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Malang,14Maret 1967
Staf Fetomaternal,Departemen Obstetri &GinekologiFKUI/RSUPNCipto Manukusumo
Pelatih Basic
FasilitatorAdvanced
Labour And
Pelatih/Advanved Trainer
Jaringan Pelatih
AnggotaPOKJAHIV/AIDS&
Pelatih
PesertaInternational
Course
SurgicalSkillPOGI,tahun
2004
RiskManagemen
t(ALARM)
as onaPelatihan
Klinik
Kesehatan
esus asNeonatusPerinasia,
tahun 2004
PMTCTKementerian
Kesehatan
exuaReproductiveHealthand
Right,. ,
2005sekarang
Reproduksi,tahun 2005
sekarang.
sekarang.Indonesia,
tahun 2007sekarang.
Swedia,Pebruari
2009
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dr. Yudianto Budi Saroyo, SpOG
Divisi Fetomaternal
Departemen Obstetri & GinekologiRSUPN dr. Cipto Mangunkusumo/
Fakultas Kedokteran Universitas Indonesia
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Goal 4: Reduce child mortality
Target 4a: Reduce by two thirds the mortality rate among children
un er ve
Goal 5: Improve maternal health
Target 5b: Achieve, by 2015, universal access to reproductive health
Goal 6: Combat HIV/AIDS, malaria and other diseases
Target 6a: Halt and begin to reverse the spread of HIV/AIDS
Target 6b: Achieve, by 2010, universal access to treatment forHIV/AIDS for all those who need it
other major diseases
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Force s & Vacuum E ui mentForce s & Vacuum E ui ment
Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics and
Gynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.
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Syarat
Anatomi
Klasifikasi
e o e ap as an ra s
Dokumentasi
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Syarat
Anatomi
Klasifikasi
e o e ap as an ra s
Dokumentasi
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IndikasiIndikasi Mempercepat Kala Dua
Kala Dua Memanjang
Kasus Khusus :
Ibu lelahIndikasi hipertensi dalam kehamilan, PEB,penyakit jantung, bekas SC
Per alanan Kala Dua tidak
a erna
memuaskan
Gawat janin
Malposisi
Asinklitismus
Vakum saat SCJanin
e a r an an n e ua pa a geme
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Indications for VacuumIndications for Vacuum--
Assisted Vaginal DeliveryAssisted Vaginal Delivery
Prolonged second stage of
labor
In nulliparous women, this is defined as lack of
progress for 3 hours with regional anesthesia or 2ours w ou anes es a.
In multiparous women, it refers to lack of
progress for 2 hours with regional anesthesia or 1
hour without anesthesia.
Nonreassuring fetal testing Suspicion of immediate or potential fetalcompromise (nonreassuring fetal heart rate
pattern, abruption) is an indication for operative
vag na e very w en an expe ous e very can
be readily accomplished.
Elective shortening of the
second sta e of labor
Vacuum can be used to electively shorten the
second sta e of labor if ushin is contraindicated
because of maternal cardiovascular or neurologic
disease.
Maternal exhaustion Largely subjective and not well defined.
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Contraindications for VacuumContraindications for Vacuum--
Absolute Contraindications
Underlying fetal disorder
Fetal bleeding disorders (eg, hemophilia, alloimmune thrombocytopenia)
Fetal demineralizing diseases (eg, osteogenesis imperfecta)
Failure to fulfill all the requirements for operative vaginal delivery
Incomplete dilatation of the cervix
Intact fetal membranes
Unen a ed vertex
Abnormalities of labor Fetal malpresentation (eg, breech, transverse lie, brow, face)
Suspected cephalopelvic disproportion
st mate gestat ona age < wee s or est mate eta we g t < g
Failure to obtain informed consent from the patient
Relative Contraindications Suspected fetal macrosomia (defined as an estimated fetal weight of > 4500 g)
Uncertainty about fetal position
Inadequate anesthesia
Prior scalp sampling or multiple attempts at fetal scalp electrode placement
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KondisiKondisi yang memyang memprediksiprediksi
kesulitan atau kegagalankesulitan atau kegagalan tindakantindakan
Perabaan abdomen :Kepala teraba1/5
ag an presen as se ngg sp na s a a.
Posisi occi ito- osterior.
Molase kepala yang luas dan tebal.
an n esar.
Perjalanan persalinan yang lambat. IMT >30.
