Professional Documents
Culture Documents
(DISTOSIA)
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
( Etiology)
Ginekoid
Antropoid
Platipelloid
Android
High
Assimilation
III. LOKASI
I. Pintu Atas Panggul
Conjucata Vera
a. Kurang 6 cm
b. Antara 6 8 cm
Panggul Sempit
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
15 Cm < 20 Cm
A < B
Adequate posterior
Sagittal diamater
JONGES
Melebarkan Arcus Pubis
Myoma
b. Pintu Rahim
c. Vagina
Septum Vagina
Batu
b. Ovarium
Kistoma
c. Tulang Pelvis
Sarkoma
CERVICAL MYOMA
OVERWEIGHT BABY
III. BENTUK
HIDROCEPHALUS
IV. JUMLAH
KEMBAR
V. PERJALANAN
PUTAR PAKSI
SEBAB :
1. AKOMODASI
2. FISIKA
PENGERTIAN LETAK
Situs
Habitus
Positio
Statiom
: Penurunan
Bidang Panggul
GESTATION
( WK)
TOTAL
NUMBER
CEPHALIC
BREECH
OTHER
21 - 24
25 - 28
29 - 32
33 - 36
37 - 40
264
367
443
638
463
54,6
61,9
78,1
88,7
91,5
33,3
27,8
14,0
8,8
6,7
12,1
10,4
7,9
2,5
1,7
47.497
1.468
117
41
22
11
96.9
3.0
0.24
0.08
0.05
0.02
1 : 33
1 : 420
1 : 1200
1 : 2235
1 : 4470
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 DEFLEKSI
PATOFISOLOGI LETAK DEFLEKSI
I. DI ATAS PAP
UNSTABLE LIE
TERABA
PENEMPATAN
U2 B
U2 K
DAHI
MUKA
BEL. KEP
PUNCAK
DAHI
MUKA
DESENSUS
FLEXI
TETAP / BERUBAH
STABLE LIE
LETAK
B. KEP, P, M, D.
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
: - PREMATUR
2. POWER
: - INERTIA UTERI
- GRANDEMULTI
- PENDULAR ABDOMEN
3. PASSAGE : - ANTROPOID
- ANDROID
FLEXI
Internal Rotasi
U2B
Anterior
Mudah
(= L.B. Kep)
Putar Paksi
U2B
Posterior
Lebih
Sulit
Ruptur Pirenium
Ya
U2K : Let. B. Kep
Internal Rotasi
U2K
Anterior
Let. B. Kep
U2K
Posterior
Di Tengah
Gangguan
DTA
Deflexi Sulit
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.).
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
R. O. P
P. O. P
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
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 = 21 5,1%
OCCIPUT POSTERIOR
N = 61 15,0%
n=334
81,9%
n=53
13,0%
OCCIPUT ANTERIOR
n = 387 94,9 %
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
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.
LETAK MUKA
Parietal
Eminence
Bitemporal
Diamater
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
and
suture
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
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
Pelvic brim
Submento
bregmatic
diameter engaged
Bitemporal diameter
Pelvic brim.
135
A.
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.
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.
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
Moulding
CERVIX
O
ccipito-mental
D
iameter decreases
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.
Sinklitismus.
Asinklitismus Anterior
Asinklitismus Posterior
B. Frank breech
Footling or
Incomplete breech
Full Breech
BO lahir
P. P. L
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 )
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
FACE TO PUBIS
Suprapubis
Pressure
Traction
on jaw
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
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
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
Thehandling
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.
Sectio caesarea.
( Partial Extr. )
( Total Extr. )
VI
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
Pada anak hidup, Aterm dan panggul normal anak tak dapat
lahir spontan pervaginam pembukaan hampir lengkap
bahu
turun
Mati
Mati
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 )
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.
PRESENTATION RANGKAP
Compound Presentation
Bila Extremitas turun Bersama bagian terendah
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
PENGELOLAAN
Kepala + Tangan
- Expectatif : Spontan / Tangan
- Tertarik ke atas
Kepala + Lengan / Tangan macet
- Reposisi tangan lengan
- Versi extraksi
- Forceps
- Sectio Caesarea.
ETIOLOGI :
Prolapse
cord
at the vulva
Presentation
of the cord
Occult
presentation
of the cord
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
: 4500 Gram
PENGELOLAAN
1. Penekanan Supra Pubis
2. Mc. Roberts Maneuver
3. Woods Corkscrew Maneuver
4. Mematahkan Clavicula
WOODS MANEUVER
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 ).
MULTIPLE PREGNANCY
Twins may present in various ways
45 %
Vertex and Vertex
37 %
Vertex and Breech
5%
2%
10 %
Breech and Breech
0,5 %
Transverse and Transverse
KEHAMILAN GANDA
INSIDEN
Bertambah karena
1. Penggunaan Obat Induksi Ovulasi
2. Peningkatan In Vitro Fertilisasi
MASALAH
1. Kebutuhan
Makanan
Lebih Banyak
Perinatal & Neonatal
Morbiditas & Mortalitas
Meningkat
2. Zygosity
(Mono)
3. Kelainan
Plasenta
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
Hypotonic Uterine
Contraction
( Inertia Uteri )
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.
- Psikis ?
- Multigrav.
- Keadaan
Umum jelek
- Multipel Preg
- Hidramnion
- Myoma
- Primigrav.
- Kel. Letak
- Kel.
Panggul
Kuat &
Sinkron
Kuat tapi
tidak
Sinkron
Tonus tetap
meningkat
Nyeri keras
dan lama
HIS lemah
dari Awal
DD : False
Labour
Prolonged
Latent Phase
- Protacted
Active
Phase
- Secondary
Arrest
Tanda Tanda
Relaksasi Ada
Nyeri Normal
Akibat
pada
Persalinan
Persalinan
Cepat
( < 3 jam)
Dilatasi
lambat
Partus Lama
KALA I
HIS
HYPERTONIC
COORD.
Akibat
pada
Persalinan
INCOORD
HYPOTONIC
PRIMER
SEKUNDER
Dystocia
Dystocia
Lelah
Lemah
Asidosis
Lelah
Lemah
Asidosis
Partus Macet
Ibu
Robekan
Luas
Nyeri Tegang
Lelah Lemah
Asidosis
Bayi
Perdarahan
Otak
(Kuat Cepat)
- Hipoksia
- Gawat Janin
- Gawat
Janin
Gawat
Janin
KALA I
HIS
HYPERTONIC
COORD.
Pencegahan 1. Riwayat
INCOORD
PRIMER
SEKUNDE
R
1. Faktor-2
1. Faktor-2
2. Pengawasan 2. Pengawasan
2. Pengawasan
2. Pengawasan
Persalinan
Persalinan
Persalinan
Persalinan
- Psikis
- Perbaikan KV
- Sedativa
- Uterotonika
- S.C
Pengelolaan Pencegahan
1. Faktor-2
HYPOTONIC
Indikasi )
- S.C
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
Pengelolaan
Rendah
- S.C
Forceps
- Vaccum
Partus Bantuan
Senam
Hamil
Pimpinan
persalinan
- Dagu - Dada
- Badan Fleksi
- Tarik Paha
- Waktu HIS
b. Lemah
Senam
Hamil
Tinggi
Rendah
Vaccum
Forceps