paper distosia bahu

7/30/2019 Paper Distosia Bahu

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PENGANTAR

Dalam mingu-minggu terakhir ini terjadi morbiditas dan mortalitas dalam penanganan kasus

distosia bahu yang pada beberapa kasus mungkin dapat dicegah,

Untuk mengingatkan kembali dan mendokumentasikan kepustakaan terakhir mengenai distosia

bahu dengan harapan dapat memperbaiki pengananan kasus distosia bahu, maka KPS bekerjasama

dengan Divisi Kedokteran Feto-Maternal menyusun buku monograf ini.

Tentunya monograf ini masih belum sempurna, saran dan masukan dari sejawat sangat kami

harapkan.

Atas perhatian sejawat kami ucapkan terima kasih.

Januari 2004Ketua Program Studi

Bagian/ SMF Obstetri & Ginekologi

FK Unair/ RSU Dr. Soetomo

Surabaya

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I. RESUME KASUS

A. KRONOLOGIS KASUS NY. IRSAL Dr. RAMELAN

A. IDENTITAS PENDERITANama : Ny. I

Umur : 29 tahunRiwayat Persalinan :1. 9bl/SptB/RSAL/2600/3 th2. Hamil iniTD PAN di Poli Hamil RSAL 8x sbg KRT ok DM GestasionalHPHT :20-3-03 ~ 37/38 mgg

B. ANAMNESA : Penderita datang sendiri ok kenceng-2C. PEMERIKSAAN FISIK : 6/12/03 Jam 17.00

GCS : 4-5-6 TD : 120/80 N : 88 tr :37 TB : 154 cmC/P : Normal

Status Obstetri :TFU : 36 cm / Kepala / DJJ : (+) 12-12-12/ His (+) jarangVT : 2 jr/50%/ kepala/s-s mell/H: I/UPD~N/Ket (+)

D.DIAGNOSA :GIIP1-1 37/38 mgg TH obs. In partu+ DM Gestasional TBJ : 3500 gr

E.PLANNING :- Obs. Tanda-tanda inpartu- Bila inpartu pro spt.B- Cek GDA,UL- Usul pemeriksaan NST

F.PERJALANAN :

18.00 S : Kenceng-kenceng sering, Gerak anak (+) baikO : Status Umum : T : 120/70 N : 80 C/P : N

Status Obstetri :His (+) adequat DJJ (+) 12-12-12VT: 3 cm/50%/kepala/ s-s mell/H:I/ UPD~N/Ket (+)Hasil Lab: GDA : 164 UL: Prot (-) Red (+) 1

A : GIIP1-1 37/38 mgg TH inpartu Kl I Fase Laten + DM Gestasional TBJ :3500P : Obs CHPB

Ev. 6 jam pro spt B.

22.00 S: Dilaporkan Ketuban pecah spontan0 : Status Umum : T : 120/70 N : 80 tr : 37 C/P : N

Status Obstetri :His (+) adequate DJJ (+) 12-12-12VT: 7 cm/50%/kepala/U-U K ki depan /H:I/ UPD~N/Ket (-) jernih

A : GIIPI-1 37/38 mgg TH inpartu KL I Fs aktif+ DM Gestational TBJ : 3500P : Obs CHPB

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Ev. 2 jam pro spt B

00.00 S : Penderita ingin mengejanO : Status Umum : T : 120/70 N : 92 C/P : N

Status Obstetri :His (+) adequate DJJ (+) 12-12-13

VT : lengkap/Kepala/U-U K depan/ H :III/Ket (-) jernihA : GlI P1-1 37/38 mgg TH inpartu KL II + DM Gestasional TBJ : 3500P : Pimpin mengejan pro spt B

1 jam dipimpin mengejan bayi belum lahir tampak ibu kelelahan, usul untuk percapat kala II denganTarikan Vakum diusulkan ke Supervisor: Disetujui Dr. Supriyono SpOG(K).

Saat dilakukan tarikan vakum kepala Bayi dapat keluar terjadi turtle sign (+), kepala bayi tidak dapat

putar paksi luar Distosia Bahu

Dilakukan :- Mc Robert Manuver

- Penekanan supra sympisis- Melahirkan lengan belakang- KIE keluarga

20 menit kemudian Bayi dapat dilahirkan Lahir By P/3800/54/2-1-0 Bayi meningga120 menit setelahgagal dilakukan resusitasi.

