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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 2004 Ketua Program Studi Bagian/ SMF Obstetri & Ginekologi FK Unair/ RSU Dr. Soetomo Surabaya

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I. RESUME KASUS A. KRONOLOGIS KASUS NY. I RSAL Dr. RAMELAN A. IDENTITAS PENDERITA Nama : Ny. I Umur : 29 tahun Riwayat Persalinan : 1. 9bl/SptB/RSAL/2600/3 th 2. Hamil ini TD PAN di Poli Hamil RSAL 8x sbg KRT ok DM Gestasional HPHT :20-3-03 ~ 37/38 mgg B. ANAMNESA : Penderita datang sendiri ok kenceng-2 C. PEMERIKSAAN FISIK : 6/12/03 Jam 17.00 GCS : 4-5-6 TD : 120/80 N : 88 tr :37 TB : 154 cm C/P : Normal Status Obstetri : TFU : 36 cm / Kepala / DJJ : (+) 12-12-12/ His (+) jarang VT : 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 (+) baik O : Status Umum : T : 120/70 N : 80 C/P : N Status Obstetri : His (+) adequat DJJ (+) 12-12-12 VT: 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 :3500 P : Obs CHPB Ev. 6 jam pro spt B. 22.00 S: Dilaporkan Ketuban pecah spontan 0 : Status Umum : T : 120/70 N : 80 tr : 37 C/P : N Status Obstetri : His (+) adequate DJJ (+) 12-12-12 VT: 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 : 3500 P : Obs CHPB

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Ev. 2 jam pro spt B 00.00 S : Penderita ingin mengejan O : 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 (-) jernih A : GlI P1-1 37/38 mgg TH inpartu KL II + DM Gestasional TBJ : 3500 P : Pimpin mengejan pro spt B

1 jam dipimpin mengejan bayi belum lahir tampak ibu kelelahan, usul untuk percapat kala II dengan Tarikan 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 setelah gagal dilakukan resusitasi. B. KRONOLOGIS PARTUS PATHOLOGIS JAGA RSAL TGL 24-11-2003 1. DATA PENDERITA : Nama : Ny. W Umur : 26 tahun Anggota : i/d Praka Menikah : 5 tahun Riwayat Persalinan Lalu : 1. 9 bl / RSAL / Eks Vakum- ai Kala II Lama Dis Bahu / / 3650 / 5 tahun 2. Hamil ini. Penderita terdaftar, melakukan PAN di Poli Hamil RSAL 6 x sebagai KRT ok DM Pragestasional + 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 jam 11.00.

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3. HASIL PEMERIKSAAN : GCS 4-5-6 TD : 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 / UPD normal / Ketuban jernih / PS : 5 4. DIAGNOSIS : GIIP1-1 36/37 mgTH + KPP + DM Pragestasional + R/ PPTO TBJ : 3300 g 5. PLANING : Cek GDA Inj. Monotard 12 IU 15 menit sebelum makan malam Diet B1 2100 kal Obs. Trec/3 jam Bila Trec > 37,6 atau 1 x 24 jam tak inpartu pro terminasi OD NST Inj. 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. Laten 23.45 Ibu ingin mengejan, VT lengkap Inp. Kala II Ibu dipimpin mengejan pro Spt. B 23.50 Lahir kepala terjadi distosia bahu Dilakukan manuver Mc. Robert Dilakukan penekanan supra symphisis gagal Diputuskan 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. M Umur : 45 th Register : 10322798 MKB : 6-12-2003, pk 15.00 G VI P5-4, menikah: 20th, KB (-) TTD, PAN (-) HPHT : merasa hamil

