lemah Asidosis

Lelah Lemah Asidosis - Gawat Janin

Lelah Lemah Asidosis Gawat Janin

Bayi

Perdarahan Otak (Kuat Cepat)

- Hipoksia - Gawat Janin

KALA I
HIS

HYPERTONIC
COORD. INCOORD 1. Faktor-2

HYPOTONIC
PRIMER 1. Faktor-2 2. Pengawasan Persalinan - Perbaikan KV - Uterotonika ( Bila tak ada Indikasi ) - S.C SEKUNDER 1. Faktor-2 2. Pengawasan Persalinan S.C

Pencegahan 1. Riwayat

2. Pengawasan 2. Pengawasan Persalinan Pengelolaan Pencegahan Persalinan - Psikis - Sedativa - S.C

KALA II
Faktor
Pencegahan

- KELAINAN TENAGA
1. HIS
2. C.P.D Ringan Inertia Uteri Sekunder 1. Evaluasi Faktor-2 Persalinan 2. Trial of Labour Tinggi Rendah

2. Otot Perut dan Diafragma

a. Ibu tak dapat mengejan Senam Hamil Pimpinan persalinan - Dagu - Dada - Badan Fleksi - Tarik Paha - Waktu HIS b. Lemah

Senam Hamil Tinggi Rendah

Pengelolaan

- S.C Forceps - Vaccum

Vaccum

Forceps

Partus Bantuan

Partus Bantuan Vaginal