14. kelainan presentasi & letak (sungsang)

8/20/2019 14. Kelainan Presentasi & Letak (Sungsang)

1/37

KELAINAN PRESENTASI

DAN LETAK

Dr.David Randel Christanto, SpOG., M.Kes

a!. " SM# O$stetri % Gine&olo!i

#K.'NCEN " RS'D (a)ap*ra

(A+AP'RA


2/37

Vaginal Breech

Delivery


3/37


4/37

Lois Jovanovic, MDThe Norbert Freinkel Lecture: Glucose meiatemacrosomia: the over!"e "etus an the "uture# $rograman abstracts o" the %&st 'cienti(c 'essions o" the

)merican Diabetes )ssociation* June ++!+%, +&*$hilael-hia, $ennsylvania# The Norbert Freinkel Lecture, an annual invited event at theScientific Sessions of the American Diabetes Associationsince 1991, is awarded to a speaker selected for outstandincontributions in the field of diabetes and prenanc!" # amhonored to be selected as this !ear$s speaker%1& and toprovide tribute to 'rofessor Freinkel for his role as a mentor,

scientist, and motivator of a eneration of researchers" Thelifetime clinical and laborator! research work of 'rofessorFreinkel was dedicated to the enhancement of ourunderstandin of the metabolic abnormalities ofprenancies complicated b! diabetes" (e was the first tointroduce the concepts of )accelerated starvation) and)facilitated anabolism) in the fastin and fed states durin

prenanc!" #n addition, he modified 'edersen$s h!pothesisof maternal h!perl!cemia as a basic cause of aberrant fetaldevelopment, and viewed prenanc! complicated b!diabetes as a disorder of fuel metabolism" #n fact, he coinedthe term to describe this abnormal metabolic state as )fuel*mediated teratoenesis")


5/37

+bectives

/ncience an

'igni(cance'election

Management– /ntra-artum– Delivery


6/37

Definition

longituinal lie

breech or lo0er e1tremity

-resentingce-halic -ole in the uterine "unus

T!pes"rank! 2e1e hi-s, e1tene knees

com-lete ! 2e1e hi-s, 2e1e

knees

"ootling ! e1tene hi-3s4


7/37

T)pes o ree-h

CompleteFootling Frank


8/37

#ncidence

5 to 67 o" all -regnancies

increases 0ith ecreasinggestational age

– 8 to &7 at 5+ 0eeks

– +9 to 597 at +; 0eeks


9/37

-tiolo! of .reech 'resentation

iio-athic

-rematurity 3hea to trunk

si


10/37

Dianosis maternal -erce-tion o"

movement

Leo-ol=s maneuversF> auscultate above umbilicus

vaginal e1am

ultrasoun

?!ray


11/37

/ecommendations for .reech Deliver!

recommen trial o" labour at 5%

0eeks or 0hen estimate 0eight is+9 to 6 grams

o@er trial o" labour at 5& to 59 0eeksgestation or 0hen estimate 0eight

is &9 to +9 gramso@er caesasean section at 50eeks gestation or 0hen estimate0eight is &9 gramsA

no recommenation "or 0henestimate 0eight is 6 gramsA

* acknowledged lack of evidence for recommendation


12/37

Selection 0riteria for Trial of Labour

"rank or com-lete breech

"etal hea not hy-ere1teneestimate "etal 0eight +9 to6g


13/37

C/LL/)M' B'T +9Methods o va!inal deliver)/. Spontaneo*s $ree-h deliver)

entirel) spontaneo*sl)0itho*t an) tra-tion or 1anip*lation

other than s*pport o the inant

2. Partial $ree-h deliver) 3.Total $ree-h deliver)


14/37

>)NN)> ET )L ++/TAL#TAS +/.#D#TAS

S0 23 1444 1,2 5

'-/6A7#NA 23 1444 2,8 5


15/37

/ND/)'/ '/. (ANIN ESAR2. PSR

3. 4IPEREKSTENSI

5. ADA INDIKASIPART'S LAMA

6. DIS#'NGSI RA4IM

7. INCOMPL OR

#OOTLINGREEC4

8. PRETERM

9. I'GR ERAT

:. RO(

/;. MO<

//. TIDAK ADA

+ANGERPENGALAMAN


16/37

ltrasound Assessment

con(rm lie an ty-e o" breech

assess hea -osition

obtain estimate o" "etal 0eight

assess "or /HGI an congenital

anomalies

assess amniotic 2ui volume

con(rm -lacental locali


17/37

0ontraindications to Trial of Labour

"etal or maternal contrainication

to labour

"ootling breechhy-ere1tension o" the "etal hea

absence o" in"orme consent

absence o" e1-erience maternityhealth care giver


18/37

anaement in Labour

-lanne elivery in hos-italamission in early labour or 0ithIM

a--ro-riate "etal surveillance

e-iural an )IM "or usualinications

immeiate vaginal e1am at IM torule out cor -rola-se

goo -rogress in labour 3 #9 cmha"ter 5 cm4

inuction an augmentation-ermissible


19/37

anaement at Deliver!

e1-erience ne0born resuscitator

-resent

em-ty maternal blaer

maternity attenant 0ith

e1-erience in breech elivery

"orce-s i" available, may be hel-"ul


20/37

Enterin! the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by ! !abbe, "# Niebyl, "$ impson% &'((')


21/37

Des-ent o the ree-h




22/37

Spontaneo*s E=p*lsion



• s-ontaneouse1-ulsion to theumbilicus

• the sacrum shoul

be gently guieanteriorly

• singleton breech

e1traction iscontrainicate

• ' is inicate"or "ailure o"escent or


23/37

(urr! up : ;ait


24/37

Deliver Le!s $) lateral rotation o thi!hs andle=ion o &nees > &eep sa-r*1 anterior



