Ny.

28 tahun datang dengan hamil presentasi bokong

Periksa tanda kegawatan :

 Periksa tekanan darah, bila diatas 160/110 mmHg  berikan nifedipin 10 mg
sublingual, periksa ulang 10 - 15 menit kemudian.
 Bila terdapat gawat janin, segera lakukan resusitasi intrauteri dan persiapkan
seksio sesaria

Tanyakan :
 Kehamilan keberapa, hamil berapa bulan, HTA, menstrual diary.
 ANC dimana, apakah selama ANC pernah terdapat keluhan kehamilan
 Riwayat penyakit dahulu, adakah DM, HT, Jantung?
 Riwayat penyakit keluarga, adakah DM, HT, Jantung?
 Riwayat obstetrik, riwayat menikah, KB, riwayat persalinan, adakah keluhan
serupa pada kehamilan sebelumnya?

Periksa :
 KU, TD, FN, RR, temp, adakah febris, BMI
 Pemeriksaan fisik : Mata : anemis, icteric
Pulmo : vesikuler, rhonki -/-, wheezing -/-
Cor : BJ I – II, mur mur, gallop
Abdomen : tanda akut, perut membuncit sesuai usia kehamilan
Extremitas : hangat
 Pemeriksaan obstetrikus : TFU, presentasi bokong, masuk PAP?, TBJ, his, DJJ
Inspeksi : v/v tampak cairan ketuban?
Inspekulo : portio licin, tertutup, fluor -, fluxus –
VT : portio, arah, tebal, pembukaan, presentasi
bokong, hodge?, ketuban?,
 Protein stik : -

Tentukan masalah :
G3 P2 hamil 39 minggu, JP Bokong TH, PK II
Tatalaksana
G3 P2 hamil 39 minggu, JP Bokong TH, PK II
 Dx : Observasi keluhan, tanda vital  mengetahui adanya kegawatan pada ibu
Observasi kontraksi, DJJ  mengetahui adanya kegawatan pada janin
 Tx : Rencana persalinan pervaginam 
Klasik
Manual aid
Ekstraksi

Persiapan : Resusitasi janin

Cunam piper

Penatalaksanaan Persalinan Sungsang

Penatalaksanaan dibagi 2, yaitu :
1. persalinan pervaginam
Berdasarkan tenaga yang dipakai dalam proses persalinan, persalinan pervaginam
dapat dibagi menjadi 3, yaitu :
 Persalinan spontan, dimana janin dilahirkan dengan kekuatan dan tenaga
ibu sendiri
 Manual aid (partial breech extraction, assisted breech delivery), dimana
janin dilahirkan sebagian dengan tenaga dan kekuatan ibu, dan sebagian
lagi dengan tenaga penolong
 Ekstraksi sungsang, dimana janin seluruhnya dilahirkan dengan memakai
tenaga penolong
2. Persalinan per abdominam (SC).

Tahapan Pada Persalinan Letak Sungsang 5

1. Tahap pertama, merupakan fase lambat. Mulai lahir bokong sampai pusat
(skapula depan). Fase ini hanya untuk melahirkan bokong
2. Tahap kedua, fase cepat. Mulai dari lahirnya pusat sampai mulut. Disebut fase
cepat karena pada fase ini kepala janin udah mulai masuk pintu atas panggul,
sehingga kemingkinan tali pusat terjepit. Oleh karena itu fase ini harus segera
 diselesaikan dan tali pusat dilonggarkan. Bila mulut sudah lahir, janin dapat
segera bernafas lewat mulut
3. Tahap ketiga, fase lambat. Yaitu mulai dari lahirnya mulut sampai seluruh kepala
lahir. Fase ini lambat karena kepala akan keluar dari ruangan yang bertekanan
tinggi ke luar dimana tekanannya lebih rendah. Hal ini untuk menghindari
terjadinya perdarahan intrakranial (adanya ruptura tentorium serebelli)

Komplikasi1,2,4,5
Komplikasi yang dapat timbul adalah :
1. Pada janin :
 Perdarahan intra kranial
 Asfiksia, karena tekanan pada tali pusat
 Perlukaan jalan lahir
 Penarikan pada pleksus brachialis
2. Pada Ibu : sama seperti persalinan pada presentasi kepala

Teknik Persalinan
1. Persalinan Spontan :
 Cara Bracht : segera setelah bokong lahir, bokong dipegang dengan kedua
ibu jari penolong sejajar sumbu panjang paha janin dan jari-jari lain
memegang panggul
 Cara Burn Marshall : memegang kedua pergelangan kaki (dilapisi dengan
kain/handuk kering) dan janin diangkat keatas dengan gerakan
hiperlordosis

2. Persalinan Dengan Manual Aid :

  Terdiri dari 3tahap :
1. Lahirnya bokong sampai pusar (dengan kekuatan ibu sendiri)
2. Lahirnya bahu dan lengan (dengan tenaga penolong). Terdapat 4 cara
untuk melahirkan bahu dan lengan, yaitu :
 Klasik : melahirkan lengan belakang lebih dahulu
 Mueller : melahirkan bahu dan lengan depan lebih dahulu
 Lovset : memutar badan janin dalam stengah lingkaran bolak
balik sambil dilakukan traksi curam kebawah shingga bahu
sebelum nya yang ada dibelakang akhirnya lahir dibawah
simfisis
 Bickenbach : kombinasi cara Mueller dan Klasik.
3. Lahirnya kepala. Terdapat 5 cara, yaitu :
 Mauriceau
 Najouks
 Wigan martin Winkle
 Prague terbalik
 Cunam Piper
3. Ekstraksi Sungsang (total breech extraction)
Teknik terdiri atas :
 Teknik ekstraksi kaki
 Teknik ekstraksi bokong

BACA SLIDE ALARM TENTANG PERSALINAN BOKONG !!!

