82533137-distosia-bahu.pptx

8/11/2019 82533137-DISTOSIA-BAHU.pptx

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DISTOSIA BAHU

Bebaskita br Ginting, S.Si.T, MPH

[email protected]


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Distosiabahuadalahtersangkutnyabahu

janindantidakdapatdilahirkansetelah

kepalajanindilahirkan. Impaksibahudepandiatassimfisis Persalinan yang membutuhkan manuver obstetri

tambahan karena kegagalan traksi ke bawah padakepala janin sebagai efek kelahiran bahu (ACOG,

Practice Bulletin 40 (November 2002)

Definisi


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Perpanjanganwaktudarilahirnya

kepala-tubuhbayiSecaraobjektif

didefinisikanselama60detik

Pengeluarankepala-tubuhbayi

denganintervalwaktu>60detikumumnyamemilikiberatlahiryang

besar,distosiabahu,danrendahnya

skorApgar1menit(Bealletal1998;Spongetal1995)

Definisi


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Sebuah persalinan dimana bahu tidakmengikuti kepala seperti biasa,

memerlukan manuver obstetrik tambahan

untuk melahirkan bahu.

Bahu anterior dapat tertahan di belakang

simfisis pubis, atau (jarang) bahu posterior

di belakang promontorium sakralis

Defnisifungsional


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Normal delivery

traction


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Dilakukanevaluasicermatterhadapperkiraanberatjanin,usiakehamilan,intoleransiglukosamaternaldantingkatancederajaninpadakehamilansebelumnya.

KeuntungandankerugianuntukdilakukannyatindakanSCharusdibahassecarabaikdenganpasiendankeluarganya.

Rekomendasi American College of

Obstetricians and Gynecologist

(ACOG,2002) untuk penatalaksanaan

pasien dengan riwayat distosia bahu pada

persalinan yang lalu:


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Sebagianbesarkasusdistosiabahutidakdapatdiramalkanataudicegah.

TindakanSCyangdilakukanpadasemuapasienyangdidugamengandungjaninmakrosomiaadalahsikapyangberlebihan,kecualibilasudahdidugaadanyakehamilanyangmelebihi5000gramataudugaanberatbadanjaninyangdikandungolehpenderitadiabeteslebihdari4500gram.

American College Of Obstetricians and

Gynecologist (2002)


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Incidence

Reported to occur in 0.2-2% of births

May recur with a higher frequency, but this

is really unknown

Many women and clinicians will opt for

cesarean in the future, especially if there

has been a fetal injury

Recurrence rates reported 1-17%


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1. Postpartumhemorrhage11%

2. Vaginallaceration19%

3. Perinealtears2nd&3rd4%

4. Cervicallaceration2%

Maternal Complications (25%)


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Brachial plexus injuries,

Fractures of the humerus, and

Fractures of the clavicle

are the most commonly reported

injuries associated with shoulder

dystocia

Fetal Complications of Sh D


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Kombinasi traksi dengan tekanan

fundal berkaitan dengan

tingginya kejadian pleksus

brachialis injury dan patah tulang



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Fewer than 10% of

deliveries complicated byshoulder dystociawill result

in a pers isten t brachialplexus injury.



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Can shoulder

dystocia be

predicted ?


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RISK FACTORS FOR SHOULDER

DYSTOCIA

PRECONCEPTIONAL:1. Maternal birth weight

2. Prior shoulder dystocia 12%

3. Prior macrosomia4. Pre-existing diabetes

5. Obesity

6. Multiparity7. Prior gestational diabetes

8. Advanced maternal age


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DYSTOCIA

Antenatal:

Excessive maternal weight gain

Macrosomia

G. diabetes Post term


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DYSTOCIA

Intrapartum:1. Protracted or arrested active phase

2. Protracted or failure of descent ofhead

3. Need for midpelvic assisted delivery


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RISK FACTORS FOR

SHOULDER DYSTOCIA

Fetal

Makrosomia


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Macrosomia

Birth weight in excess of a specific

weight, usually defined as either

4500 grams (1.5% of births) or 4000

grams (10% of births)

Birth weight > 4500 grams rate of

shoulder dystocia is 10-25%

Birth weight > 4500 grams AND

maternal diabetes rate of

shoulder dystocia is 20-50%


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Pathophysiology

A mismatch between fetal size and

maternal pelvic capacity

Positional variations vertical rather

than oblique orientation of shoulders

Increased diameter of shoulder girdle

Subcutaneous fat deposition may

be increased in infant of diabetic

mother especially with sub-

optimal glucose control


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Diagnosisdistosiabahu:

Kepala janin dapat

dilahirkan tetapi tetap

berada dekat vulva.

