BebaskitabrGinting,S.Si.

T,MPH
reborn_life@yahoo.com
Distosiabahuadalahtersangkutnyabahu
janindantidakdapatdilahirkansetelah
kepalajanindilahirkan.
Impaksibahudepandiatassimfisis
Persalinan yang membutuhkan manuver obstetri
tambahan karena kegagalan traksi ke bawah pada
kepala janin sebagai efek kelahiran bahu (ACOG,
Practice Bulletin 40 (November 2002)

Definisi
Perpanjanganwaktudarilahirnya
kepala-tubuhbayiSecaraobjektif
didefinisikanselama60detik
Pengeluarankepala-tubuhbayi
denganintervalwaktu>60detik
umumnyamemilikiberatlahiryang
besar,distosiabahu,danrendahnya
skorApgar1menit
(Bealletal1998;Spongetal1995)

Definisi
Sebuahpersalinandimanabahutidak
mengikutikepalasepertibiasa,
memerlukanmanuverobstetriktambahan
untukmelahirkanbahu.

Bahuanteriordapattertahandibelakang
simfisispubis,atau(jarang)bahuposterior
dibelakangpromontoriumsakralis

Defnisifungsional
Normal delivery
traction
Dilakukanevaluasicermatterhadap
perkiraanberatjanin,usiakehamilan,
intoleransiglukosamaternaldantingkatan
cederajaninpadakehamilansebelumnya.
Keuntungandankerugianuntuk
dilakukannyatindakanSCharusdibahas
secarabaikdenganpasiendankeluarganya.
RekomendasiAmericanCollegeof
ObstetriciansandGynecologist
(ACOG,2002)untukpenatalaksanaan
pasiendenganriwayatdistosiabahupada
persalinanyanglalu:
Sebagianbesarkasusdistosiabahu
tidakdapatdiramalkanataudicegah.
TindakanSCyangdilakukanpada
semuapasienyangdiduga
mengandungjaninmakrosomiaadalah
sikapyangberlebihan,kecualibila
sudahdidugaadanyakehamilanyang
melebihi5000gramataudugaanberat
badanjaninyangdikandungoleh
penderitadiabeteslebihdari4500
gram.
AmericanCollegeOfObstetriciansand
Gynecologist(2002)
Incidence
Reportedtooccurin0.2-2%ofbirths
Mayrecurwithahigherfrequency,butthis
isreallyunknown
Manywomenandclinicianswilloptfor
cesareaninthefuture,especiallyifthere
hasbeenafetalinjury
Recurrenceratesreported1-17%
1. Postpartumhemorrhage11%
2. Vaginallaceration19%
3. Perinealtears2
nd
&3
rd
4%
4. Cervicallaceration2%
Maternal Complications (25%)
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
Kombinasi traksi dengan tekanan
fundal berkaitan dengan
tingginya kejadian pleksus
brachialis injury dan patah tulang

Fetal Complications of Sh D
Fewer than 10% of
deliveries complicated by
shoulder dystocia will result
in a persistent brachial
plexus injury.
Fetal Complications of Sh D
Can shoulder
dystocia be
predicted ?

RISK FACTORS FOR SHOULDER
DYSTOCIA
PRECONCEPTIONAL:
1. Maternal birth weight
2. Prior shoulder dystocia 12%
3. Prior macrosomia
4. Pre-existing diabetes
5. Obesity
6. Multiparity
7. Prior gestational diabetes
8. Advanced maternal age

RISKFACTORSFORSHOULDER
DYSTOCIA
Antenatal:
Excessive maternal weight gain
Macrosomia
G. diabetes
Post term
RISK FACTORS FOR SHOULDER
DYSTOCIA
Intrapartum:
1. Protracted or arrested active phase
2. Protracted or failure of descent of
head
3. Need for midpelvic assisted delivery
RISKFACTORSFOR
SHOULDERDYSTOCIA
Fetal
Makrosomia
Birthweightinexcessofaspecific
weight,usuallydefinedaseither
4500grams(1.5%ofbirths)or4000
grams(10%ofbirths)
Birthweight>4500gramsrateof
shoulderdystociais10-25%
Birthweight>4500gramsAND
maternaldiabetesrateof
shoulderdystociais20-50%
Pathophysiology
Amismatchbetweenfetalsizeand
maternalpelviccapacity
Positionalvariationsverticalrather
thanobliqueorientationofshoulders
Increaseddiameterofshouldergirdle
Subcutaneousfatdepositionmay
beincreasedininfantofdiabetic
motherespeciallywithsub-
optimalglucosecontrol
Diagnosisdistosiabahu:
Kepalajanindapat
dilahirkantetapitetap
beradadekatvulva.
Tidakterjadigerakan/
restitusispontan
Dagutertarikdan
menekanperineum.
Tarikanpadakepala
gagalmelahirkanbahu
yangterperangkapdi
belakangsimfisispubis.