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TP : 9 bulan Riwayat persalinan : 1. 9bl/ dukun/ spt B/ L/ 4000/ 15 th 2. 9bl/ dukun/ spt B/ L/ 3500/ 13 th 3. 9bl/ dukun/ spt B/ L/ 4000/ 9 th 4. 9bl/ dukun/ spt B/ W/ 3500/ 3 th 5. 9bl/ dukun/ spt B/ 4000/ dukun 6. hamil ini Retrospektif Px 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 rujuk RSDS (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 besar O: GCS: 456 AICD (-) St. umum: T: 180/ 110, N: 88x/m, RR: 20x/m, Tr: 37,1 oC, C/P dbn, Edema: -/-, Alb (+) 4 St. 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 3800 P: 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 17.00 S: kenceng-kenceng (+) sering, gerak anak (+) baik O: GCS: 456 AICD (-) St. umum: T: 200/ 110, N: 92x/m, RR: 20x/m, Tr: 37,1 oC, C/P dbn St. Obstetri: DJJ: (+) 12-12-12, His (+) adekuat VT : 7cm, Eff: 75% Pres: kepala, Den :UKK ki mel, H:I, UPD ~N, ket: (-) keruh A: G VI P5-4 ATH Inpartu kala I fasee aktif + PEB + U > 35 th + GM TBJ 3800 P: Obs CHPB Evaluasi 2 jam pro percepat kala II Pk 18.30 S: 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: 37,1 oC, C/P dbn St. Obstetri: DJJ: (+) 12-12-12, His (+) adekuat VT : lengkap, Eff: -, Pres: kepala, Den :UKK depan, H:I, UPD ~N, ket: (-) keruh A: G VI P5-4 ATH Inpartu kala II + PEB + U > 35 th + GM TBJ 3800 P: Informed Consent pro Percepat Kl II Pk 19.10 Lahir bayi Eks Vakum/ L/ 5300/ 60/ AS 2-1-0 Saat melahirkan bahu terjadi distosia bahu, sehingga diputuskan dilakukan 1. Manual Mc Robert 2. Kompresi symphisis 3. Memutar bahu

Bayi lahir dilakukan resusitasi pada bayi inj Adrenalin pada bayi 0,4 cc 15 menit resusitasi gagal bayi meninggal Pk 19.15 Lahir plasenta spontan, perdarahan 100 cc ANALISA PENYEBAB KEMATIAN KELAINAN A Kelainan/ penyakit utama pada bayi/ Bayi besar janin B Kelainan-kelainan lain yang ditemukan pada bayi atau janin C Kelainan/ penyakit utama ibu yang PEB mempengaruhi janin D Kelainan lain yang ditemukan pada ibu E Factor-faktor lain yang di duga Distosia bahu mempengaruhi bayi/ janin PERSANGKAAN PENYEBAB KEMATIAN: Distosia Bahu ICD

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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 dys tocia 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 incidence defined 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. E. 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 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 secondstage 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 mac rosomia 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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TABEL 1. Incidence of Shoulder Dystocia According to Birthweight Grouping in Singleton Infants Delivered Vaginally in 1994 at Parkland Hospital Shoulder Dystocia Birthweight Group Births (Percent) s 3000 g 2953 0 3001-3500 g 4309 14 ( 0.3) 3501-4000 g 2839 28 ( 1.0) 4001-4500 g 704 38 ( 5.4) > 4500 g 91 17 (19.0) All weights 10,896 97( 0.9) The American College of Obstetricians and Gynecologists (1997, 2000) reviewed studies classi fied according to the evidence-based methods outlined by the United States Preventive Services Task Force. It concluded that the preponderance of current evidence is consistent with the view that: 1. Most cases of shoulder dystocia cannot be predicted or prevented because there are no accurate methods to identify which fetuses will develop this complication. 2. Ultrasonic measurements to estimate macrosomia have limited accuracy. 3. Planned cesarean delivery based on suspected macrosomia is not a reasonable strategy. 4. Planned cesarean delivery may be reasonable for the nondiabetic with an estimated fetal weight exceeding 5000 g or the diabetic whose fetus is estimated over 4500 g. F. MANEUVERS Because shoulder dystocia cannot be predicted, the practitioner of obstetrics must be well versed in the management principles of this occasionally devastating complication. Reduction in the interval of time from delivery of the head to delivery of the body is of great importance to survival. An initial gentle attempt at traction, assisted by maternal expulsive efforts is recommended. Overly vigorous traction on the head or neck, or excessive rotation of the body, may cause serious damage to the infant. ALARM international also gave a similar statement as follow: Given our inability to predict the occurrence of shoulder dystocia reliably; every delivery should be seen as having the potential to result in shoulder dystocia. Therefore, a management protocol must be in place and well known to all caregivers. The ALARM mnemonic has been developed to assist in the appropriate and consistent management of this common complication.

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A L A R M

ASK FOR HELP LIFT HYPERFLEX LEGS ANTERIOR SHOULDER DISIMPACTION ROTATION OF THE POSTERIOR SHOULDER 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 R EPISIOTOMY ROLL OVER ONTO 'ALL FOURS' 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

ASK FOR HELP

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 di mensions, 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 the stirrups and sharply flexing the thighs upon the abdomen, as shown by the hori zontal arrow. The assistant 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 shoulderto-shoulder diameter and displacement of the anterior shoulder fro hind the symphysis pubis (Fig. 2).

