Download pdf - 08 Seksio Sesarea

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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

  • Age >65 years Emergency surgery Malignancy Anemia: hemotocrit 30 kg/m2 Ascites Diabetes mellitus Pulmonary disease, COPD, chronic cough Shock Poor nutrition: albumin
  • 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.


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