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PERSALINAN PATOLOGIS( D I S T O S I A )
Dr. Dovy Djanas, SpOG-KBAGIAN. / SMF. OBSTETRI - GINEKOLOGI
FK. UNAND / RSUP Dr. M. DJAMIL PADANG
PENGERTIAN DISTOSIA
UMUM : - Difficult Labor - Abnormally Slow Progress of Labor
GREEK : EUTOCIA : NORMAL LAHIRDYSTOCIA : ABNORMAL LAHIR DIFFICULT CHILDBIRTH
MACAM DISTOSIA(American College of Obstetricians and Gynecologist 1995)
I. Abnormalies of PowersII. “ involving PassangersIII. “ of The Passage
KELAINAN JALAN LAHIR(PASSAGE)
PANGGUL SEMPIT
BILA SALAH SATU ATAU LEBIHUKURAN PANGGULNYA MENGECIL1 CM ATAU LEBIH
PEMBAGIAN KELAINAN JALAN LAHIR
a. Jalan Lahir Kerasb. Jalan Lahir Lunak
Causes of Contracted Pelvis
A. Genetic : 1. With deformity (e.g. achondroplasia. Naegele’s pelvis absence of one sacral ala).
2. Without deformity 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
III. LOKASIIII. LOKASII. Pintu Atas Panggul Conjucata Vera
c. Antara 8,5 – 10 cm
Panggul SempitAbsolut
Panggul SempitRingan
a. Kurang 6 cmb. Antara 6 – 8 cm
MANAJEMEN :
a. SC. Absolut (H / M)
b. SC. Primer (H)
c. SC. Sekunder / Partus Percobaan
MOULDING OF THE HEADThe 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
IV. KAPASITAS PANGGUL
1. PINTU ATAS PANGGUL a. Penurunan Kepala b. Osborn c. Munro - Kerr
2. RONGGA PANGGUL & PINTU BAWAH “ Trial of Labour “
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. LETAKII. BESARIII. BENTUKIV. JUMLAH V. PERJALANAN
SEBAB : AKOMODASI
PUTAR PAKSI
KEMBAR
HIDROCEPHALUS
OVERWEIGHT BABY
PENGERTIAN “ PENGERTIAN “ LETAKLETAK “ “
Situs :Sumbu Janin - Sumbu Uterus
Habitus :Sikap Kedudukan Janin
Presentasi :Bagian terendah
Positio :Bagian Janin (Denominator) – Ka – KiDepan – Belakang
Statiom : Penurunan Bidang Panggul
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)
POOR MODERATE
ADVANCED COMPLETE
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
A. LETAK DEFLEKSIPATOFISOLOGI LETAK DEFLEKSII. DI ATAS PAP “ UNSTABLE LIE “ TERABA
U2 KU2 BDAHIMUKA
PENEMPATANBEL. KEPPUNCAKDAHIMUKA
DESENSUS
FLEXI
TETAP / BERUBAH
II. MELEWATI PAPDALAM RONGGA PANGGUL - LINGKARAN TERBESAR LEWAT PAP
“ STABLE LIE “
LETAKB. KEP, P, M, D.
