history, development and clinical implication

CAESAREAN SECTION

Prof. dr. Mgs. Usman Said, SpOG(K)

History
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.

History
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.

Developing country
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.

 Embriotomi

Craniotomy. Perforation of the skull, removal of cranial contents, and extraction of the collapsed skull.

Contraindication
Fetal malformation < 28 week pregnancy DIC

Indication
PHILOSOPHY : THE PROCEDURE SHOULD BE ON SCIENTIFIC BASE , FOR THE SAKE/BENEFIT OF THE PATIENT AND WITH LEAST BURDEN.

Risk

Risk of maternal death due to CS

Trend of rising CS rate

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

Indication of CS by country

Indications
Dystocia
Placenta previa & abruptio Fetal distress

Shoulder pres.
Prev. CS Breech

Triplets++

Dystocia

Antepartum hemorrhage
Indikator plasenta

previa USG pada kehamilan > 37 mgg

Dikutip dari: Cuningham dkk, 2001

Dystocia
The use of PARTOGRAM CPD head or abdominal

circumference of >35 cm; Contracted pelvis (Ro or CT) incidence of 1% Malpresentation - posterior occiput Malposisi

Vasa Uterina
Risk of laceration U incision is the

best avoiding the vessels Hemostatic stitch perpendicular to the vessels

Dikutip dari: Cuningham dkk, 2001

Opening the low segment

Lebih baik dengan

cara avue : Gunting arah keatas ! Bentuk U Hindari pelebaran tumpul mencapai vasa uterina

Dikutip dari: Cuningham dkk, 2001

Dikutip dari: Cuningham dkk, 2001

Fetal Hypoxia
Severe Preeclampsia

FDJP /Biophysical profile < 6

CTG : Severe deceleration, non reactive Thick meconium

Placental Insufficiency : Postterm > 42 mgg

Prolaps t.pusat READY FOR RESCUCITATION

Complications
PROBLEM PREVENTION Uincision Hemostatic stitches Stitches, tampon forsep, vacuum,

laceration
hematoma Bleeding from LS Delivery of infant placenta di depan

extraction insisi longitudinal rdh

Complication
Robekan Hematoma Perdarahan dari

insersi Atonia Kesulitan pengeluaran kepala Malposisi kepala

Dikutip dari:W.C. Wong et al 2001

Low longitudinal Incision

Indication :

preterm
Placenta previa in

anterior Shoulder pres.

Emergency CS
INDIKASI: Keadaan

umum buruk, risiko anestesi umm/regional CARA: Infiltrasi lidokain 0.5% , Atau: ketamin 50 mg bolus + Tetes Ketamin 100 mg/500 RL

Intraoperative
Spinal is the best Antiseptic Universal

precaution Facilities, vital monitoring recording

Dikutip dari: E.J. Quilligan, 2001

Dikutip dari: E.J. Quilligan, 2001

Trends

Amerika berusaha untuk mencapai tingkat angka seksio 15%

Dikutip dari: Cuningham dkk, 2001

When is it safe for next pregnancy ?

Risik of uterine rupture will increase if interval is less than 18 months. Evaluation of the thickness of low segmen at term. Rozenberg (1996): risk of uterine rupture increase if < 3.5 mm sensitifity 88%, specificity 99%.

VBAC

RATE

Rebound effect

Due to rate of CS VBAC

Dikutip dari: Cuningham dkk, 2001

Contraindication for VBAC

Contracted pelvis Macrosomia Classic incision or deep myomectomy Overdistended Readiness for emergency CS (?)

Dikutip dari: E.J. Quilligan, 2001

Dikutip dari: Cuningham dkk, 2001

Dikutip dari: Cuningham dkk, 2001

INFORMED CONSENT
Information on indication, risk and benefit

AUDIT

Regular Maternal Perinatal meeting (weekly/monthly) Review for indications (e.g fetal distress) Morbidity Guidelines (EFM) May reduce the rate Report and dissemination

Hysterectomy

Early preparation

multidisciplinary team, Hemorrhage Protocol activation, operating team ready, neonatology, interventional radiology

Unplanned v. planned procedure Communication with patient and family

Unplanned Peripartum Hysterectomy- etiology

Study
Year Accreta Atony Rupture

Clark
1978-82 21 (30%) 30 (43%) 9 (13%)

Stanco
1985-90 55 (45%) 25 (20%) 14 (11%)

Zelop
1983-91 75 (64%) 25 (21%) 10 (9%)

Unplanned Hysterectomy Morbidity and Mortality

Clark # 70 EBL 3.5 L Transfusion 67 (96%) Reexplore 0 Febrile 35 (50%) Ureter 3 (4%) Urologic 3 (4%) Death 1 (1%) Stanco 123 3.0 L 102 (83%) 0 4 (3%) Zelop 117 3.0 L 102 (87%) 3 (1%) 39 (33%) 3 (3%) 10 (95) -

Planned Hysterectomy
Morbidity
Ward 1953-64 # 254 McNutty 1972-82 80 15 (19%) 5 (6%) 4 (5%) 0 Yancey 1979-90 43 17 (40%) 1 (2%) 0

Transfused 195 (77%) Febrile Urologic Ureteral damage 8 (3%) 0