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-
55.
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Syarat
Anatomi
Klasifikasi
e o e ap as an ra s
Dokumentasi
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Prerequisites for Forceps orPrerequisites for Forceps or
Engaged fetal vertex
Ruptured membranes
Fully dilated cervix
Assessment of maternal pelvis reveals adequacyfor the estimated fetal wei ht
Adequate maternal analgesia is available Bladder drained
Knowledgeable operator
Willingness to abandon the procedure, if
Informed consent has been obtained
Necessar su ort ersonnel and e ui ment
are present
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Prerequisites for operativePrerequisites for operative
Preparation Essential
Full abdominal
and vaginal
examination
Head is 1/5 palpable per abdomen
Vertex presentation
Cervix is fully dilated and the membranes ruptured
Exact position of the head can be determined so proper placement of
t e nstrument can e ac eve
Pelvis is deemed adequate
Mother Informed consent must be obtained and clear explanation given
Appropriate analgesia is in place, for mid-cavity rotational deliveries this
will usually be a regional block
A pudendal block may be appropriate, particularly in the context ofurgent delivery
Maternal bladder has been emptied recently
Indwell ng catheter should be removed or balloon de lated
Aseptic techniques
Staff Operator must have the knowledge, experience and skills necessary to
use the instruments Adequate facilities and back-up personnel are available
Back-up plan in place in case of failure to deliver
Anticipation of complications that may arise (e.g. shoulder dystocia,
postpartum haemorrhage)
Personnel present who are trained in neonatal resuscitation
SOGC, 2004 & RANZOG 2002
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Prerequisites for OperativePrerequisites for Operative
Maternal Criteria Fetal Criteria Uteroplacental
Criteria
Other Criteria
Adequate analgesia
Patient in the
lithotomy position
Vertex presentation
The fetal head must
be engaged in the
Cervix fully dilated
Membranes ruptured
No placenta previa
An experienced
operator who is fully
acquainted with the
Clinical pelvimetry
must be adequate in
dimension and size
the fetal head must
be known with
certainty The station
instrument
Ability to monitor
fetal well-being
to facilitate an atrau-
matic delivery
Verbal or written
of the fetal head
must be 0/+ 5
The estimated fetal
continuously
The capability to
perform an
documented (ideally
2500-4500 g)
The attitude of the
delivery if required
fetal head and the
presence of caput
succedaneum and/or
-
noted
Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16
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Syarat
Anatomi
Klasifikasi
e o e ap as an ra s
Dokumentasi
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PAP : Promontorium tak teraba CV > panjang jari
pemeriksa -1,5. Bila teraba harus disebutkan ukuran
Linea inominata : semakin sedikit teraba semakin luas
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Diameters of the MaternalDiameters of the Maternal
PelvisPelviseg on o e e v s easuremen en me ers
Brim (Inlet)
AP 11.5
Transverse 13.0
Midpelvis
AP 12.0Transverse 10.5
ut et
AP 12.5
.
AP, anteroposterior.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
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Pintu tengah panggul :
in ing samping se ai nya urus
Spina tajam agar sebagai tempatpu aran pa s a am poros
defleksi kepala
konkaf
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PBP :
Arcus Pubis > 900
Intertuberositas > 8 cm
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StationStation
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The pure types of maternal pelves andThe pure types of maternal pelves and
the conver ence and diver ence of theirthe conver ence and diver ence of their
sidewalls.sidewalls.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
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ntero-poster or o r m
(Obstetric conjugate) 12 cmTransverse of brim 13 cm
Ischial bispinous 10,5 cm
Antero-posterior of outlet 10,5 cmSub-pubic angle 850
de Jong P. Vacuum Delivery Procedures. 3rd ed. Gothenburg: Cascade Publications; 2007
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Bony anatomy, sutures, andBony anatomy, sutures, and
skullskull
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
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Diameters of the fetal head.Diameters of the fetal head.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
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Diameter
(Centimeters)
Suboccipital-Bregmatic 9.5
Submental-Bregmatic
Below chin to center of bregma9.5
-
Point of chin to above posterior fontanelle
14.0
Basal-Vertical
Base of skull to most distant oint of vertex9.0
Occipital-Frontal
Root of nose to occipital protuberance11.5
Bi arietalBetween the two parietal eminences
.