B. KRONOLOGIS PARTUS PATHOLOGISJAGA RSAL TGL 24-11-2003

1. DATA PENDERITA :

Nama : Ny. WUmur : 26 tahunAnggota : i/d PrakaMenikah : 5 tahun

Riwayat Persalinan Lalu :1. 9 bl / RSAL / Eks Vakum- ai Kala II Lama Dis Bahu / / 3650 / 5 tahun2. Hamil ini.

Penderita terdaftar, melakukan PAN di Poli Hamil RSAL 6 x sebagai KRT ok DMPragestasional + Riwayat PPTO

HPHT : berdasarkan USG ~ 36/37 minggu

MKB : 24-11-2003 jam 14.00

2. KELUHAN :Penderita datang sendiri oleh karena keluar air dari kemaluan. Ketuban pecah tgl. 24-11-2003 jam11.00.

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3. HASIL PEMERIKSAAN :GCS 4-5-6TD : 130/80, N : 88, trec : 37,5, C/P : dbn., Edema : -/-St. Obst. : Tfu : 35 cm, Letak kepala, DJJ +/12-12-12, His +/jarang

VT : 1 jari longgar / Eff. 50 % / Presentasi kepala / Denominator SS melintang / Hodge I / UPDnormal / Ketuban jernih / PS : 5

4. DIAGNOSIS :GIIP1-1 36/37 mgTH + KPP + DM Pragestasional + R/ PPTO TBJ : 3300 g

5. PLANING :Cek GDAInj. Monotard 12 IU 15 menit sebelum makan malamDiet B1 2100 kalObs. Trec/3 jamBila Trec > 37,6 atau 1 x 24 jam tak inpartu pro terminasi ODNSTInj. Ampicillin 4 x 1 g iv.Bila inpartu pro Spt. B

Hasil GDA : 95 g%

Hasil NST : 160-170 / 2-4 / tak jelas reaktif Fetal tachicardi

Konsul Chief jaga dan SPV jaga RSAL disetujui

6. PROGRESS NOTE :

21.00 Kenceng-kenceng sering, VT 3 cm

Inp. Kala I fs. Laten23.45 Ibu ingin mengejan, VT lengkap Inp. Kala II Ibu dipimpin mengejan pro Spt. B23.50 Lahir kepala terjadi distosia bahu

Dilakukan manuver Mc. Robert

Dilakukan penekanan supra symphisis gagalDiputuskan melahirkan bahu belakang

00.15 Lahir bayi / / 3300 / 50 / 1-1-3-5, didapatkan CF. Humerus 1/3 tengah sinistra

C. KRONOLOGIS DISTOSIA BAHU

Nama : Ny. MUmur : 45 thRegister : 10322798MKB : 6-12-2003, pk 15.00G VI P5-4, menikah: 20th, KB (-)TTD, PAN (-)HPHT : merasa hamil

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TP : 9 bulanRiwayat persalinan :

1. 9bl/ dukun/ spt B/ L/ 4000/ 15 th2. 9bl/ dukun/ spt B/ L/ 3500/ 13 th3. 9bl/ dukun/ spt B/ L/ 4000/ 9 th

4. 9bl/ dukun/ spt B/ W/ 3500/ 3 th5. 9bl/ dukun/ spt B/ 4000/ dukun6. hamil ini

RetrospektifPx datang ke RS Tambak rejo tgl. 6-12-03, dilakukan pemeriksaan oleh DM ditensi 190/110 dan TFU 46

cm. diberi tx SM konsul ke SpOG setempat direncanakan SC tapi anestesi tidak siap rujukRSDS (ai: bayi besar TBJ: 4060 gr)

Saat MKB tgl. 6-12-2003, pk 15.00

S: Px datang kiriman RS Dr Soewandi dengan tensi tinggi dan curiga bayi besarO: GCS: 456 AICD (-)St. umum: T: 180/ 110, N: 88x/m, RR: 20x/m, Tr: 37,1oC, C/P dbn, Edema: -/-, Alb (+) 4St. Obstetri : TFU ~ 40 cm, letak janin = kepala, DJJ : (+) 12-12-12, His (+)

