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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
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

Antropoid

Platipelloid

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

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

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

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


Bagian Janin (Denominator) Ka
Ki
Depan Belakang

Positio

Statiom

: Penurunan

Bidang Panggul

FETAL PRESENTATION AT VARIOUS GESTATIONAL AGES


DETERMINED SONOGRAPHICALLY
PERCENT

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

From Scheer and Nubar (1976)

FETAL PRESENTATION IN 49,156 SINGLETON


PREGNANCIES AT PARKLAND HOSPITAL, 1983 1986
PRESENTATION
NUMBER
PERCENT
INCEDENCE
Cephalic
Breech
Tranverse
Face
Compound
Brow

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

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
U2 K
DAHI
MUKA

BEL. KEP
PUNCAK
DAHI
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
U2B : Let. P

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.).

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 = 21 5,1%

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

n=53
13,0%

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
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

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
Occipito-frontal
Diameter Increases

Moulding

CERVIX

O
ccipito-mental
D
iameter 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
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.

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

Sectio caesarea.

( Partial Extr. )
( Total Extr. )

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
Asphixia Instrauterin
Anak :
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.

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
-

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

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

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 %
Vertex and Breech

5%

2%

Vertex and Transverse Breech and Transverse

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

HIS mulamula kuat


lalu lemah

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

Spasme Otot lokal


Lingkaran Konsriksi

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

( Bila tak ada

Pengelolaan Pencegahan

1. Faktor-2

HYPOTONIC

Indikasi )
- S.C

S.C

KALA II
Faktor
Pencegahan

- KELAINAN TENAGA
1. HIS

2. Otot Perut dan Diafragma

2. C.P.D Ringan
Inertia Uteri
Sekunder

a. Ibu tak dapat


mengejan

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

Partus Bantuan Vaginal

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