history, development and clinical implication

CAESAREAN SECTION

Gulardi H. Wiknjosastro Bagian Obstetri Ginekologi FKUI RS Dr. Cipto Mangunkusumo Jakarta

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 laceration hematoma Bleeding from LS Delivery of infant PREVENTION Uincision Hemostatic stitches Stitches, tampon forsep, vacuum, extraction insisi longitudinal rdh

placenta di depan

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