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.