Tidak terjadi gerakan/

restitusi spontan

Dagu tertarik dan

menekan perineum.

Tarikan pada kepala

gagal melahirkan bahu

yang terperangkap di

belakang simfisis pubis.


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Into the Delivery Room


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ClinicalManagement

Step One: Recognize the presence ofa shoulder dystocia

Step Two: Be sure enough help ispresentAskForHelp

Mintalahpertolongan

Mintalahibuuntukkooperatif

Panggilpartner

Beritahupersonellainnya


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Step Three: Apply primary maneuvers

Mc Roberts maneuver

Oblique suprapubic pressure

Pertama kali yang harus dilakukan bila terjadi

distosia bahu adalah melakukan traksi curam

bawah sambil meminta ibu untuk meneran.

Lakukan episiotomi. Setelah membersihkan

mulut dan hidung anak, lakukan usaha untuk

membebaskan bahu anterior dari simfsis

pubis dengan berbagai maneuver

ClinicalManagement


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Liftthelegs&buttocks

Anteriorshoulderdisimpaction

Rotationofposteriorshoulder

Manualremovalposteriorarm

Upayautkmemudahkanmelakukan

manuver2tsb:

-Episotomi

-Handandkneesposition


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Abdominal

approach Diameter

biakromiallebih

kecil Tidakmenekan

fundus

Disimpaksibahudepandengan

penekanandisuprapubis(Massanti

Manuver)


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The most common mistake is to apply fundal

pressure instead of suprapubic pressure


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Do you know the difference

Fundal

pressureSuprapubic

pressure

fundus

Pubic bone


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Never Apply Fundal Pressure

Fundal pressure will only

further impact the

shoulder.


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Clinicalmanagement

Step Four: Apply secondary

maneuvers; no prescribed order

Rubin; Woods screw; Posteriorarm; All-fours; Clavicular fracture


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Woods manoeuvre:

Pakailah sarung tangan

yang telah didisinfeksi

tingkat tinggi, masukkan

tangan ke dalam vagina.

Tangan diletakkan di

belakang bahu belakang

anak,

Kemudian bahu dirotasi180 derajat ke anterior

sehingga impaksi bahu

anterior dilepaskan

If Mc Roberts and Mazzanti failed:


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Lengan bayi biasanya fleksi pd siku

Bila lengan tidak fleksi, dorong lengan

pada siku

Dorong lengan kearah dada

Ambil tangan, lahirkan

Delivery of the posterior arm:

(Shwartz)


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1

2

3


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Hands & Knees

The hand and

knees position

also facilitates anadditional

maneuver in which

the practitioner

goes into the

vagina and draws

out the baby's

posterior arm.Canbe difficult if

woman has an

epidural.


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TheRoleoftheMidwife

Familiarize yourself with the maneuvers in

order to anticipate the practitioner actions

Make sure your resuscitation equipment is

set up and ready.

Call the Baby nurse into the room for

delivery.

Observe the delivery of the head and

watch for signs of shoulder dystocia.


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When a Shoulder Dystocia is Evident

Immediately remove all extra pillows fromunder the mother and place her in a supine

position.

Inform your patient there is a problem with

delivery of the baby's shoulders, that you and

the baby need her cooperation, and that you

will be doing things that may cause some

discomfort.

Doing McRoberts maneuver.

Doing superpubic pressure.


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Documentationiscritical

afteraShoulderDystocia Shoulder Dystocia is one

of the most litigious

emergencies in

obstetrics.

It is therefore critical that

the charting is accurate

and complete.


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Shoulder Dystocia

Documentation

Timeofheaddelivery

Timeofbodydelivery

Documentationthatthemotherwasinformedabouttheoccurrenceofshoulderdystocia,aswellasthe

potentialsequelae Patientcomplianceornon-compliance

Positionandrotationofinfant'shead

Documentorder,duration,andresultsofmaneuversemployed

Timingofepisiotomyifperformed Timingofbladdercatheterizationifperformed

Staffpresenttoassistandwhentheyarrived

DocumentifPediatricand/oranesthetichelpwereavailable


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Vigilance is the Key

AlthoughShoulderDystociaisararecomplication,itcanbeoneofthemost

frighteningforallinvolved.

Thekeyispreparationandteamwork.

Reviewthestepsyouwouldtakeinyour

mindandstayvigilant.

Remembertochartaccuratelyandhaveconfidenceinyourskills.


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TERIMA KASIH YA

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