FIGURE 2. Rubin (second) maneuver. A. The shoulderto-shoulder diameter is shown as the distance between the two small arrows. B. The more easily accessible fetal shoulder (the anterior is shown here) is pushed toward the anterior chest wall of the fetus. Most often, this results in abduction of both shoulders, reducing the shoulder-to-shoulder diameter and freeing the impacted anterior 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. The shoulder is the tated progressively 180 degrees in a corkscrew manner sc the impacted anterior is released. MANUAL REMOVAL OF THE POSTERIOR ARM Delivery of the posterior shoulder consists of care fully 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 de livery 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's hand i s introduced into the vagina along the fetal posterior humcrus, which is splinted as the arm is swept across the chest, keeping the arm flexed al the elbow. B. The fetal hand i s grasped and the arm extended along the side of the face. C. The posterior arm is delivered from 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 h o uld e r d ysto cia d r ill 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 initially by most practitioners because it has the advantage of simplicity. Only one assistant is needed to provide suprapubic pressure while normal downward traction is applied 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 rap idly, and is not nearly as serious as a brachial nerve injury, asphyxia, or death. 4. Cleidotomy consists of cutting the clavicle with scis sors 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 sym physiotomy 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 erbduchenne 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 Ya tidak

A. ANESTESI LOKAL DAN EPISIOTOMI Tempatkan jari telunjuk dan jari tengah (dari tangan kiri anda) antara kepala bayi 1. dan perineum. Hal ini sangat penting untuk mencegah jarum suntik kepala bayi yang mengenai dapat menyebabkan kematian bayi. Masukkan jarum secara subkutan, mulai komisura posterior, menelusuri 2. sepanjang perineum dengan sudut 45 0 ke arah kanan ibu (tempat akan dilakukan episiotomi). Aspirasi untuk memastikan ujung jarum tidak memasuki pembuluh darah. Apabila pada aspirasi terdapat cairan darah, tarik jarum sedikit dan kembali 3. masukkan dengan arah yang berbeda. Kemudian ulangi lagi prosedur aspirasi. Injeksi bahan anestesi ke dalam pembuluh darah, dapat menyebabkan detak jantung tidak teratur atau konvulsi. 4. 5. Suntikkan bahan anestesi (Lidokain 1%) 5 - 10 ml sambil menarik jarum ke luar. 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. Minta asisten untuk melakukan penekanan fundus uteri ke arah bawah, 2. 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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Masih diikuti dengan dorongan pada fundus uteri dilakukan putaran berlawanan 3. dengan arah putaran pertama sehingga akan menyebabkan bahu depan dapat melewati simfisis. C: DEKONTAMINASIOAN PENCEGAHAN INFEKSI PASCATINDAKAN 1. 2. 3. 4. Aspirasi larutan klorin 0.5% ke dalam tabung suntik. Rendam tabung suntik dalam larutan klorin 0.5%. Masukkan sarung tangan, bersihkan dari cemaran, kemudian lepaskan dan rendam dalam larutan klorin 0.5%. Cuci tangan dan keringkan dengan handuk bersih dan kering.

D: PERAWATAN PASCATINDAKAN

MA N U V E R UNTUK ME LA HIRK A N B A HU BE L AK A NG LANGKAH KLINIK A. 1. 2. MANUVER UNTUK MELAHIRKAN BAHU BELAKANG Masukkan tangan mengikuti lengkung sakrum sampai jari penolong mencapai fosa antecubiti. Dengan tekanan jari tengah, lipat lengan bawah ke arah dada. 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 Bahu depan dapat lahir dengan mudah setelah bahu dan lengan belakang dilahirkan. Bila bahu depan sulit dilahirkan, putar bahu belakang ke depan 4. (jangan menarik lengan bayi tetapi dorong bahu posterior) dan putar bahu depan ke belakang (mendorong anterior bahu depan dengan jari telunjuk dan jari tengah operator) mengikuti arah punggung bayi sehingga bahu depan C. D. dapat dilahirkan. DEKONTAMINASI DAN PENCEGAHAN 'INFEKSI-PASCATINDAKAN PERAWATAN PASCATINDAKAN Ya Tidak

3.

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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. 3. 4. 5. 6. 7. Alarm International. 2001. Ottawa: The Society of Obstetrician and Gynecologists of Canada Creasy R, Resnik R. 1999. Maternal Fetal Medicine 4 th edition. Philadelphia: W.B Saunders Company. 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. DeCherney H. A, Pernoll L.M. 1994. Current Obstetric & Gynecologic Diagnosis and Treatment, 8th edition. Connecticut: Appleton & Lange. DeCherney H. A, Pernoll L.M. 2003. Current Obstetric & Gynecologic Diagnosis and Treatment, 9th edition. Connecticut: Appleton & Lange. 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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