Bitemporal
Greatest distance between two halves of coronal suture8.5
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
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Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Fetal Growth and Development: The McGraw-Hill
Companies; 2010. Available from: www.accessmedicine.com.
Ci f f F l H dCi f f F l H d
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Circumferences of Fetal HeadCircumferences of Fetal Head
Circumferenceeasuremen
(Centimeters)
- Well-flexed vertex
Occipital-Frontal Biparietal 33.0
Deflexed vertex, OP positionMentum-Vertical Biparietal 35.5
row presen a on
OP, occiput posterior.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
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Metoda Stewart untuk menentukanMetoda Stewart untuk menentukan
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
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Syarat
Anatomi
Klasifikasi
e o e ap as an ra s
Dokumentasi
T f P d d Cl ifi ti fVT f P d d Cl ifi ti fV
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Type of Procedure and Classification of Vacuum orType of Procedure and Classification of Vacuum or
Force s Deliver accordin to Station and RotationForce s Deliver accordin to Station and Rotation
Outlet forceps/Vacuum
Scalp is visible at the introitus without separating the labia.
e a s u as reac e e pe v c oor.
Sagittal suture is in the AP diameter or right or left OA or OP position.
Fetal head is out or on the perineum.
Rotation does not exceed 450
Low forceps/Vacuum
Leading point of fetal skull is at station +2 cm and not on the pelvic floor.0
Rotation is >450
.Midforceps/Vacuum
a on s cm pa pa e u e a ea s engage .
Rotation is 450
Rotation is >450
Not included in classification
AP, anteroposterior; OP, occiput posterior. Adapted from American College of Obstetricians and Gynecologists.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and Gynecology: LippincottWilliams & Wilkins; 2008.
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55
. . , .
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Syarat
Anatomi
Klasifikasi
e o e ap as an ra s - a um
Dokumentasi
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..
The original vacuum extractor developed in the 1950s by the Swedish obstetrician Dr. Tage
Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16
, , ,
device.
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Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Forceps Delivery and Vacuum Extraction: The McGraw-Hill Companies; 2010.
Available from: www.accessmedicine.com.
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Desain Man kuk Vakum.Desain Man kuk Vakum.
A: Tipe umum berbentuk lonceng dengan pompa tangan. B: Versi sekali pakai
terbuat dari plastik (versi Bird) dengan perangkat pompa tangan sekaligus penarik.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
: ang u r . : pe se a pa a er en u amur.
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en s u ama perang a
vakum genggam sekali pakai
ini : (A) mangkuk yang lembutyang entur an er entulonceng. (B) mangkuk kaku,yang kokoh dan berbentukseperti jamur mang u .Alat tersebut dapat terbuatdari plastik, polietilen atausilikon. Batang bebas berputarperangkat genggam ini
mencegah torsi (rotasi) darimangkuk dan cederasayat/lecet ke kulit kepalaanin.
Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16
Dua perangkat vakum kiwiDua perangkat vakum kiwi--pompapompa
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Dua perangkat vakum kiwiDua perangkat vakum kiwi--pompapompa
en am dan eran kat en ukuren am dan eran kat en ukur
tekanantekanan..
Berbeda dengan mangkuk dalam B, batang pada mangkuk di A, OmniCup bersifat
fleksibel dan dapat diletakkan mendatar terhadap mangkuk.(From Vacca A:
an oo o acuum e very n s e r c rac ce. on, us ra a, acca
Research Pty. Ltd., 2003.)Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.
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PenempatanPenempatan Mangkuk VakumMangkuk Vakum
Correct placement of the suction cup on the fetal scalp is shown. The suction cupshould be placed symmetrically astride the sagittal suture at the median flexion point
Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16
a so nown as t e pivot point , w ic is cm anterior to t e posterior ontane e or
cm posterior to the anterior fontanelle.
