PERSALINAN PATOLOGIS

( D I S T O S I A )
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
J ALAN 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 ( Etiology)
III. Lokasi
IV. Kapasitas
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 Platipelloid
Antropoid Android
The Anthropoid pelvis can be considered
normal for clinical purposes as its
measurements are equivalent to a
gynaecoid pelvis turned through 90o
High
Assimilation
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 75
o
rather
than the normal 55
o
. 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.
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

c. Antara 8,5 10 cm
Panggul Sempit
Absolut
Panggul Sempit
Ringan
a. Kurang 6 cm
b. Antara 6 8 cm
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).
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.
15 Cm < 20 Cm
A < B
J O N G E S
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
III. BENTUK
IV. JUMLAH
V. PERJALANAN
SEBAB :
1. AKOMODASI
2. FISIKA
PUTAR PAKSI
KEMBAR
HIDROCEPHALUS
OVERWEIGHT BABY
PENGERTIAN LETAK
Situs : Sumbu Janin - Sumbu Uterus
Habitus : Sikap Kedudukan Janin
Presentasi :


Bagian terendah
Positio : Bagian Janin (Denominator) Ka Ki
Depan Belakang
Statiom : Penurunan Bidang Panggul
FETAL PRESENTATION AT VARIOUS GESTATIONAL AGES
DETERMINED SONOGRAPHICALLY
GESTATION
( WK)
TOTAL
NUMBER
PERCENT
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
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
JANIN DALAM AKHIR KEHAMILAN
Beberapa Sikap Badan Janin
A. LETAK DEFLEKSI
PATOFISOLOGI LETAK DEFLEKSI
I. DI ATAS PAP
UNSTABLE LIE
TERABA

U2 B
U2 K
DAHI
MUKA
PENEMPATAN

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 U
2
K masih tetap di Posterior
4. POSITIO OCCIPITALIS
Posterior Directa Sacralis
- Bila lahir / Macet dengan U
2
K
di depan Sacrum
5. DEEP TRANSVERSE ARREST
- Putar Paksi Tak Sempurna
- U
2
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 (U
2
B, U, K, M, D)
- Obliq Desensus
II. LEWAT PAP MASUK RONGGA PANGGUL
FLEXI
Tidak
U
2
B : Let. P
Ya
U
2
K : Let. B. Kep
Internal Rotasi Internal Rotasi
U
2
B
Anterior
U
2
B
Posterior
U
2
K
Anterior
U
2
K
Posterior
Di Tengah
Mudah
(= L.B. Kep)
Putar Paksi
Lebih
Sulit
Ruptur Pirenium
Let. B. Kep Gangguan
Deflexi Sulit
DTA
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.
B 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%
OCCIPUT POSTERIOR
N = 61 15,0%
KELAHIRAN
OCCIPUT ANTERIOR
n = 387 94,9 %
OCCIPUT POSTERIOR
n = 21 5,1%
n=334
81,9%
n=53
13,0%
n=53
13,0%
n=53
13,0%
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
Standar
2. Disproporsi SC
B. Perjalanan & Manajemen
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
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
Parietal Bitemporal
Eminence Diamater
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 suture and
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
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
Suboccipito
bregmatic diameter
Submento
bregmatic diameter
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
Mechanism of labour for right mentosposterior position
135
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
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
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.
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 mento-
vertical 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
Occipito-mental
Diameter decreases
CERVIX
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
V
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
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
Aetiology : The breech is the presenting part in 25% of cases before 30
weeks therefore prematurity is an important factor
Fully flexed foetus