Physical:
  Leopold maneuvers: During the first maneuver, the hard fetal head can be palpated at
uterine fundus.
 Auscultation: Heart sounds can be heard above the umbilicus.
 Vaginal examination
o In frank presentations, the ischial tuberosities, sacrum, anus, and/or genitals may
be palpated. In addition, meconium staining of the examiner's digit may occur.
o In complete presentations, the feet of the fetus may be palpated with the
buttocks. In incomplete presentations, one or both of the feet/knees may be
palpated.
 The following conditions make vaginal delivery in case of frank breech less risky:
o Favorable pelvis - Gynecoid (ie, round) or anthropoid (ie, elliptical)
o Fetus weighing less than 3600 g - The larger the fetus, the larger the head is, as
well as other noncompressible body parts, leading to increased fetal hypoxia and
birth trauma
o Complete dilation and effacement of the cervix - Provides the head a better
chance to pass through the pelvis.
o Availability of skilled obstetrician, neonatal resuscitation equipment, and
anesthesia
 The following conditions are unfavorable for delivery:
o Fetus weight more than 3600 g
o Unfavorable pelvis - Breech delivery does not allow sufficient time for molding of
the fetal head; thus, a platypelloid (ie, anteroposterior flat) or android (ie, heart-
shaped) pelvis decreases ability of the head of the fetus to navigate maternal
pelvis
o Hyperextension of the head - Increases risk of cervical spine injury
o Footlings - Incidence of umbilical cord prolapse increases with coiling of the
umbilical cord around the legs of the fetus

Causes:
  Risk factors for breech presentation include the following:
o Gestational age of fetus less than term. Prior to onset of labor, the fetus turns
into cephalic presentation. If labor occurs abruptly or unexpectedly (eg, following
trauma), the fetus may not have had the chance to shift position.
o Increased maternal parity may cause stretch or laxity of the uterus, predisposing
the patient to breech deliveries.
o Multiple fetuses: As a result of limited space in the uterus, fetuses in cases of
multiple births may position themselves head to foot.
o Hydramnios, or too much amniotic fluid, may allow the fetus too much
movement.
o Oligohydramnios, or too little amniotic fluid, may impede final shift of the fetus to
cephalic presentation.
o Placenta previa, or placental implantation over the cervical os, allows the fetus
too much space for movement within the uterus.
o Hydrocephalus, or enlarged head in the fetus, makes it more difficult for the fetus
to make final shift to cephalic presentation prior to onset of labor.
o Previous breech deliveries may increase likelihood of breech presentation, as the
uterus may have an anomaly, predisposing it to breech presentations.
o Uterine anomalies that predispose to breech presentation include bicornuate
uterus and septate uterus.
o Pelvic tumors may impede fetal movement and trap the fetus in breech
presentation position.
o Placental cornual-fundal implantation also increases risk of breech presentation.

Mengetahui penatalaksanaan presentasi bokong di poliklinik :

 Knee to chest position pada usia kehamilan 34 minggu
 Versi luar

Procedure
Prepare for the possibility of cesarean delivery. Type and screen the patient's blood, and consult
with an anesthesiologist. The night before the procedure, the patient should have nothing by
mouth after midnight. Perform an ultrasound to confirm breech, check growth and amniotic fluid
volume, and rule out anomalies associated with breech.

Perform a nonstress test (biophysical profile as backup) prior to ECV to confirm fetal well-being.

Perform ECV in or near a delivery suite because in the unlikely event of fetal compromise during
or following the procedure, emergent delivery may be necessary.

ECV can be performed with 1 or 2 operators. An assistant may help turn the fetus, elevate the
breech out of the pelvis, or monitor the ultrasound position of the baby. ECV is accomplished by
judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward
the fundus. Attempt a forward roll first and then a backward roll if the initial attempts are
unsuccessful. No consensus has been reached regarding how many ECV attempts are
appropriate at one time.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical
profile if needed) prior to discharge. Also, administer Rh immune globulin to women who are Rh-
negative. Be prepared for an unsuccessful ECV; version failure with this maneuver is not
necessarily a reflection of the skill of the practitioner. Some physicians induce labor following
successful ECV, while others discharge and wait for spontaneous labor.

Success rate

Success rates vary widely but range from 35-86% (average, 58%). Improved success rates occur
with multiparity, with earlier gestational age, with frank breech, with a transverse lie, and in
African American patients. Opinions differ regarding the influence of maternal weight, placental
position, and amniotic fluid volume, but these factors may also influence success rates.

BACA ROCG !!!