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Pemasangan di atas sutura
-
kecil
Penempatan terhadap KepalaPenempatan terhadap Kepala
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Penempatan terhadap KepalaPenempatan terhadap Kepala
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
ALARM (VACUUM MNEMONIC)ALARM (VACUUM MNEMONIC)
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ALARM (VACUUM MNEMONIC)ALARM (VACUUM MNEMONIC)A ANAESTHESIA
ASSISTANCE
Adequate pain relief
Neonatal support
B BLADDER Bladder empty
u y a e , mem ranes rup ure
D DETERMINE Position, station and pelvic adequacy
Think possible shoulder dystocia
E E UIPMENT Ins ect vacuum cu um tubin and check ressure
F FONTANELLE Position the cup over the posterior fontanelle
Sweep finger around cup to clear maternal tissue
G GENTLE 100 mmHg initially and between contractions
pu w t contract ons on y as contract on eg ns:
o increase pressure to 600 mmHgo prompt mother for good expulsive effort
o traction in axis of birth canal
H HALT (Rule of 3s) no progress with three traction aided contractions
vacum pops-off three times
no significant progress after 30 minutes of assisted vaginal
e very
I INCISION Consider episiotomy if laceration imminent
J JAW Remove vacuum when jaw is reachable or delivery assured
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-
55.
Penempatan MangkukPenempatan Mangkuk
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Penempatan MangkukPenempatan Mangkuk
Placement of the OmniCup with flexible stem at the point of flexion of a fetal head in the
occiput posterior position, which is otherwise difficult to accomplish with the traditional
. . ,
Australia, Vacca Research Pty, Ltd., 2003.)
Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.
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The three other abnormal positions are much less likely to lead to a successful vaginal delivery
and are more associated with fetal trauma.
Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics and
Gynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.
P t M k k & P i iP t M k k & P i i
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Penempatan Mangkuk & PosisiPenempatan Mangkuk & Posisi
Jari OperatorJari Operator
Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics andGynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.
Vacuum extraction with JVacuum extraction with J--shapedshaped
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pp
direction of traction similar to force sdirection of traction similar to force s
delivery.delivery.
Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.
Berbagai Tipe Vakum dengan MangkukBerbagai Tipe Vakum dengan Mangkuk
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dan ukurann adan ukurann aPerangkat Ukuran Bahan Material
Soft Cups
, ,
Kiwi ProCup (Clinical Innovations, Murray, UT) 65 mm Soft plastic
Mityvac MitySoft Bell (Cooper-Surgical, Trumball,
CT)60 mm Soft silicone
Secure Cup (Utah Medical, Midvale, UT) 63 mm Rubber
Silc Cup 50-60 mm Silicone rubber
Soft Touch (Utah Medical) 60 mm Soft polyethylene
en er ouc a e ca mm o s cone
Vac-U-Nate (Utah Medical) 65 mm Soft siliconeRigid Anterior Cups
Flex Cu Utah Medical 60 mm Pol urethane
Kiwi OmniCup (Clinical Innovations) 50 mm Rigid plastic
Malmstrm (Dickinson Healthcare, Hungerford, UK) 40-60 mm Metal
Mityvac M-Style (CooperSurgical) 50 mm Rigid polyethylene
Rigid Posterior Cups
Bird posterior cup 40-60 mm Metal
Kiwi OmniCup (Clinical Innovations) 50 mm Rigid plastic
Greenberg JA. Procedure for vacuum assisted operative vaginal delivery. UpToDate Web site. http://www.uptodate.com/patients/content/topic.do?topicKey=~cWABY9RJfJlwne. Accessed February 3, 2009. In :Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics &
Gynecology. 2009;2(1):1-16
B b i K iT k N tifB b i K iT k N tif
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Berbagai Konversi Tekanan NegatifBerbagai Konversi Tekanan Negatif
VakumVakumk /cm2 kPa mmH in H cm H 0 Ib/in2
0,23 13 100 3,9 134 1,9
0,27 27 200 7,9 268 3,90,41 40 300 11 ,8 402 5,8
0,54 53 400 15,7 536 7,7
, , ,
0,82 80 600 23,6 804 11,6
, ,
1,03 101 760 29,9 1018 14,7
Vacca A. The place of the vacuum extractor in modern obstetric practice. Fetal Med Rev 1990;
2:103. Reprinted from MJ Lucas, The role of vacuum extraction in modern obstetrics [Review],Clinical Obstetrics & Gynecology,Vol. 37, No. 4, pp. 794805, 1994, with permission
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D
(cm)
r =
(1/2 D)
Luas Lingkaran
MangkukTekanan Negatif (kgf/cm2)
, , ,4 2 12,6 7,5 8,8 10,1
5 2,5 19,6 11,8 13,8 15,7, , , ,