D li f A


25/37

Deliver! of Armsgoo maternal-ushingeliver 0hen 0inging

o" sca-ulae seenrotate arm toanteriors0ee- humerus

across the chest aneliverrotate other armanterior an re-eatto eliver




26/37

Avoid Over>e=tension

Obstetrics - Normal and Problem Pregnancies,2nd Edition



27/37

Delivery o" the hea

• Mauriceau - Smellie - Veit

manoeuvre to deliver the head infexion

• The body should be supported

in a horizontal position


28/37

Deliver) o the head

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by ! !abbe, "# Niebyl, "$ impson% &'((')


29/37

Deliver) o the head

Forceps

assistant elevatingbabe

direct application




30/37

'revention of .reech

consier e1ternal ce-halic version at

5% 0eeks gestation "or eligiblecaniates

success rate 5 ! 87 e-ening on

e1-erience

results in lo0er cesarean section rate


31/37

0onclusions

-ro-er selection o" -atients

thorough e1-lanation an in"orme

consentgoo -rogress in labour 3 #9 cmh a"ter

5 cm4

inuction an augmentation -ermissible

e1-erience attenantsstanar "etal monitoring

assiste elivery ! DN=T $HLL ! stay coolK


32/37

LA.+/ AND D-L#6-/= '/+.L-S

./--0( '/-S-NTAT#+N AT T-/


33/37

./--0( '/-S-NTAT#+N AT T-/

Managementoption

Quality ofevidence

Strength ofrecommendation

References

Version inprenatal period

Evidence for redced breec+ presentation atdelivery and in cesarean section rate wit+ eternalcep+alic version &EC) at term

Ia A 1

.ocolysis is associated wit+ fewer EC failres Ia A 2

Fetal vibroacostic stimlation in medicine fetal position is associated wit+ fewer EC failre

Ia A 2

Need for fetal +eart rate monitoring before and afterEC

III B 3

/pparent safety in women wit+ a previos cesareansection

IIa B

No evidence to spport postral management toencorage spontaneos version

Ia A !

"etal assessment Confirm diagnosis and determine placental side # √

#

Confirm normality as association of breec+ presentation wit+ congenital anomaly

III B $

/ssess fetal attitde-+yperetension of fetal +ead isassociated wit+ spinal cord in0ry dring vaginaldelivery

III B %

&a'or anddelivery

Evidence t+at planned cesarean section for breec+at term as preferred met+od of delivery significantlyredced perinatal mortality and morbidity

Ia A (


34/37

'/-T-/ ./--0( '/-S-NTAT#+N

Management

option

Quality of

evidence

Strength of

recommendatio

n

References

)renatal Evidence t+at eternal cep+alic versionis not sefl in preterm breec+

presentation

Ia A 1

&a'or anddelivery#general

1nfant otcome worse wit+ breec+ presentation t+an verte

III B 2*3

#otine cesarean section wold caseiatrogenic prematrity I' A

)reterm'reech

presenting inla'or

Confirm in labor, inclding vaginaleamination

# √

#

Confirm normality # √

#

Confirm type of breec+ # √

#

No strong evidence of benefit bt probably cesarean section preferred,especially for '-'3 g

III B !#+

For babies less t+an ' g no evidenceof benefit from eit+er mode of delivery

III B +*1,

'/+L+N7-D '/-7NAN0=


35/37

'/+L+N7-D '/-7NAN0=

Managementoption

Quality ofevidence

Strength ofrecommendation

References

)renatal-general

Establis+ accrate gestational age as early as possible

III B 1

4enstral dates overestimate gestation% #otineearly scan of vale in preventing indction for 5postdates6

Ia A 2

7reast stimlation does not redce incidence of postterm pregnancy

Ia A 2

weeping membranes at term redces c+ance of pregnancy going beyond 8' weeks

Ia A !

)renatal- at 1.ee/s

#eevalated for possible risk factors # √

#

#otine indction of labor redce perinatalmortality

Ia A 2

Active management9

Cervical ripening redce risk of failed indction

$abor indction does not increase rate of cesareansection or operative vaginal delivery if cervi madefavorable first

I'

Ia

A

A

2

0pectant management 9

#otine fatal movement conts alone +ave not been s+own to be of vale in redcing perinataldeat+s-bt no

4aternal perception of sond-provoked fetalmovements may be of vale w+ere facilities forfre:ent nonstress testing &N.) are not available

erial N. twice weekly at least +elpfl inmonitoring fetal wellbeing in postterm pregnancies

Fetal acostic stimlation test may be of vale in

t+ose wit+ a nonreactive N.

I'

III

IIa

Ia

A

B

B

B

!

$

%

(


36/37

anaement option

Quality ofevidence

Strength ofrecommenda

tion

'erinatal> at?1 weeks

-@pectant manaement>

Assess1ent o a1nioti- l*id inde= vers*s verti-al po-&etso a1nioti- l*id in-reases o$stetri- intervention

ioph)si-al proile t0i-e 0ee&l) 1a) $e help*l or1onitorin! etal 0ell$ein! $*t is ti1e>-ons*1in!

Co1$ination o ?*st a1nioti- l*id vol*1e and etal

a-o*sti- sti1*lation test 1a) $e a--epta$le'1$ili-al arter) Doppler has not $een sho0n to $e an)

$etter than NST

I'

II'

III

III

A

B

B

B

Labor anddeliver!

Mana!e as hi!h>ris& pre!nan-) # √

I *1$ili-al -ord -o1pression ro1 oli!oh)dra1nions %a1nion*sion is *se*l

Ia A

e vi!ilant or sho*lder d)sto-ia III B


37/37

RINGKASAN

14. kelainan presentasi & letak (sungsang)

Documents