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ALARM - INDONESIA
DENPASAR, AGUSTUS 2014
SPECIFIC
HEART
ATTITUDE
PERSONALITY
EXPERIENCES
Caesarean
Mitos : J. caesar
dilahirkan dari ibu
Aeralius
The extraction of Asclepius from the abdomen of his mother Coronis by his father Apollo. Woodcut from the 1549
edition of Alessandro Beneditti's De Re
Medica.
J. Caesar melakukan
invasi ke Inggeris,
Ibu merestuinya
One of the earliest printed illustrations of Cesarean section. Purportedly the birth of Julius Caesar. A live infant being surgically removed from a dead woman. From Suetonius' Lives of the Twelve Caesars, 1506 woodcut.
Seksio dilakukan
pada ibu yang
sekarat/meninggal
Successful Cesarean section performed by indigenous healers in Kahura, Uganda. As
observed by R. W. Felkin in 1879.
Tindakan merupakan upaya
berdasar ilmiah yang lebih
menguntungkan pasien dan
kerugian yang kecil
.
.
Belanda dengan
angka seksio yang
rendah mempunyai
angka kematian ibu
dan perinatal yang
rendah di dunia
Dikutip dari: E.J. Quilligan, 2001
Dikutip dari: E.J. Quilligan, 2001
Community
hospitals
Deliveries,
N
Caesarean
sections, n
(%)
Maternal mortality
n n/1000 CS
Sweden 19511980 2 198 846 82 901 (3,8) 103 1,2Netherlands 19831992 1 872 586 108 587 (5,8) 57 0,5United States 20002006 1 461 270 458 097 (31,0) 58 0,01
Distosia
HAP: plasenta previa & solusio
Gawat Janin
Letak lintang
Pernah seksio
Sungsang
Kembar
Location Caesarea
n section,
N
Maternal
mortality, n(%)
Europe
1798 73 42 57
1844 338 210 62
Britain
1798 17 15 88
1841 79 57 72
1878 100 56 56
United States
1878 100 56 56
Years
Caesarean
sections
N
Maternal
mortality
n
n/1000 CS
18911895 83 23 277
18961900 91 14 153
19011905 369 50 135
19061910 711 58 81
Community
hospitals
Deliveries,
N
Caesarean
sections, n
(%)
Maternal mortality
n n/1000 CS
1926 33480 154 (0,45) 20 130
1930 33988 203 (0,6) 9 44
Selected
obstetric
units
192337
New York20127 912 (4,5) 27 30
193749
Chicago56 650 2871 (5,1) 12 4
Vaginal Delivery Cesarean Delivery
Mortality: 1in 8,000 Mortality: 1in 2,000
Morbidity Morbidity
Urinary incontinence. Endometritis/febrile morbidity
Rectal incontinence Longer recovery, wound infection, wound
dehiscence
Hemorrhage: uterine atony, inversion,
rupture
Operative injury, ureteral, bladder, GI
injury, hemorrhage
Deep venous thrombosis Pelvic infection/abscess/hematoma
Subjectively decreased pelvic tone Deep venous thrombosis/pelvic vein
thrombosis
Risk of emergency cesarean delivery in
labor Delayed breastfeeding/holding neonate
Rectal or perineal injury/laceration Urinary tract infection
Birth canal laceration Ileus
Secundines Formation of adhesions
Endo/parametritis Rehospitalization
Dyspareunia Long-term complications:
Placenta previa Placenta accreta/increta/percreta Abruptio placentae Endometritis/adenomyosis Scar rupture Infertility
Vaginal Delivery Cesarean Delivery
Mortality: 1-3 in 4,000 Mortality: 1in 1,000
Common Morbidity: Common Morbidity:
Shoulder dystocia Transient mild respiratory acidosis
Intrauterine hypoxia. Lacerations: face, buttocks, extremities
Fracture of clavicle, long bones, or skull Fracture of clavicle, long bones, or skull
Intracranial hemorrhage 1 in 2,000 Intracranial hemorrhage 1 in 2,000
Facial nerve injury* 1 in 3,000 Facial nerve injury 1 in 2,000
Brachial plexus injury* 1 in 1,300 Brachial plexus injury 1 in 2,400
Convulsions* 1in 1,560 Convulsions 1 in 1,160
CNS depression* 1 in 3,230 CNS depression 1 in 1,500
Feeding difficulty* 1 in 150 Feeding difficulty 1 in 90
Mechanical ventilation* 1in 390 Mechanical ventilation 1 in 140
Persistent pulmonary hypertension* 1 in
1,240
Persistent pulmonary hypertension 1 in
270
Transient tachypnea of newborn* 1 in 90 Transient tachypnea of newborn 1 in 30
Respiratory distress syndrome* 1 in 640 Respiratory distress syndrome 1 in 470
Long-term increased risk of
unexplained stillborn
Difference statistically significant p 0.05.