VT : 5cm, Eff: 75%. Pres: kepala, Den: UUK ki mel, H:I, UPD~N, ket: (-)A: G VI P5-4 ATH Inpartu kala I fase aktif + PEB + U > 35 th + GM TBJ 3800P:

CTG

Pasang Kateter dan infuse

Inj Ampi 4x1 gr

SM lanjutan

Cek DL/ UL/ LFT/ RFT/ GDA/ serum albumun Obs CHPB

Evaluasi 2 jam pro percepat kala II

Tgl. 6-12-2003, pk 17.00S: kenceng-kenceng (+) sering, gerak anak (+) baikO: GCS: 456 AICD (-)

St. umum: T: 200/ 110, N: 92x/m, RR: 20x/m, Tr: 37,1oC, C/P dbnSt. Obstetri: DJJ: (+) 12-12-12, His (+) adekuat

VT : 7cm, Eff: 75% Pres: kepala, Den :UKK ki mel, H:I, UPD ~N, ket: (-) keruhA: G VI P5-4 ATH Inpartu kala I fasee aktif + PEB + U > 35 th + GM TBJ 3800P:

Obs CHPB

Evaluasi 2 jam pro percepat kala II

Pk 18.30S: kenceng-kenceng (+) sering, gerak anak (+) baik

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O: GCS: 456 AICD (-)St. umum: T: 190/ 110, N: 92x/m, RR: 20x/m, Tr: 37,1oC, C/P dbnSt. Obstetri: DJJ: (+) 12-12-12, His (+) adekuat

VT : lengkap, Eff: -, Pres: kepala, Den :UKK depan, H:I, UPD ~N, ket: (-) keruhA: G VI P5-4 ATH Inpartu kala II + PEB + U > 35 th + GM TBJ 3800

P: Informed Consent pro Percepat Kl II

Pk 19.10Lahir bayi Eks Vakum/ L/ 5300/ 60/ AS 2-1-0Saat melahirkan bahu terjadi distosia bahu, sehingga diputuskan dilakukan

1. Manual Mc Robert2. Kompresi symphisis3. Memutar bahu

Bayi lahir

dilakukan resusitasi pada bayi

inj Adrenalin pada bayi 0,4 cc

15 menit

resusitasi gagal bayi meninggal

Pk 19.15Lahir plasenta spontan, perdarahan 100 cc

ANALISA PENYEBAB KEMATIAN KELAINAN ICD

A Kelainan/ penyakit utama pada bayi/janin

Bayi besar

B Kelainan-kelainan lain yang ditemukanpada bayi atau janin

-

C Kelainan/ penyakit utama ibu yangmempengaruhi janin PEB

D Kelainan lain yang ditemukan pada ibu -

E Factor-faktor lain yang di dugamempengaruhi bayi/ janin

Distosia bahu

PERSANGKAAN PENYEBAB KEMATIAN: Distosia Bahu

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II. TINJAUAN KEPUSTAKAAN MENGENAI DISTOSIA BAHU

A. INTRODUCTION

The incidence of shoulder dystocia varies greatly depending on the criteria used for

diagnosis. For example, Gross and co-authors (1987) identified that 0.9 1 of almost 11,000

vaginal deliveries were coded for shoulder dystocia at the Toronto General Hospital. True

shoulder dystocia, however, diagnosed because maneuvers were required to deliver the

shoulders in addition to downward traction and episiotomy, was identified in only 24 births (0.2

percent). Significant infant trauma was observed only in shoulder dystocias requiring a

maneuver to effect delivery. Current reports, where the diagnosis of shoulder dystocia is limited

to those delivery requiring a maneuver, cite an incidence that varies between 0.6 percent and

1.4 percent (American College of Obstetricians and Gynecologists, 2000; Bask and Allen, 1995;

McFarland and co-workers, 1995; and co-workers, 1993).

There is some evidence that the incidence of shoulder dystocia increased from 1960 to

1980 (Hopwood, 1982). This is likely due to increasing birthweight. Modanlou and co-workers

(1982) showed that neonates experiencing shoulder dystocia had significantly greater

shoulder to-head and chest-to-head disproportions compared with equally macrosomic infants

delivered with dystocia. It is also likely that the increased incidence of shoulder dystocia is due

in part to increased attention to its appropriate documentation (Nocon and co-workers, 1993).

