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