DISTOSIA BAHU

Dr. Budi Ermanto, SpOG

Objektif :
•  Definisi dan insiden
•  Faktor risiko
•  Diagnosis
•  Tatalaksana
•  Komplikasi
DEFINISI
•  Tertahannya bahu anterior di atas simpisis
•  Kesulitan melahirkan bahu dengan metode biasa
Shoulder Dystocia
 Shoulder Dystocia

INSIDEN

Insiden bervariasi antara 0.2% - 7% dari

semua persalinan kepala
Dapatkah Distosia Bahu Diprediksi ?

Terdapat hubungan antara ukuran bayi dengan distosia bahu

tetapi bukan prediktor yang baik karena :
•  perbedaan akurasi perkiraan berat janin
•  48 % kelahiran dengan distosia bahu masih terjadi pada bayi
dengan berat lahir < 4000 g

Klinisi harus mengenali faktor risiko distosia bahu.

 FAKTOR RISIKO
Antepartum Intrapartum
Riwayat distosia bahu Persalinan kala I memanjang

Makrosomia Distosia kala II

Diabetes mellitus Augmentasi oksitosin

Indeks massa tubuh ibu > 30 kg/m2 Ekstraksi vakum / forsep

Induksi persalinan
 DIAGNOSIS

•  ‘turtle’ sign (kepala tertahan di perineum)

•  kesulitan melahirkan bahu
•  bahu bayi berada pada aksis vertikal
(tertahan simpisis)
 Shoulder Dystocia

International

TATALAKSANA

Tujuan :
1.  Melepaskan bahu anterior yang tertahan
simpisis
2.  Mengurangi diameter biakromion
3.  Memperbesar kapasitas panggul
International Shoulder Dystocia
Avoid 4P :
•  Panic
•  Pulling (on the head)
•  Pushing (on the fundus)
•  Pivoting (sharply angulating the head, using
the coccyx as a fulcrum)
 Shoulder Dystocia

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Lift - McRobert’s Maneuver

Lifting the legs and buttocks

•  flexion of thighs on abdomen
•  requires assistance
•  relieves 40% of shoulder
dystocias

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501–531
International Shoulder Dystocia
Lift - McRobert’s Maneuver

The McRoberts maneuver does not change the actual dimension of the maternal pelvis.
Rather, the maneuver straightens the sacrum relative to the lumbar spine, allowing cephalic
rotation of the symphysis pubis sliding over the fetal shoulder.
Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501–531
 Shoulder Dystocia

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McRoberts' maneuver

Removing the maternal legs

from the stirrups and putting
the knees up to the chest
fulcrums the pubic
symphysis over the impacted
anterior shoulder.

Pelvis tilts, orienting

symphysis more horizontallt
to facilitate shoulder delivery.

John A. Marx, Robert S. Hockberger, Ron M. Walls. James G. Adams. Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.
Mosby 2006
 Shoulder Dystocia

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Anterior Disimpaction :

1)  Suprapubic Pressure (Massanti Maneuver)

2)  Rubin Maneuver

 Shoulder Dystocia

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Anterior Disimpaction :
Suprapubic Pressure (Massanti Maneuver)

Suprapubic pressure is applied

directing the anterior shoulder
downward and laterally, from the
side of the fetal spine toward the
face.

Pressure should be applied by an

assistant with either the palm or
fist.

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501–531
 Shoulder Dystocia

International

Anterior Disimpaction :
Suprapubic Pressure (Massanti Maneuver)

Suprapubic pressure
applied from the posterior
aspect of the anterior
shoulder (adduction) to
dislodge it

In conjunction with Mc
Roberts relieves 50% of
dystocias.
 Shoulder Dystocia

International

Anterior Disimpaction :
(Rubin Maneuver)

Rubin's maneuver decreases the bisacromial diameter AP, anteroposterior

 Shoulder Dystocia

International

Rotation of Posterior Shoulder

•  no fundal pressure

•  the shoulder must be

rotated utilizing pressure
on the scapula and
clavicula

•  deliver posterior shoulder

 Shoulder Dystocia

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Reverse Wood’s Screw (Rubin Technique):

Insert two fingers into the vagina posteriorly and apply pressure to the posterior
surface of the posterior shoulder to rotate 180° to deliver that shoulder anteriorly

Lew GH, Pulia MS. Emergency Childbirth. In: Robenrts J, editor. Roberts Hedges Clinical Procedures
In Emergency Medicine. Elsevier 2013; 1170.
 Shoulder Dystocia

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Manual Removal of Posterior Arm

•  flex arm at elbow

•  (pressure in
antecubital fossa to
flex arm)
•  sweep arm over chest
•  grasp wrist / forearm or
hand
•  deliver arm
•  fracture of clavicle and/
 Shoulder Dystocia

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Episiotomy

may facilitate Wood’s Maneuver or allow

room for delivery of the posterior arm
 Shoulder Dystocia

Roll Over
International

• = all-fours (Gaskin maneuver)

•  May allow easier access to posterior
shoulder
•  Radiographic studies : pelvic diameters
increase (10 mm true obstetric conjugate and
sagital pelvic outlet)
 Shoulder Dystocia

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Gaskin Maneuver

The Gaskin posi-on.

The ‘‘all fours’’ posi-on
exploits the effects of
gravity and increased
space in the hollow of
the sacrum to facilitate
delivery of the posterior
shoulder and arm.

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501–531
 Shoulder Dystocia

International

As a last resort
•  Clavicular fracture
•  Cephalic replacement (Zavenelli
maneuver)
•  Symphysiotomy
 Shoulder Dystocia

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Zavanelli Maneuver
cephalic replacement via reversal of the cardinal
movements of labor follow be Cesarean section
Ask for help
Lift - the buttocks
- the legs
Anterior disimpaction
-  rotate to oblique
-  suprapubic pressure
Rotate the posterior shoulder
Manual removal of the posterior arm
Episiotomy à consider
Roll over
 Shoulder Dystocia
•  Management
–  Help –
–  Episiotomy
–  Legs – elevate (McRoberts)
–  Pressure - suprapubic
–  Enter vagina – Rubin’s and Woods’ screw
–  Roll or Remove posterior arm
–  Zavanelli, clavicular #, symphysiotomy
 Shoulder Dystocia

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SIMPULAN

•  Antisipasi dan siap (umumnya kasus distosia

bahu tidak diprediksi)
•  Ingat pada mnemonic “ALARMER”
•  Tetap tenang, hindari stay 4P (panic, pull,
push, pivot)
TERIMAKASIH