Use of maneuvers to define shoulder dystocia has been criticized (Beall and associates, 1998;

Spong and colleagues, 1995). In deliveries in which shoulder dystocia is anticipated, one or more

maneuvers may be used prophylactically, but no diagnosis of shoulder dystocia is recorded. In other

cases, one or two maneuvers may be used with rapid resolution of shoulder dystocia and excellent

outcome, and the diagnosis is not identified. Spong and colleagues (1995) attempted to more objec-

tively define shoulder dystocia by witnessing 250 unselected deliveries and timing intervals from

delivery of the head, to delivery of the shoulders, and to completion of the birth. The incidencedefined by the use of obstetrical maneuvers was higher than previously reported (11 percent);

however, only about half of these were diagnosed by the clinicians. The mean head-to-body delivery

time in normal births was 24 seconds compared with 79 seconds in those with shoulder dystocia.

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They proposed that a head-to-body delivery time exceeding 60 seconds be used to define shoulder

dystocia.

This literature study designed to help the residence in training to get more informations

which are useful for their daily activities.

B. DEFINITION

Impaction of anterior shoulder above symphysis

Inability to deliver shoulders by usual methods

Following the delivery of the head, there is impaction of the anterior shoulder on the symphysis pubis

in the AP diameter, in such a way that the remainder of the body cannot be delivered in the usual

manner. The head may be tight against the maternal buttocks, known as the "turtle sign".

Spontaneous restitution may fail to occur.

C. INCIDENCE

Incidence ranges from 1 in 1,000 for babies weighing less than 3,500g, to over 16 in 1,000 in

babies over 4,OOOg. Despite numerous studies attempting to identify factors predicting this problem,

more than 50% of cases occur in the absence of any identified risk factor.

D. DIAGNOSIS

Head recoils against perineum, turtle' sign

Spontaneous restitution does not occur

Failure to deliver with expulsive effort and usual gentle downward direction

Identified risk factors are present in less than 50% of cases

E. MANAGEMENT

PREVENTION BY RISK FACTOR DETECTION

RISK FACTORS. A variety of maternal, intrapartum, and fetal characteristics have been implicated

in the development of shoulder dystocia (Baskett and Allen, 1995; Nesbitt and associates, 1998;

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Nocon and coauthor authors, 1993). Several maternal risk factors, including obesity, multiparity, and

diabetes, all exert their effects because of associated increased birthweight. For example, Keller

and co-workers (1991) identified shoulder dystocia in 7 percent of pregnancies complicated

gestational diabetes. Similarly, the association of post term pregnancy with shoulder dystocia is

likely because many fetuses continue to grow after 42 weeks (Ch, 28, p. 738).

Intrapartum complications associated with shoulder dystocia include midforceps delivery and

prolonged first- and second-stage labor (Baskett and Allen, 1995; Nocon and co-authors, 1993).

McFarland and co-workers (1995), however, using matched controls, found that first- and second-

stage labor abnormalities were not useful clinical predictors of shoulder dystocia.

The common thread running through all current reports on risk factors for shoulder dystocia is

increased birthweight (Nesbitt and colleagues, 1998). Table 19-2 gives the incidence of shoulder

dystocia related to birthweight groupings at Parkland Hospital during 1994. Clearly, shoulder dystocia

increases with greater birthweight; however, almost half of the births with shoulder dystocia weighed

less than 4000 g. Indeed, Nocon and co-workers (1993) described shoulder dystocia with birth of a

2260-g infant. Despite this, some authors (O'Leary, 1992) advocate identification of macrosomia with

ultrasound and liberal use of cesarean delivery to shoulder dystocia. Others have disputed the

concept that cesarean delivery is indicated for identified large fetuses, even those estimated to weigh

in excess of 4500 g. Rouse and Owen (1999) concluded that a prophylactic cesarean policy for

macrosomic infants would require more than 1000 cesarean deliveries and millions of dollars to avert

a single permanent brachial plexus injury. The American College of Obstetricians and Gynecologists

(2000) has concluded that performing cesarean deliveries for all women suspected of carrying a

macrosomic fetus is not appropriate, except possibly for estimated fetal weights over 5000 g in nondi -

abetic women and over 4500 g in those with diabetes.