A. Complete or Full breech
Not fully flexed foetus With legs extended
B. Frank breech
One or both thighs extended
Footling or
Incomplete breech
C
BREECH PRESENTATION MANAGEMENT
RECOGNITION
PALPATION
Longitudinal lie.
Firm lower pole.
Limbs to oneside.
Hard head at fundus.
( Head may not be palpable at fundus because it is
under the ribs always confirm by pelvic
examination )
Full Breech
Frank Breech
AUSCULATATION
The foetal heart ( F.H ) is best heard above the umbilicus
Flexi Kepala Putar paksi dalam
Hipomochlion : Subocciput
Gerakan Flexi ( Hiperlordose )
Diameter intertrochanterica P. A. P
Putar paksi dalam : sacrum ke ka - ki
Hipomochlion : Troch.mayor depan
P. P. D Hipomochlion : Acromion dep
Latero flexi / lordose bahu belakang lahir
Lateroflexi BO lahir P. P. L
MEKANISME PERSALINAN SUNGSANG
BOKONG :
BAHU :
Diameter Bacromial P. A. P
KEPALA :
Diameter Suboccip Bregmatica
Sut. Sagitalis Melintang
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 sacro-
anterior ( 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 : Dilatator yang Baik
Letak Kaki : 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
The 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.
Intra-cranial haemorrhage
From rupture of tentorium
Cerebral or falx cerebni-due
To rapid moulding
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
Disruption of knee joint.
Hyperextension instead of
Flexion when delivering legs
Dislocation of neck,
Erb-Duchenne Paralysis,
Damege to sternomastoid
Nuscies
Due to Traction
Rupture of viscus
Uusaly liver or kidney
Due to pressures or
Faulty handling
Genital oedema and
Ecchymoses due to
caput formation
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 ( Partial Extr. )
Extr. Bo / Kaki ( Total Extr. )
Sectio caesarea.
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 Mati
( Letak lintang kasep )
Akhirnya SBR robek
( Ruptura uteri )
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 Mati
( Letak lintang kasep )
Akhirnya SBR robek
( Ruptura uteri )
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
Anak :
Asphixia Instrauterin 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.
Rectificatio spontanae Letak kepala
Versio Spontanea Letak sungsang
Conduplicatio Corpore Tubuh terlipat bahu lahir
Disusul kepala bersamaan dengan perut
Evolutio spontanea
BO + Kaki disusul bahu kepala
MEKANISME PERSALINAN
Modus denmam :
Tubuh Terlipat pada pinggang lahir
Modus Douglas : Bahu lahir disusul dada, perut,
Bo+kaki, baru kemudian disusul kepala.
Douglas method of spontaneous Denmans method of spontaneous
evolution in transverse lie. evolution in transverse lie.
Extreme lateral flexion of vertebral Same extreme lateral flexion of
column with birth of lateral aspect vertebral column as in Figure A
of thorax before buttocks. but in opposite direction, so that
buttocks are born before thorax
A B
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.
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
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
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
Prolapse cord
at the vulva

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
M A S A L A H
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
A
B
C



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
A B
The maneuver consists of
A. Removing the legs from the stirrups and
B. Sharply flexing them upon the abdomen
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 %
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 GANDA
INSIDEN
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. BBLR
b. Preterm
c. Kel. Comigenal
d. Distosia
Perinatal & Neonatal
Morbiditas & Mortalitas
Meningkat
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 Hypotonic Uterine
Contraction Contraction
( Inertia Uteri )
Coordinated U.C Incoordinated UC
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
Tanda -
Tanda
Kuat & Sinkron

Relaksasi Ada

Nyeri Normal
Kuat tapi tidak
Sinkron
Tonus tetap
meningkat
Nyeri 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 HYPOTONIC
HIS COORD. INCOORD PRIMER SEKUNDER
Akibat
pada
Persalinan
Spasme Otot lokal

Lingkaran Konsriksi

Partus Macet

Dystocia

Dystocia
Ibu Robekan
Luas
Nyeri Tegang

Lelah Lemah
Asidosis
Lelah
Lemah
Asidosis
Lelah
Lemah
Asidosis
Bayi Perdarahan
Otak
(Kuat -
Cepat)
- Hipoksia
- Gawat Janin
- Gawat
Janin
Gawat
Janin
KALA I HYPERTONIC HYPOTONIC
HIS COORD. INCOORD PRIMER SEKUNDER
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
( Bila tak ada
Indikasi )
- S.C
S.C
KALA II - KELAINAN TENAGA
Faktor
1. HIS 2. Otot Perut dan Diafragma
2. 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