CONSENT for
Caesarean section
Tilt table
Catheterise
Prepare for skin to skin contact
Td
Midline
Enables access
To upper uterus
Pfannenstiel
Surgical dissection
Cohen
Tear inner tissues
(less blood loss)
Because these lines are predominantly
horizontal in the abdomen, transverse
incisions generate less tension in the
skin.
(A) "Low" Pfannenstiel: the skin incision is placed lower for cosmetic reasons. The subcutaneous tissues are dissected to allow standard placement of rectus sheath incision. (B) Fascia is separated from rectus muscle superiorly and inferiorly. (C) The rectus muscle is separated in the midline and the peritoneum is incised longitudinally. (D) Sutures may be placed in the rectus muscle to close a rectus diastasis. (E) Sheath is closed with continuous suture. Skin is approximated with a subcuticular suture.
Surgical bleeding
m.Obliqus ext
Luka operasi
sebelumnya
Well healed and cosmetic: ? re-use
Tethered or ugly: excise
Hypertrophic: excise
Keloid:
marginal incisions to excise old keloid
but leave edge of old scar, then steroid
injection topically or post-operative
radiotherapy
Luka bekas
0perasi
Accessibility
Extensibility
Preservation of function
Security
Need for rapid entry
Certainty of the diagnosis
Body habitus
Location of previous scars
Potential for significant bleeding
Cosmetic outcome
Vertical classical
Fibroids / Placenta
praevia accreta
De Lee
Deficient lower
segment
Transverse lower
Segment
Indikasi
BMI
LETAK LINTANG
ESTETIK?
Check and Correct uterine rotation
Ensure good exposure (reflect bladder and clear angles)
Assess lower segment and confirm appropriate incision
Correct uterine rotation
Ensure good exposure (reflect bladder and clear angles)
Assess lower segment and confirm appropriate incision
Correct dextro-rotation
Stabilise the lie: longitudinal plain (and
dont let go), especially with: placenta praevia
fibroids
transverse lie
Fundal pressure and follow it down
Make sure
someone
calls the
Neonat-
ologist
Menggunakan
forceps/vacuum
Tehnik
Pembebasan fascia
inferior
Evidence category IA - Well designed studies Cancel elective surgery if the patient has an
infection at or remote from the surgical site Achieve maximal subcutaneous concentration of
perioperative antibiotics Maintain prophylactic antibiotics for only a few
hours after closing incisions For high-risk cesarean, administer the
prophylactic antimicrobial immediately after the umbilical cord is clamped
If it is necessary to remove hair, use clippers, not shaving, immediately before operation
Adapted from the Centers for Disease Control Guidelines for Prevention of Surgical Site Infection
(www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html).
Time of
administration
*
Percent
with SSI
Odds
ratio
95
percent
CI
Early 3.8 4.3 1.8-10.4
Preoperative 0.6 1.0 -
Perioperative 1.4 2.1 0.6-7.4
Postoperative 3.3 5.8 2.4-13.8
Timing of planned caesarean
section
immediate threat to the life of the woman or fetus
maternal or fetal compromise which is not immediately life-threatening
no maternal or fetal compromise but needs early delivery
delivery timed to suit woman or staff Peri mortem
Death to
Delivery (min). Number of Patients Percent
0-5 42 (normal infants) 70
6-107 (normal infants) 1 (mild
neurologic sequelae) 13
11-156 (normal infants) 1 (severe
neurologic sequelae) 12
16-201 (severe neurologic
sequelae) 1,7
21+ 2 (severe neurologic
sequelae) 3,3
Total 60 100Estimated time from death of the mother until delivery (cases from 1900 to 1985).