PRIOR SHOULDER DYSTOCIA . Smith and colleagues (1994) identified recurrent shoulder

dystocia in 5 of 42 (12 percent) women. Seven of these women had heavier infants in their

subsequent pregnancy, but only two experienced recurrent shoulder dystocia. In contrast, Baskett and

Allen (1995) found a much lower risk (1 to 2 percent) of recurrent shoulder dystocia.

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A ASK FOR HELP

L LIFT HYPERFLEX LEGS

A ANTERIOR SHOULDER DISIMPACTION

R ROTATION OF THE POSTERIOR SHOULDER

M MANUAL REMOVAL POSTERIOR ARM

Shoulder dystocia is not a maternal soft tissue problem. However, episiotomy may facilitate the

performance of the above manoeuvres, by allowing for additional access. One may consider the

following addition to the mnemonic.

E EPISIOTOMY

R ROLL OVER ONTO 'ALL FOURS'

ASK FOR HELP

Set up for obstetric emergencies

Get the co-operation of the mother, partner, coach, etc

Establish and practice a nursing protocol

Notify your physician backup, and enlist other appropriate personnel

LIFT THE LEGS

Hyperflex both legs (McRobert's manoeuver)

Shoulder dystocia is resolved in 70% of cases by this manoeuver alone

The McRoberts maneuver was described by Gonik and associates (1983) and named for

William A. McRoberts, Jr., who popularized its use at the University of Texas at Houston. The

maneuver consists of removing the legs from the stirrups and sharply flexing them upon the abdomen

(Fig. 19-10). Gherman and colleagues (2000) analyzed the McRoberts maneuver using x-ray

pelvimetry. They found that the procedure caused straightening of the sacrum relative to the lumbar

vertebrae, along with accompanying rotation of the symphysis pubis toward the maternal head and a

decrease in the angle of pelvic inclination. While this does not increase pelvic dimensions, pelvic

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rotation cephalad tends to free the impacted anterior shoulder. Gonik and co-workers (1989) tested

the McRoberts position objectively

Figure-1. The McRoberts maneuver. The maneuver consists of removing the legs from thestirrups and sharply flexing the thighs upon the abdomen, as shown by the horizontal arrow. Theassistant is also providing suprapubic pressure sirnultancously (vertical arrow).

ANTERIOR DISIMPACTION

Abdominal approach - suprapubic pressure applied with the heel of clasped hands from the

posterior aspect of the anterior shoulder to dislodge it (Mazzanti manoeuvre)

Vaginal approach - adduction of the anterior shoulder by pressure applied to the posterior aspect

of the shoulder (i.e. the shoulder is pushed towards the chest)

This results in the smallest possible diameter (Rubin manoeuvre)

Rubin (1964) recommended two maneuvers. First, the fetal shoulders are rocked from side

to side by applying force to the abdomen. If this is not successful, the pelvic hand reaches the

most easily accessible fetal shoulder, which is pushed toward the anterior surface of the chest.

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This most often results in abduction of both shoulders. This in turn produces a smaller shoulder-

to-shoulder diameter and displacement of the anterior shoulder fro hind the symphysis pubis (Fig.

2).

A

FIGURE 2. Rubin (second) maneuver. A. The shoulderto-shoulder diameter is shown as thedistance between the two small arrows. B. The more easily accessible fetal shoulder (the anterior isshown here) is pushed toward the anterior chest wall of the fetus. Most often, this results inabduction of both shoulders, reducing the shoulder-to-shoulder diameter and freeing the impactedanterior shoulder.

ROTATION OF THE POSTERIOR SHOULDER

Woods' screw manoeuvre is a screw-like manoeuver. Pressure is applied to the anterior aspect

of the posterior shoulder, and an attempt is made to rotate that shoulder 180 to the anterior position.

Success of this manoeuvre allows easy deliver of that shoulder.

In practice, the anterior disimpaction manoeuver and Woods' manoeuver may be done

simultaneously and repetitively to achieve disimpaction of the anterior shoulder.