Presentasi puncak kepala, presentasi dahi, presentasi muka
1. LETAK PUNCAK
PENGERTIAN1.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. 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 : - PREMATUR2. POWER : - INERTIA UTERI - GRANDEMULTI - PENDULAR ABDOMEN
3. PASSAGE : - ANTROPOID - ANDROID
PATOFISIOLOGI LETAK PUNCAK I. DI ATAS PAP - Unstable (U2B, U, K, M, D) - Obliq Desensus
II. LEWAT PAP MASUK RONGGA PANGGUL
FLEXITidakU2B : Let. P
YaU2K : Let. B. Kep
Internal Rotasi Internal Rotasi
U2B Anterior
U2B Posterior
U2K Anterior
U2K Posterior
Di Tengah
Mudah(= L.B. Kep)Putar Paksi
Lebih Sulit
Ruptur Pirenium
Let. B. Kep Gangguan
Deflexi Sulit
DTA
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
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
1. Power – Tanpa Disproporsi - Oxytosin Drip Dengan Monitor Ketat - Forceps Kielland Standar2. Disproporsi SC
B. Perjalanan & Manajemen
LETAK MUKA
Right Mento - Anterior
Right Mento - Posterior
Left Mento - Anterior
AUSCULTATIONFoetal heart best heard at front of foetus
VAGINAL EXAMINATION Malar processesNose – rubbery – saddle
shaped Mouth – hard areolar ridges
Supra-orbital ridges
Frontal suture and
anterior fontanelle
FACE PRESENTATION – MECHANISMThe engaging diameters in a face presentation are the submento – bregmatic followed by the biparietal
The submento – bregmatic and suboccipito – bregmatic diameter are the same size ( 9 ½ cm, 3 ¾ in. ). Therefore the engaging diameters are the same size as in a normal vertex presentation
Suboccipito –bregmatic diameter
Submentobregmatic diameter
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
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 Kielland’s forceps applied
3. LETAK DAHI
3. LETAK DAHI
Sering merupakan PenempatanDeflexi Max letak MukaPemeriksaan dalam : Dagu Tak TerabaBila teraba letak MukaPada keadaan NormalLetak dahi tak dapat lahir pervaginam
30 – 40 % Partus Spontan sebagai Letak Muka atau B
Brow posteriorPresentation
Brow anteriorPresentation
BROW PRESENTATION – MECHANISMThis is only possible when the baby is small for the pelvis
Occipito-frontalDiameter Increases
Moulding
Occipito-mental
Diameter decreases
CERVIX
V
Fully flexed foetus
A. Complete or Full breech
B. Frank breech
One or both thighs extended
Footling or Incomplete breech
C
JALAN PERSALINANBO / Kaki Lunak Kurang EfektifLahirnya BO tak menjamin LahirnyaBahu + Kepala Penilaian Disproporsi F – P Sulit
Persalinan Lebih LamaKemacetan Bokong
BahuKepalaLetak BO + Kaki diameter sama dengan Kepala
Letak BO : Dilatator yang BaikLetak Kaki: Paling Jelek
PROGNOSA PERSALINANIbu :
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 visceraPersalinan bokong Fraktur os femoris Paralysa Kematian perinatal 3 kali
( Kematian prematur : 5 kali )
CARA PERSALINAN SUNGSANG Versi luar ke Letak Kepala Persalinan Pervaginam
Panggul + B. B. NormalKepala FlexiPembukaan + Penurunan Lancar
Spontan BrachtManual Aid ( Partial Extr. )Extr. Bo / Kaki ( Total Extr. )
Sectio caesarea.
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
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 terminasi3. Letak lintang kasep Anak terjepit dalam S.B.R4. 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 PerinatalPersalianan Pervaginam TinggiKecenderungan S.C
PRESENTATION RANGKAP
Compound Presentation Bila Extremitas turun Bersama bagian terendah
Macam : Kepala + Tangan Kepala + Lengan Kepala + Kaki ( jarang ) BO + Tangan / Lengan.
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
PENGELOLAANKepala + Tangan - Expectatif : Spontan / Tangan - Tertarik ke atas
Kepala + Lengan / Tangan macet - Reposisi tangan – lengan - Versi extraksi - Forceps - Sectio Caesarea.