Ke a alanVakumKe a alanVakum aturan 3aturan 3
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Ke a alan VakumKe a alan Vakum aturan 3aturan 3
, ,
kemajuan
3 kali lepas: setelah satu kjali gagal, nilai
-
memasang kembali
Setelah 30 menit pemasanan tanpa
Vakum Le asVakum Le as SebabSebab sebabsebab
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Vakum Le asVakum Le as SebabSebab--sebabsebab
Perlen aka an an salah/ enutu an burukmenyebabkan kebocoran vakum
tak dikenali adanya CPD
presentasi OP
Sudut traksi yang kurang tepat menyebabkan
ro e an
Terkenanya jaringan lunak ibu pada introitus
Fetal scalp injuries associated withFetal scalp injuries associated with
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eta sca p ju es assoc ated w teta sca p ju es assoc ated w t
vacuum ex rac onvacuum ex rac onCa ut succedaneum scal edema isa normal finding, but may beexaggerated by vacuum-assisteddelivery. Use of a vacuum device can
refers to bleeding into the fetal scalpthat is located in the subperiostealspace and, as such, is contained
a subgaleal hematoma (bleeding into
the fetal scalp which is subaponeuroticand therefore not confined to a single
.complication is an intracranialhemorrhage, which includessubarachnoid, subdural,
,hemorrhage.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.Ali UA, Norwitz ER. Vacuum-Assisted Vaginal Delivery. Reviews In Obstetrics & Gynecology. 2009;2(1):1-16
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Syarat Anatomi
Klasifikasi e o e ap as an ra s - orsep
Dokumentasi
Indications for forceps deliveryIndications for forceps delivery
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Indications for forceps deliveryIndications for forceps delivery
Relative indications (vacuum extraction or
caesarean section may be an alternative
o tion Delay or maternal exhaustion in the second stage of
Dense epidural block with diminished urge to push
Rotational instrumental delivery for malpositioned
fetus Suspected fetal distress
Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. 2004;328:1302-5.
Indications for forceps deliveryIndications for forceps delivery
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Indications for forceps deliveryIndications for forceps delivery
Specific indications (forceps delivery is usually superior
circumstances)
Delivery of the head at assisted breech delivery (singleton ortwin
Assisted delivery of preterm infant ( < 34 weeks gestation)
Assisted delivery with a face presentation
thrombocytopenia in fetus
Instrumental delivery for maternal medical conditions thatprec u e pus ng
Instrumental delivery under general anaesthesia
Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. 2004;328:1302-5.
Anatomi ForseAnatomi Forse
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Anatomi ForseAnatomi Forse
Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics andGynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.
Forceps DeliveryForceps Delivery--Instrument TypeInstrument Type
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p yp y ypyp
Procedure InstrumentOutlet delivery Classical forceps
mpson or ot type
Laufe divergent forceps
Low-forceps delivery45-degree rotation Classical forceps
Kielland
Tucker-Mclane
Bailey-Williamson
Hawks-Dennen
Breech delivery Piper
a ey- amsonCesarean section Vectis blade-Murless type
Classical forceps
Laufe forceps
Gilstrap-III LC, Cunningham FG, VanDorsten JP. Forceps Delivery. In: III LCG, Cunningham FG, VanDorsten JP, editors. Operative Obstetrics. 2nd ed. New
York: The McGraw-Hill; 2002. p. 89-122.
Classification of forcepsClassification of forceps
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pp
Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.
Berba aiTi e Forse CunamBerba aiTi e Forse Cunam
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Berba ai Ti e Forse CunamBerba ai Ti e Forse Cunam
A: Laufe divergent
forceps. B: Salinas
forceps. C: Elliot
forceps. D: Simpsonorceps. : ie an
forceps. F: Barton
forceps with a traction
ar. : per a er-
coming head forceps.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
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Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. 2004;328:1302-5.
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T es of locksT es of locks
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T es of locksT es of locks
A: Sliding lock of the Kielland
.
many types of forceps. C:
French lock of the Tarnier
force s historical interestonly). D: Lock/handle of the
Salinas forceps. E: Pivot lock
of the Laufe diver ent
forceps.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins; 2008.