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Woods (1943) reported that, by progressively rotating the posterior shoulder 180 degrees in

a corkscrew fashion, the impacted anterior shoulder could be released. This is frequently referred

to as the Woods corkscrew maneuver (Fig. 4).

FIGURE 4. Woods mancuvcr. The hand is placed bt the posterior shoulder of the fetus. Theshoulder is the tated progressively 180 degrees in a corkscrew manner sc the impacted anterior isreleased.

MANUAL REMOVAL OF THE POSTERIOR ARM

Delivery of the posterior shoulder consists of carefully sweeping the posterior arm of the

fetus across the chest, followed by delivery of the ann. The shoulder girdle is then rotated into

one of the ohlique diameters of the pelvis with subsequent delivery of the anterior shoulder (Fig.

5).

The arm is usually flexed at the elbow. If it is not, pressure in the antecubital fossa can assist

with flexion. The hand is grasped, swept across the chest and delivered.

Finally, if unsuccessful in repeated attempts or if unable to gain access:

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FIGURE 5. Shoulder dvstocia with impacted anterior shoulder of the fetus. A. The op erator'shand i s introduced into the vagina along the fetal posterior humcrus, which i s splinted as thearm is swept across the chest, keeping the arm flexed al the elbow. B. The fetal hand i sgrasped and the arm extended along the side of the face. C. The posterior arm is deliveredfrom the vagina.

Delivery of the posterior arm is attempted, but if it is in fully extended position, this is usually

difficult to accomplish

EPISIOTOMY is an option that may facilitate the Woods' manoeuvre or manual removal of the

posterior arm.

ROLL OVER TO KNEE CHEST POSITION

Some British midwifery texts advocate this manoeuvre, as it appears to allow easier access to

the posterior shoulder. Prior experience xvith delivery in this position would be an asset.

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Hernandez and Wendel (1990) suggested use of a s hou lde r dys toc ia d r i l l to better

organize emergency management of an impacted shoulder. The drill is a set of maneuvers

performed sequentially as needed to complete vaginal delivery. The American College of

Obstetricians and Gynecologists (1991) recommends the following steps-their sequence will

depend on the experience and preference of the individual operator:

1. Call for help-mobilize assistants, an anesthesiologist, and a pediatrician. At this time,

an initial gentle attempt at traction is made. Drain the bladder if it is distended.

2. A generous episiotomy (mediolateral or episioproctotomy) may afford room posteriorly.

3. Suprapubic pressure is used ini tial ly by most practi tioners because i t has the

advantage of simplicity. Only one assistant is needed to provide suprapubic pressure

whi le normal downward traction is app lied to the fetal head.

4. The McRoberts maneuver requires two assistants. Each assistant grasps a leg and

sharply flexes the maternal thigh against the abdomen.

These maneuvers will resolve most cases of shoulder dystocia. If they fail, however, the

following steps may be attempted:

5. The Woods screw maneuver

6. Delivery of the posterior arm is attempted, but if it is in fully extended position, that is

usually difficult to accomplish

7. Other techniques generally should be reserved for cases in which all other maneuvers have

failed. These include intentional fracture of the anterior clavicle or humerus and the

Zavanelli maneuvre

OTHER MANEUVRES

If nothing has worked to this point and all the procedures have been tried again, then some have

suggested:

1. Hibbard (1982) recommended that pressure applied to the fetal jaw and neck in the

direction the maternal rectum, with strong fundal pre applied by an assistant as the anterior

shoulder freed.

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2. Sandberg (1985) reported the Zavanelli maneuver for cephalic replacement into the pelvis

and cesarean delivery. The first part of the maneuver consists of returning the head to the

occiput anterior or occiput posterior position if the head has rotate from either position. The

second step is to flex the head and slowly push it back into the vagina, following which

cesarean delivery is performed. Terbuta line (250 g subcutaneously) is given to produce

uterine relaxation. Sandberg (1999) has subsequently reviewed 103 reported cases in

which the Zavanelli maneuver was used. This maneuver was successful in 91 percent of

cephalic cases and in all cases of breech head entrapments. Fetal injury were common in

the desperate circumstances under which the Zavanelli maneuver was used; there were

eight neonatal deaths, six stillbirths, and 10 neonates suffered brain damage. Uterine

rupture was also reported.

