MEET THE EXPERT

PADANG Maret 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

Caesarean
Community Deliveries,
sections, n
hospitals
N
(%)
Sweden 1951
1980
2 198 846
82 901 (3,8)
Netherlands
19831992
1 872 586
108 587 (5,8)
United States
20002006
1 461 270 458 097 (31,0)

Maternal mortality
n

n/1000 CS

103

1,2

57

0,5

58

0,01

 Distosia

HAP: plasenta
Gawat

Janin
Letak lintang
Pernah seksio
Sungsang
Kembar

previa & solusio

Location
Europe
1798
1844
Britain
1798
1841
1878
United States
1878

Caesarea
Maternal
n section, mortality, n
N

(%)

73
338

42
210

57
62

17
79
100

15
57
56

88
72
56

100

56

56

Years
18911895
18961900
19011905
19061910

Caesarean Maternal
sections
mortality
N
n
83
23
91
14
369
50
711
58

n/1000 CS
277
153
135
81

Caesarean
Community Deliveries,
sections, n
hospitals
N
(%)
1926
33480
154 (0,45)
1930
33988
203 (0,6)
Selected
obstetric
units
192337
20127
912 (4,5)
New York
193749
56 650
2871 (5,1)
Chicago

Maternal mortality
n

n/1000 CS

20
9

130
44

27

30

12

Vaginal Delivery
Mortality: 1in 8,000
Morbidity
Urinary incontinence.
Rectal incontinence

Hemorrhage: uterine atony, inversion,

rupture
Deep venous thrombosis
Subjectively decreased pelvic tone
Risk of emergency cesarean delivery in
labor
Rectal or perineal injury/laceration
Birth canal laceration
Secundines
Endo/parametritis
Dyspareunia

Cesarean Delivery
Mortality: 1in 2,000
Morbidity
Endometritis/febrile morbidity
Longer recovery, wound infection, wound
dehiscence
Operative injury, ureteral, bladder, GI
injury, hemorrhage
Pelvic infection/abscess/hematoma
Deep venous thrombosis/pelvic vein
thrombosis
Delayed breastfeeding/holding neonate
Urinary tract infection
Ileus
Formation of adhesions
Rehospitalization
Long-term complications:
Placenta previa
Placenta accreta/increta/percreta
Abruptio placentae
Endometritis/adenomyosis
Scar rupture

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 Persistent pulmonary hypertension 1 in
1,240
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

Catheterise

Tilt table
Prepare for skin to skin contact

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.

Surgical bleeding
m.Obliqus ext
Luka operasi
sebelumnya

(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.

 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

 Accessibility
Extensibility
Preservation
Security

of function

 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
Indikasi
BMI
LETAK LINTANG
ESTETIK?

Transverse lower
Segment

De Lee
Deficient lower
segment

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

Menggunakan
forceps/vacuum
Tehnik
Pembebasan fascia
inferior

Make sure
someone
calls the
Neonatologist

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
Percent
administration
with SSI
*
Early
3.8
Preoperative
0.6
Perioperative
1.4
Postoperative
3.3

Odds
ratio
4.3
1.0
2.1
5.8

95
percent
CI
1.8-10.4
0.6-7.4
2.4-13.8

Age >65 years

Emergency surgery
Malignancy
DEHISENSI
Anemia: hemotocrit <30 percent
Obesity: body mass index >30 kg/m2
Ascites
Diabetes mellitus
Pulmonary disease, COPD, chronic cough
Shock
Poor nutrition: albumin <3.5 g/dL
Infection
Immunosuppressive therapy, glucocorticoids, antineoplastic
agents
Jaundice
Male gender

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

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

AUDIT MEDIK

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 kontraksi
uterus tidak baik , atonia uteri diupayakan perbaikan , masalah bisa diatasi,operasi selesai dalam
45 menit.
Post operatip tranfusi , pasien pulang hari ke enam.

 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

Death to
Number of Patients
Percent
Delivery (min).
0-5
42 (normal infants)
70
7 (normal infants) 1 (mild
6-10
13
neurologic sequelae)
6 (normal infants) 1 (severe
11-15
12
neurologic sequelae)
1 (severe neurologic
16-20
1,7
sequelae)
2 (severe neurologic
21+
3,3
sequelae)
Total
60
100
Estimated time from death of the mother until delivery (cases from 1900 to
1985).
From Katz VL, Dotters DJ, Droegmueller W: Perimortem cesarean delivery. Obstet

Vern Katz; Keith Balderstone;

Perimortem Cesarean Delivery: Were
our assumption Correct?, American
Journal Obs and Gyne,
2005,192:1916-21

Class IIb, LOE C

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

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.