From Katz VL, Dotters DJ, Droegmueller W: Perimortem cesarean delivery. Obstet
Gynecol. 1986. 68:571576; with permission.
Vern Katz; Keith Balderstone;
Perimortem Cesarean Delivery: Were
our assumption Correct?, American
Journal Obs and Gyne,
2005,192:1916-21
.
Maternal apnea associated with rapid declines in PaO2 and arterial pH
Fetus of an apnoeic and a systolic mother has 2 minutes of oxygen reserve
After 4 minutes without restoration of circulation, dramatic action must occur
Evidence from literature and review of maternal and fetal physiology suggests that a caesarean delivery should begin within four minutes of cardiac arrest and delivery be accomplished by five minutes.
Pregnant women develop anoxia faster than non-pregnant women and can suffer irreversible brain damage within four to six minutes after cardiac arrest.
When a mother in the second half of her pregnancy suffers a cardiac arrest, immediate resuscitation should commence.
Should immediate resuscitation fail, every attempt should be made to start the caesarean section by four minutes and deliver the infant by five minutes.
CPR must be continued throughout the caesarean section and afterwards, as this increases the chances of a successful neonatal and maternal outcome
Class IIb, LOE C
Wear double gloves for CS for women are HIV-positive.
Use a transverse lower abdominal incision (Joel-Cohen incision).
When there is a well formed lower uterine segment use blunt extension of the uterine incision.
Use oxytocin 5 IU by slow intravenous injection.
Remove the placenta using controlled cord traction.
Undertake intraperitoneal repair of the uterus at CS.
Suture the uterine incision with two layers.
If a midline abdominal incision is used, use mass closure with slowly absorbable continuous sutures.
Perform umbilical artery pH after all CS for suspected fetal compromise.
Accommodate womens preferences for the birth (such as music playing in theatre) where possible.
Only use forceps if there is difficulty delivering the babys head.
Do not exteriorise the uterus.
Do not manually remove the placenta.
Do not use separate surgical knives to incise the skin and the deeper tissues.
Do not suture the visceral or the parietal peritoneum.
Do not routinely close the subcutaneous tissue space unless the woman has more than 2 cm subcutaneous fat.
Do not use superficial wound drains.
Material
Technique
Jangan mengakibatkan nyeri kronik.
Hemostatik
Approximasi
Simetric
Tension
KWALITAS
KONTRAKSI
PERIKSA
TUBA/OV
Dasar penetapan tarifnya bagaimana!
Adakah pembedaan tarif berdasarkan indikasi ?
Adakah perbedaan tarif karena kelas ruang rawat ?
Adakah perbedaan tarif karena adanya tindakan / prosedur tambahan misalnya pembenahan luka operasi berulang/keloid atau tubektomi
Pasien tiba di RB jam 09.00 pasien rujukan puskesmas G2P1001dengan inpartu, anak pertama di E.Vakum di Rs 2 tahun lalu.
Diputuskan rencana partus P/V, pembukaan 3 cm diobservasi dalam dua jam masuk fase aktip , kontraksi diperbaiki dengan augmentasi oksitosin prosedur biasa
Jam 18 00 pembukaan lengkap , terpantau mekonium dan fetal distress
Dilakukan SC jam 19.00 , lahir anak laki2, 4200 gr , A/S 4/6 resusitasi.setelah bayi lahir kontraksiuterus tidak baik , atonia uteri diupayakan perbaikan , masalah bisa diatasi,operasi selesai dalam45 menit.
Post operatip tranfusi , pasien pulang hari ke enam.
AUDIT MEDIK
it is easy to be a cesarean-surgeon,
but not for a good obstetrician
(Mandruzzato GP. The fetus as a patient. Barcelona, 2003).
Terima kasih
Moving the mother to an operating theatre (e.g. from a labour room or accident and emergency department) is not necessary.
Diathermy will not be needed initially, as there is little blood loss if no cardiac output.
If the mother is successfully resuscitated, she can be moved to theatre to complete the operation.