3. Deliberate fracture of the clavicle by pressing the anterior clavicle against the ramus of

the pubis can be done to tree the shoulder impaction. In practice, however, it is difficult

to deliberately fracture the clavicle of a large infant. The fracture will heal rapidly, and

is not nearly as serious as a brachial nerve injury, asphyxia, or death.

4. Cleidotomy consists of cutting the clavicle with scissors or other sharp instruments, and

is usually used on a dead fetus (Schramm, 1983).

5. Symphysiotomy also has been applied successfully as described by Hartfield (1986).

Goodwin and colleagues (1997) reported three cases in which symphysiotomy was

performed after the Zavanelli maneuver had failed-all three infants died and maternal

morbidity was significant due to urinary tract injury.

G. 4 DO NOT

Avoid the 4 P's.

DO NOT? 1. Pull

2. Push

3. Panic

4. Pivot (i.e. severely angulating the head, using the coccyx as a fulcrum)

Strong fundal pressure applied at the wrong time may result in even further impaction of the

anterior shoulder. Gross and associates (1987) reported that fundal pressure in the absence of

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other maneuvers "resulted in a 77 percent complication rate and was strongly associated

with (fetal) orthopedic and neurologic damage ."

H. COMPLICATIONS

Complications of shoulder dystocia include:

Fetal/ neonatal

Death

Hypoxia/ asphyxia and sequelae

Birth injuries

fractures - clavicle, humerus

brachial plexus palsy

Maternal

Postpartum hemorrhage

uterine atony

maternal lacerations

uterine rupture

Fetal asphyxia secondary to cord compression may result in permanent neurologic damage and

even death. In the fetal monkey model the fetal pH drops by 0.04/min when the cord is totally

occluded. If all has been well up to that time, then even after total occlusion for 7 minutes, the pH will

have only dropped by 0.28. In shoulder dystocia, unless the cord has been clamped and divided, there

is likely some preservation of maternal-fetal circulation and therefore less risk of fetal hypoxia.

Fractures of the clavicle and humerus can occur even during appropriate management. These in

fact are preferable to fetal asphyxia

Brachial plexus injury is most commonly caused by extreme lateral traction on the fetal head.nerve root damage usually involves the origins at the cs and c6 level. these nerve roots supply the

forearm flexors and supinators. thus the arm is extended and pronated resulting in the classical erb-

duchenne palsy. this brachial plexus injury is of varying degree and fortunately, rarely results in

permanent damage.

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III. LEMBAR EVALUASI LANGKAH-LANGKAH PENATALAKSANAAN DISTOSIA BAHU

MANUVER "CORKSCREW" WOODS

LANGKAH KLINIK ja

A. ANESTESI LOKAL DAN EPISIOTOMI Ya tidak

1.

Tempatkan jari telunjuk dan jari tengah (dari tangan kiri anda) antara kepala bayi

dan perineum. Hal ini sangat penting untuk mencegah jarum suntik kepala bayi

yang mengenai dapat menyebabkan kematian bayi.

2.

Masukkan jarum secara subkutan, mulai komisura posterior, menelusuri

sepanjang perineum dengan sudut 450 ke arah kanan ibu (tempat akan

dilakukan episiotomi).

3.

Aspirasi untuk memastikan ujung jarum tidak memasuki pembuluh darah.

Apabila pada aspirasi terdapat cairan darah, tarik jarum sedikit dan kembali

masukkan dengan arah yang berbeda. Kemudian ulangi lagi prosedur aspirasi.

Injeksi bahan anestesi ke dalam pembuluh darah, dapat menyebabkan detak

jantungtidak teratur atau konvulsi.

4. Suntikkan bahan anestesi (Lidokain 1%) 5 - 10 ml sambil menarik jarum ke luar.

5.Tekan tempat infiltrasi agar anestesi menyebar. Untuk hasil yang optimal tunggu

1 - 2 menit sebelum melakukan episiotomi.

B: MANUVER '"CORKSCREW' WOODS

1. Masukkan dua jari tangan kanan ke arah anterior bahu belakang janin.

2.