E T I O L O G I : 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
Sim’s position
Genu - pectoral position
PENGERTIANSPONG 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
M A S A L A HIBU – 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 Pubis2. Mc. Roberts Maneuver3. Woods Corkscrew Maneuver4. Mematahkan Clavicula
A
B
CShoulder dystocia with impacted anterior shoulder of the fetus
A. The Operator’s 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 BAWAANPENYEBAB DISTOCIA
Kelainan tanpa menyebabkan kesukaran PartusKelainan Penyebab Distocia
HidrocephalusAnencephalusTumor AbdomenAsitesKembar SiamHidrops Foetalis
ANENCEPHALUS
Otak + calvariumtak terbentuk
Bahu besar
Akibat : Postdatisme Kelainan Letak ( M - SU ) Distocia bahuTX : 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 PREGNANCYTwins may present in various ways
45 % 37 % 10 %
Vertex and Vertex Vertex and Breech Breech and Breech
Vertex and Transverse Breech and Transverse Transverse and Transverse
5% 2 % 0,5 %
KEHAMILAN GANDAINSIDEN
MASALAH
Bertambah karena 1. Penggunaan Obat Induksi Ovulasi 2. Peningkatan In Vitro Fertilisasi
1. Kebutuhan Makanan Lebih Banyak
2. Zygosity (Mono)
3. Kelainan Plasenta
a.BBLRb.Pretermc.Kel. Comigenald.Distosia
Perinatal & NeonatalMorbiditas & Mortalitas
Meningkat
MULTIPLE PREGNANCYLocked 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 - TENAGAKALA I PEMBUKAAN
- Fase Laten- “ Aktif
H I S
Hypertonic Uterine Hypotonic UterineContraction Contraction
( Inertia Uteri ) Coordinated U.C Incoordinated UC
Primary I.U Secondary I.UKALA II : 1. HIS 2. Tenaga Mengejan ( Kontraksi otot perut dan diafragma Pelvis )
Fundal Dominance Relaksasi yang cukup Frekuensi 2-4 menit Intensitas cukup 50-60 mmHg Lama Kontraksi cukup 40-50 sec.
KALA I HYPERTONIC HYPOTONICMACAM COORD. INCOORD PRIMER SEKUNDERFaktor Tak Jelas - Primigrav.
- Psikis ?- Multigrav.- Keadaan Umum jelek
- Multipel Preg
- Hidramnion- Myoma
- Primigrav.- Kel. Letak- Kel. Panggul
Tanda -Tanda
Kuat & Sinkron
Relaksasi Ada
Nyeri Normal
Kuat tapi tidakSinkronTonus tetap meningkatNyeri keras dan lama
HIS lemah dari Awal DD : False Labour
HIS mula-mula kuat lalu lemah
Akibat pada
Persalinan
Persalinan Cepat
( < 3 jam)
Dilatasi lambat
Partus Lama
Prolonged Latent Phase
- Protacted Active Phase
- Secondary Arrest
KALA I HYPERTONIC HYPOTONICHIS COORD. INCOORD PRIMER SEKUND
ERAkibat pada
Persalinan
Spasme Otot lokal
Lingkaran Konsriksi
Partus Macet
DystociDystociaa
DystociaDystocia
Ibu Robekan Luas
Nyeri Tegang
Lelah LemahAsidosis
LelahLemah
Asidosis
LelahLemah
Asidosis
Bayi Perdarahan
Otak(Kuat - Cepat)
- Hipoksia- Gawat Janin
- Gawat Janin
Gawat Janin
KALA I HYPERTONIC HYPOTONICHIS COORD. INCOORD PRIMER SEKUNDE
R
Pencegahan 1. Riwayat
2. Pengawasan
Persalinan
1. Faktor-2
2. Pengawasan
Persalinan
1. Faktor-2
2. Pengawasan
Persalinan
1. Faktor-2
2. Pengawasan
Persalinan
Pengelolaan Pencegahan - Psikis
- Sedativa
- S.C
- Perbaikan KV
-Uterotonika
- S.C
S.CS.C
KALA IIKALA II - KELAINAN TENAGA- KELAINAN TENAGA
Faktor
1. HIS 2. Otot Perut dan Diafragma2. C.P.D Ringan Inertia Uteri Sekunder
a. Ibu tak dapat mengejan
b. Lemah
Pencegahan 1. Evaluasi Faktor-2 Persalinan
2. Trial of Labour
Senam Hamil
Senam Hamil
Pengelolaan
Tinggi Rendah Pimpinan persalinan Tinggi Rendah
- S.C- Vaccum
Forceps - Dagu - Dada- Badan Fleksi- Tarik Paha- Waktu HIS
Vaccum Forceps
Partus Bantuan Partus Bantuan Vaginal