DISTOSIA BAHU

Bebaskita br Ginting, S.Si.T, MPH

reborn_life@yahoo.com

Definisi
Distosia bahu adalah tersangkutnya bahu janin dan tidak dapat dilahirkan setelah kepala janin dilahirkan. Impaksi bahu depan diatas simfisis
 Persalinan

yang membutuhkan manuver obstetri tambahan karena kegagalan traksi ke bawah pada kepala janin sebagai efek kelahiran bahu (ACOG, Practice Bulletin 40 (November 2002)

Definisi
Perpanjangan waktu dari lahirnya kepala - tubuh bayi Secara objektif didefinisikan selama 60 detik Pengeluaran kepala-tubuh bayi dengan interval waktu > 60 detik umumnya memiliki berat lahir yang besar, distosia bahu, dan rendahnya skor Apgar 1 menit (Beall et al 1998; Spong et al 1995)

Defnisi fungsional
Sebuah persalinan dimana bahu tidak mengikuti kepala seperti biasa, memerlukan manuver obstetrik tambahan untuk melahirkan bahu. Bahu anterior dapat tertahan di belakang simfisis pubis, atau (jarang) bahu posterior di belakang promontorium sakralis

Normal delivery traction

Rekomendasi American College of Obstetricians and Gynecologist (ACOG,2002) untuk penatalaksanaan pasien dengan riwayat distosia bahu pada persalinan yang lalu:
Dilakukan evaluasi cermat terhadap perkiraan berat janin, usia kehamilan, intoleransi glukosa maternal dan tingkatan cedera janin pada kehamilan sebelumnya. Keuntungan dan kerugian untuk dilakukannya tindakan SC harus dibahas secara baik dengan pasien dan keluarganya.

American College Of Obstetricians and Gynecologist (2002)

Sebagian besar kasus distosia bahu tidak dapat diramalkan atau dicegah. Tindakan SC yang dilakukan pada semua pasien yang diduga mengandung janin makrosomia adalah sikap yang berlebihan, kecuali bila sudah diduga adanya kehamilan yang melebihi 5000 gram atau dugaan berat badan janin yang dikandung oleh penderita diabetes lebih dari 4500 gram.

Incidence
Reported to occur in 0.2-2% of births May recur with a higher frequency, but this is really unknown Many women and clinicians will opt for cesarean in the future, especially if there has been a fetal injury Recurrence rates reported 1-17%

Maternal Complications (25%)

1. Postpartum hemorrhage 2. Vaginal laceration 3. Perineal tears 2nd&3rd 4. Cervical laceration 11% 19% 4% 2%

Fetal Complications of Sh D
Brachial plexus injuries, Fractures of the humerus, and Fractures of the clavicle are the most commonly reported injuries associated with shoulder dystocia

Fetal Complications of Sh D Kombinasi traksi dengan tekanan fundal berkaitan dengan tingginya kejadian pleksus brachialis injury dan patah tulang

Fetal Complications of Sh D

Fewer than 10% of deliveries complicated by shoulder dystocia will result in a persistent brachial plexus injury.

Can shoulder dystocia be predicted ?

1. 2. 3. 4. 5. 6. 7. 8.

RISK FACTORS FOR SHOULDER DYSTOCIA PRECONCEPTIONAL: Maternal birth weight Prior shoulder dystocia 12% Prior macrosomia Pre-existing diabetes Obesity Multiparity Prior gestational diabetes Advanced maternal age

RISK FACTORS FOR SHOULDER DYSTOCIA

Antenatal:
Excessive maternal weight gain

Macrosomia G. diabetes
Post term

RISK FACTORS FOR SHOULDER DYSTOCIA

Intrapartum:
1. Protracted or arrested active phase 2. Protracted or failure of descent of head 3. Need for midpelvic assisted delivery

RISK FACTORS FOR SHOULDER DYSTOCIA Fetal Makrosomia

Macrosomia
Birth weight in excess of a specific weight, usually defined as either 4500 grams (1.5% of births) or 4000 grams (10% of births) Birth weight > 4500 grams rate of shoulder dystocia is 10-25% Birth weight > 4500 grams AND maternal diabetes rate of shoulder dystocia is 20-50%

Pathophysiology A mismatch between fetal size and maternal pelvic capacity Positional variations vertical rather than oblique orientation of shoulders Increased diameter of shoulder girdle  Subcutaneous fat deposition may be increased in infant of diabetic mother especially with sub-optimal glucose control

Diagnosis distosia bahu :

Kepala janin dapat dilahirkan tetapi tetap berada dekat vulva. Tidak terjadi gerakan/ restitusi spontan Dagu tertarik dan menekan perineum. Tarikan pada kepala gagal melahirkan bahu yang terperangkap di belakang simfisis pubis.