ALARM (FORCEPS MNEMONIC)ALARM (FORCEPS MNEMONIC)
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ASSISTANCE
equate pa n re e
Neonatal supportB BLADDER Bladder empty
D DETERMINE Position, station and pelvic adequacy
Think possible shoulder dystocia
E EQUIPMENTF FORCEPS Phantom application
Left blade, left hand, maternal left side, pencil grip and
vertical insertion, with right thumb directing blade
, , ,
and vertical insertion with left thumb directing blade
Lock blade and support check application Posterior fontanelle 1 cm above plane of shanks
Fenestration no > fingerbreadth between it and scalp
Sagittal suture perpendicular to plane or shranks with
occipital sutures 1 cm above respective blades
TRACTION
H HANDLE
ELEVATED
Traction in axis of birth canal
Do not elevate handle too early
I INCISION Consider episiotomy
J JAW Remove forceps when jaw is reachable or delivery assuredEdozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
Abdominal palpation and the determination of theAbdominal palpation and the determination of the
amount of the fetal head palpable above the pelvicamount of the fetal head palpable above the pelvic
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r m.r m.
Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
Forsep RendahForsep Rendah
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pp
Arah tarikan : pertama ke arah belakang sehingga dengan simfisis sebagai
menyesuaikan ke arah depan.
Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.
Langkah Pemasangan ForsepLangkah Pemasangan Forsep
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Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia: Churchill Livingstone Elsevier; 2007.
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Pitkin J, Peattie AB, Magowan BA. Operative delivery. In: Pitkin J, Peattie AB, Magowan BA, editors. Obstetrics andGynecology- An Illustrated Colour Text. Edinburgh: Elsevier Science; 2003. p. 54-7.
Pemasan an Forse an BenarPemasan an Forse an Benar
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1.Ubun-ubun kecil di tengah antara batang forseps dan satu jari di atasbidang datar dari tangkai forseps dengan sutura lambdoid satu jari di atas
2.Masuknya tangkai harus nyaris tak terasa dan tidak lebih dari seujung jaridapat diselipkan antara tangkai forseps dengan kepala bayi
From O'Brien WF, Cefalo RC: Labor and delivery. In Gabbe SG, Niebyl JR, Simpson JL [eds]: Obstetrics: Normal and Problem Pregnancies, 3rd ed. New
York, Churchill Livingstone, 1996, p 377, with permission. In :Nielsen PE, Galan HL, Kilpatrick S, Garrison E. Operative Vaginal Delivery. Philadelphia:
Churchill Livingstone Elsevier; 2007.
3.Sutura sagitalis tegak lurus terhadap bidang datar dari tangkai forseps
Application of forceps to fetussApplication of forceps to fetuss
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Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. 2004;328:1302-5.
Application of forceps to fetuss head in occipito-anterior position followed by controlled
traction and assisted delivery of head
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Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
Force s & The Pelvic AxisForce s & The Pelvic Axis
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e cav ty o t e
true pelvis is
compara e to anobliquely truncated,
ent cy n er w t ts
greatest heightpos er or y.
Note the curvature
of the pelvic axis, thecurve of Caruso
Gilstrap-III LC, Cunningham FG, VanDorsten JP. Forceps Delivery. In: III LCG, Cunningham FG, VanDorsten JP, editors. Operative Obstetrics. 2nd ed. NewYork: The McGraw-Hill; 2002. p. 89-122.
Methods of hand placement and physicianMethods of hand placement and physician
. .
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Bofill JA, Jr. JNM. Operative Vaginal Delivery. In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE, editors. Danforth's Obstetrics andGynecology: Lippincott Williams & Wilkins; 2008.
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Syarat Anatomi
Klasifikasi e o e ap as an ra s
Dokumentasi
Forceps versus Vacuum Maternal
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neonatus yang bermakna
Lebih sedikit membutuhkan anestasire ional/umum
Lebih sedikit trauma terhadapvag na per neum u
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perdarahan subaponeurotik (subgaleal)
Perdarahan retina pada neonatus tidak jelas bermakna secara klinis
Cenderung gagal, perlu alternatif lain
Pasien harus dibuat waspada terhadap
resiko-resiko ini
Effect of Method of Delivery onEffect of Method of Delivery on
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Hemorrhage (ICH)Hemorrhage (ICH)
Delivery ICH
Vacuum and forceps 1:280
Forceps 1:664
Vacuum 1:860
Cesarean with labor 1:907
Spontaneous 1:1900
Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Forceps Delivery and Vacuum Extraction: The McGraw-Hill Companies; 2010.Available from: www.accessmedicine.com.