Minta asisten untuk melakukan penekanan fundus uteri ke arah bawah,

kemudian putar (se arah putaran jarum jam) bahu belakang bayi dengan kedua

jari tangan operator (penolong persalinan) ke arah depan (ventral terhadap ibu)

sehingga lahir bahu belakang.

Perhatikan posisi punggung bayi karena putaran bahu belakang ke depan

adalah ke arah punggung bayi.

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3.

Masih diikuti dengan dorongan pada fundus uteri dilakukan putaran berlawanan

dengan arah putaran pertama sehingga akan menyebabkan bahu depan dapat

melewati simfisis.

C: DEKONTAMINASIOAN PENCEGAHAN INFEKSI PASCATINDAKAN

1. Aspirasi larutan klorin 0.5% ke dalam tabung suntik.

2. Rendam tabung suntik dalam larutan klorin 0.5%.

3.Masukkan sarung tangan, bersihkan dari cemaran, kemudian lepaskan dan

rendam dalam larutan klorin 0.5%.

4. Cuci tangan dan keringkan dengan handuk bersih dan kering.

D: PERAWATAN PASCATINDAKAN

MANUVER UNTUK MELAHIRKAN BAHU BELAKANG

LANGKAH KLINIK

A. MANUVER UNTUK MELAHIRKAN BAHU BELAKANG Ya Tidak

1.Masukkan tangan mengikuti lengkung sakrum sampai jari penolong mencapai

fosa antecubiti.

2. Dengan tekanan jari tengah, lipat lengan bawah ke arah dada.

3.

Setelah terjadi fleksi tangan, keluarkan lengan dari vagina (menggunakan jari

telunjuk untuk melewati dada dan kepala bayi atau seperti mengusap muka

bayi), kemudian tarik hingga hahu belakang dan seluruh lengan belakang

dapat dilahirkan

4.

Bahu depan dapat lahir dengan mudah setelah bahu dan lengan belakang

dilahirkan. Bila bahu depan sulit dilahirkan, putar bahu belakang ke depan

(jangan menarik lengan bayi tetapi dorong bahu posterior) dan putar bahu

depan ke belakang (mendorong anterior bahu depan dengan jari telunjuk danjari tengah operator) mengikuti arah punggung bayi sehingga bahu depan

dapat dilahirkan.

C. DEKONTAMINASI DAN PENCEGAHAN 'INFEKSI-PASCATINDAKAN

D. PERAWATAN PASCATINDAKAN

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IV. PENUTUP

Demikian Monograp distosia bahu ini, semoga dapat dimanfaatkan terutama untuk PPDS. Dan

pada gilirannya berdampak pada turunnya morbiditas dan mortalitas akibat distosia bahu.

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DAFTAR PUSTAKA

1. Adriaansz G, Saifudin A.B, Waspodo D, Wiknjosastro G.H. 2000. Buku Acuan Nasional

Pelayanan Kesehatan Maternal dan Neonatal, edisi pertama. Jakarta: Yayasan Bina Pustaka

Sarwono Prawiroharjo.

2. Alarm International. 2001. Ottawa: The Society of Obstetrician and Gynecologists of Canada

3. Creasy R, Resnik R. 1999. Maternal Fetal Medicine 4th edition. Philadelphia: W.B Saunders

Company.

4. Cunningham G, Gant M.F, Leveno K.J, Gilstrap L.C, Hauth J.C, Wenstrom K.D. 2001.

Williams Obstetrics 21st edition. NewYork: McGraw-Hill.

5. DeCherney H. A, Pernoll L.M. 1994. Current Obstetric & Gynecologic Diagnosis and

Treatment, 8th edition. Connecticut: Appleton & Lange.

6. DeCherney H. A, Pernoll L.M. 2003. Current Obstetric & Gynecologic Diagnosis and

Treatment, 9th edition. Connecticut: Appleton & Lange.

7. Wiknjosastro G.H, Waspodo D, Madjid O.M, Hadijono S. 2002. Pelayanan Obstetri Neonatal

Emergensi Dasar (PONED). Jakarta: Jaringan Nasional Pelatihan Klinik-Kesehatan

Reproduksi-Departemen Kesehatan RI dan WHO.

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