Into the Delivery Room

Clinical Management
Step One: Recognize the presence of a shoulder dystocia Step Two: Be sure enough help is present Ask For Help
Mintalah pertolongan Mintalah ibu untuk kooperatif Panggil partner Beritahu personel lainnya

Clinical Management
Step Three: Apply primary maneuvers Mc Roberts maneuver Oblique suprapubic pressure
Pertama kali yang harus dilakukan bila terjadi distosia bahu adalah melakukan traksi curam bawah sambil meminta ibu untuk meneran. Lakukan episiotomi. Setelah membersihkan mulut dan hidung anak, lakukan usaha untuk membebaskan bahu anterior dari simfsis pubis dengan berbagai maneuver

L ift the legs & buttocks Anterior shoulder disimpaction R otation of posterior shoulder Manual removal posterior arm Upaya utk memudahkan melakukan manuver2 tsb : - Episotomi - Hand and knees position

Lift the legs & buttocks: McRoberts Manuver:

Meminta ibu untuk menekuk kedua tungkainya dan mendekatkan lututnya sejauh mungkin ke arah dadanya dalam posisi ibu berbaring terlentang. Meminta bantuan 2 asisten untuk menekan fleksi kedua lutut ibu ke arah dada.

Disimpaksi bahu depan dengan penekanan di suprapubis (Massanti Manuver)

Abdominal approach Diameter biakromial lebih kecil Tidak menekan fundus

The most common mistake is to apply fundal pressure instead of suprapubic pressure!!

Do you know the difference ?

Fundal pressure
fundus Pubic bone

Suprapubic pressure

Never Apply Fundal Pressure !!!

Fundal pressure will only further impact the shoulder.

Clinical management
Step Four: Apply secondary maneuvers; no prescribed order Rubin; Woods screw; Posterior arm; All-fours; Clavicular fracture

If Mc Roberts and Mazzanti failed:

Woods manoeuvre:
Pakailah sarung tangan yang telah didisinfeksi tingkat tinggi, masukkan tangan ke dalam vagina. Tangan diletakkan di belakang bahu belakang anak, Kemudian bahu dirotasi 180 derajat ke anterior sehingga impaksi bahu anterior dilepaskan

Delivery of the posterior arm : (Shwartz)

Lengan bayi biasanya fleksi pd siku Bila lengan tidak fleksi, dorong lengan pada siku Dorong lengan kearah dada Ambil tangan, lahirkan

Hands & Knees

The hand and knees position also facilitates an additional maneuver in which the practitioner goes into the vagina and draws out the baby's posterior arm. Can be difficult if woman has an epidural.

The Role of the Midwife

Familiarize yourself with the maneuvers in order to anticipate the practitioner actions. Make sure your resuscitation equipment is set up and ready. Call the Baby nurse into the room for delivery. Observe the delivery of the head and watch for signs of shoulder dystocia.

When a Shoulder Dystocia is Evident

Immediately remove all extra pillows from under the mother and place her in a supine position. Inform your patient there is a problem with delivery of the baby's shoulders, that you and the baby need her cooperation, and that you will be doing things that may cause some discomfort. Doing McRoberts maneuver. Doing superpubic pressure.

Documentation is critical after a Shoulder Dystocia

Shoulder Dystocia is one of the most litigious emergencies in obstetrics. It is therefore critical that the charting is accurate and complete.

Shoulder Dystocia Documentation

Time of head delivery Time of body delivery Documentation that the mother was informed about the occurrence of shoulder dystocia, as well as the potential sequelae Patient compliance or non-compliance Position and rotation of infant's head Document order, duration, and results of maneuvers employed Timing of episiotomy if performed Timing of bladder catheterization if performed Staff present to assist and when they arrived Document if Pediatric and/or anesthetic help were available

Vigilance is the Key

Although Shoulder Dystocia is a rare complication, it can be one of the most frightening for all involved. The key is preparation and team work. Review the steps you would take in your mind and stay vigilant. Remember to chart accurately and have confidence in your skills.

TERIMA KASIH YA uuuu