Intelligence Test Scores at Age 17 for SubjectsIntelligence Test Scores at Age 17 for Subjects
orn n erusa em e ween anorn n erusa em e ween an
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Type of Delivery
Mean Intelligence
Score (SE)
na us e us e
Spontaneous (n = 29,136) 105.4 (0.1) 105.7 (0.1)
orceps n = . . . .
Vacuum extraction (n = 1207) 109.6 (0.5) 105.9 (0.4)esarean e very n . . . .
SE = standard error. aAdjusted by multiple regression for confounding effects of sex, birthweight, ethnic
origin, birth order, maternal age, and paternal and maternal education and social class.
.
Long-term effects of vacuum and forceps deliveries, pp. 15831585, Copyright 1991, with permission from
Elsevier.
Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Forceps Delivery and Vacuum Extraction: The McGraw-Hill Companies; 2010.Available from: www.accessmedicine.com.
Neonatal and maternal morbidity by mode ofNeonatal and maternal morbidity by mode of
delivery in New Jersey, 1989delivery in New Jersey, 1989--93.93.
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Unassisted
(n=327 373)
Forceps
(n=26 491)
Vacuum
(n=19 120)
Vacuum plusforceps
(n=1889)
Neonatal morbidity
Cephalohaematoma* 5457 (166,7) 1681 (634,6) 2135 (1116,6) 257 (1360,5)
Facial nerve injury 78 (2,4) 98 (37,0) 10 (5,2) 10 (52,9)
Intracranial haemorrha e 31 16 2Adjusted odds ratio (95%
CI)
122 (3,7)
0,29 (0,20 to 0,41)
45 (17,0)
1
0,96 (0,62 to
1,52)
5 (26,5)
1,35 (0,53 to 3,42)
Shoulder dystocia
Ad usted odds ratio 95% 1464 44 7 145 54 7
216 (113,0)
2 00 1 62 to 12 63 5
CI) 0,71 (0,59 to 0,85) 1
2,48) 1,10 (0,59 to 2,03)
Feeding difficultyAdjusted odds ratio (95%
CI
763 (23,3)
0 89 0 69 to 1 15
68 (25,7)
1
57 (29,8)1,15 (0,80 to
1 64
6 (31,8)
1 23 0 53 to 2 84
Mechanical ventilation
Adjusted odds ratio (95%
CI)
768 (23,5)
0,84 (0,66 to 1,06)
83 (31,3)
1
77 (40,3)
1,27 (0,92 to
1,74)
14 (74,1)
2,22 (1,24 to 3,97)
Adjusted odds ratio (95%
CI)
597 (18,2)
0,87 (0,65 to 1,18)
51 (19,3)
1
,
0,78 (0,50 to
1,24)
6 (31,8)
1,65 (0,71 to 3,86)
Maternal morbidity
Adjusted odds ratio (95%
CI)
12 359 (377,5)
0,39 (0,38 to 0,41)
3316 (1251,7)
1
,
0,78 (0,73 to
0,83)
295 (1561,7)
1,21 (1,06 to 1,38)
Fourth degree perinealDemissie K, Rhoads GG, Smulian JC, Balasubramanian BA, Gandhi K, Joseph KS, et al. Operative vaginal delivery and neonatal and infant adverseoutcomes: population based retrospective analysis. BMJ. 2004;329:1-6.
Advantages and disadvantages of forcepsAdvantages and disadvantages of forceps
delivery compared with vacuum extractiondelivery compared with vacuum extraction
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and emergency caesarean sectionand emergency caesarean sectionForceps delivery
Advantages Disadvantages
extraction in distress; lower failure rate;
reduced need for sequential use
analgesia needed; greater
maternal perineal trauma;
cephalohaematoma and retinal
haemorrhage
nerve palsy more common
mergency
caesarean
section
a or o s e r c aemorr age
and admission to neonatal
intensive care less common;
rauma o a y more
likely; perineal trauma,
dyspareunia, and urinary
shorter hospital stay; fewerreadmissions; subsequent
s ontaneous va inal deliver
incontinence morecommon
Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. BMJ. 2004;328:1302-5.
more likely
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Syarat Anatomi
Klasifikasi e o e ap as an ra s
Dokumentasi
INDICATIONS FOR ABANDONMENTINDICATIONS FOR ABANDONMENT
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.The attempt at instrumental vaginal
delivery should be abandoned if: there is difficulty in applying the
instrument; there is no descent with each pull; delivery is not imminent following
three pulls of a correctly appliedinstrument;
a reasona e me m nu es,depending on the local protocol) has elapsed
.