ClinicalManagement
Step One: Recognize the presence of
a shoulder dystocia

Step Two: Be sure enough help is
present AskForHelp
Mintalahpertolongan
Mintalahibuuntukkooperatif
Panggilpartner
Beritahupersonellainnya

StepThree:Applyprimarymaneuvers
McRobertsmaneuver
Obliquesuprapubicpressure

Pertamakaliyangharusdilakukanbilaterjadi
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
pubisdenganberbagaimaneuver

ClinicalManagement
Liftthelegs&buttocks
Anteriorshoulderdisimpaction
Rotationofposteriorshoulder
Manualremovalposteriorarm

Upayautkmemudahkanmelakukan
manuver2tsb:
-Episotomi
-Handandkneesposition

Memintaibuuntuk
menekukkedua
tungkainyadan
mendekatkanlututnya
sejauhmungkinkearah
dadanyadalamposisi
ibuberbaringterlentang.
Memintabantuan2
asistenuntukmenekan
fleksikedualututibuke
arahdada.
Liftthelegs&buttocks:McRoberts
Manuver:
Abdominal
approach
Diameter
biakromiallebih
kecil
Tidakmenekan
fundus

Disimpaksibahudepandengan
penekanandisuprapubis(Massanti
Manuver)

Do you know the difference ?

Fundal
pressure
Suprapubic
pressure
fundus
Pubic bone
NeverApplyFundalPressure!!!
Fundalpressurewillonly
furtherimpactthe
shoulder.
Clinicalmanagement
StepFour:Applysecondary
maneuvers;noprescribedorder
Rubin;Woodsscrew;Posterior
arm;All-fours;Clavicularfracture

Woods manoeuvre:
Pakailahsarungtangan
yangtelahdidisinfeksi
tingkattinggi,masukkan
tangankedalamvagina.
Tangandiletakkandi
belakangbahubelakang
anak,
Kemudianbahudirotasi
180derajatkeanterior
sehinggaimpaksibahu
anteriordilepaskan

IfMcRobertsandMazzantifailed:
Lenganbayibiasanyafleksipdsiku
Bilalengantidakfleksi,doronglengan
padasiku
Doronglengankearahdada
Ambiltangan,lahirkan
Delivery of the posterior arm :
(Shwartz)
1
2
3
The hand and
knees position
also facilitates an
additional
maneuver in which
the practitioner
goes into the
vagina and draws
out the baby's
posterior arm. Can
be difficult if
woman has an
epidural.

TheRoleoftheMidwife
Familiarizeyourselfwiththemaneuversin
ordertoanticipatethepractitioneractions.
Makesureyourresuscitationequipmentis
setupandready.
CalltheBabynurseintotheroomfor
delivery.
Observethedeliveryoftheheadand
watchforsignsofshoulderdystocia.
WhenaShoulderDystociaisEvident
Immediately remove all extra pillows from
under 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.


Documentationiscritical
afteraShoulderDystocia
ShoulderDystociaisone
ofthemostlitigious
emergenciesin
obstetrics.

Itisthereforecriticalthat
thechartingisaccurate
andcomplete.
ShoulderDystocia
Documentation
Timeofheaddelivery
Timeofbodydelivery
Documentationthatthemotherwasinformedabout
theoccurrenceofshoulderdystocia,aswellasthe
potentialsequelae
Patientcomplianceornon-compliance
Positionandrotationofinfant'shead
Documentorder,duration,andresultsofmaneuvers
employed
Timingofepisiotomyifperformed
Timingofbladdercatheterizationifperformed
Staffpresenttoassistandwhentheyarrived
DocumentifPediatricand/oranesthetichelpwere
available
AlthoughShoulderDystociaisarare
complication,itcanbeoneofthemost
frighteningforallinvolved.
Thekeyispreparationandteamwork.
Reviewthestepsyouwouldtakeinyour
mindandstayvigilant.
Remembertochartaccuratelyandhave
confidenceinyourskills.

TERIMA KASIH YA