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
Examples of error in instrumentalExamples of error in instrumental
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Type of error Description Possible
consequence
Safe practice
A: Action
Operation omitted Abdominal palpation not
done
Level of
presenting part
Use of
proforma/checklistmisjudged
Operation mistimed Rotation done during a
contraction
Cervical spine
injury to the
Rotate only when
uterus is relaxed
e us
Operation too long or
too short
Prolonged traction Intracranial
injury
Stick to time limits
and number of pullsO eration in wron Traction directed forwards Third de ree Mind axis of traction
direction and upwards too soon; this
causes premature extension
of the head as a result of
perineal tear
w c a argercircumference of the head
emerges at the introitus
O eration too much Continuous traction Com ression of Onl a l traction
applied fetal head during a contraction
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
Examples of error in instrumentalExamples of error in instrumental
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Type of error Description Possible
consequence
Safe practice
B: Information
retrieval
Information not No assessment Prophylaxis not Incorporate this
thromboprophylaxis documentation proforma
History of diabetes
disre arded
Shoulder dystocia
not antici ated
Identify background risk
factors before offerin
instrumental delivery
Wrong informationretrieved
Mistaken head levelor position
Misapplication ofinstrument; trauma
Double check
n ng e cerv x s
fully dilated when it is
not
erv ca ear
Incom lete Failure to assess Traumatic deliver Ado t s stematic
information retrieved moulding brain injury approach to assessment
Omission of
equipment check
Delay in delivery;
stress and
mpa rment o
cognition
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
Examples of error in instrumentalExamples of error in instrumental
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Type of error Description Possible
consequence
Safe practice
C: Procedural checks
Check omitted or not
properly done
Failure to ensure cup
does not catch tissue
Training
Vaginal laceration
Check for proper
application of forceps
Trauma to babys
face and eye
Understand reason for
check
no one as escr e
in text
No check for descentwith ull
Undue tractiona lied
Beware of confirmationbias
PR not done at end of
procedure
Third degree tear
missed
Include VE, PR, swab
check in documentation
VE not done at end of Retained swab in
proce ure vag naSwabs not counted
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
Examples of error in instrumentalExamples of error in instrumental
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Type of error Description Possible consequence Safe practice
D: Communication
Failure to
communicate
With woman Valid consent not obtained Verbal and eye
contact; empathy
With midwife Patient iven conflictin Preo erativeinformation briefing
With senior colleague Required supervision not
provided
anaes e s na equa e ana ges a eam wor
With paediatrician Neonatal resuscitationdelayed
E: Selection (choosing
from a number of
options)
type ventouse
Ill-advised sequential
instrumentation
Neonatal handicap
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
Examples of error in instrumentalExamples of error in instrumental
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Type of error Description Possible
consequence
Safe practice
F: Cognition
Failure to anticipate Failure to anticipate
PPH in prolonged
Massive
haemorrhage
Have Syntocinon infusion
ready at delivery
labour
Failure to ask the
right
No descent despite
traction: is position
Trauma Situational awareness
ques ons correc y
determined? Is pulling
in the right direction?Force s have less Trauma Situational awareness
than secure grip of
head: is there
undiagnosed OP? Is
orceps app e overbabys face?
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
DOCUMENTATIONDOCUMENTATION
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indication for intervention; consent;
fifths palpable (abdominal examination);
position and station of the fetal head (vaginal examination);
de ree of mouldin and ca ut adequacy of maternal pelvis;
fetal heart rate;
assessmen o u er ne con rac ons;
ease of application of instrument; number of pulls;
number of detachments;
duration of instrumentation; condition of baby;
assessment of va ina and erineum after deliver
findings on rectal examination after delivery;
umbilical cord pH;
,
Edozien LC. Towards safe practice in instrumental vaginal delivery. Best Practice & Research Clinical Obstetrics and Gynaecology. 2007;21(4):639-55.
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setiap kasus
o umentasi ini arus memi i ipenjelasan terhadap intervensi operasiyang telah dilakukan
Termasuk ambaran tentan carapelaksanaan tehnik operasi dan indikasi-indikasin a
Kebutuhan untuk Intervensi harus:
convincin com ellin consented tocharted
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TERIMA KASIHTERIMA KASIH