Permortem Cesarian
Permortem Cesarian
Permortem Cesarian
Yudianto Budi Saroyo, SpOG
Divisi Fetomaternal
Departemen Obstetri & Ginekologi
RSUPN dr. Cipto Mangunkusumo
Fakultas Kedokteran Universitas Indonesia
Indikasi dan syarat
• Tenaga medis mempunyai kemampuan dan keahlian untuk
melakukan prosedur tersebut.
• Ibu gagal untuk berespon terhadap resusitasi kardiopulmoner
• Janin viabel untuk dilahirkan
• Adanya fasilitas dan sumber daya yang mampu untuk perawatan
lebih lanjut.
Mellissa Whitten; Postmortem and perimortem caesarian section : What the
indication?
Journal of Royal Society of medicine, 2000; 93:6‐9 SOP
Tempat dan waktu persalinan
tindakan di ruang rawat
Pada bayi dengan survival yang rendah /
Infeksi, prematuritas
dengan risiko tinggi
Alat resusitasi dan SC Tidak tersedia
Risiko pada penolong dan tim Risiko tinggi
TINDAKAN DILAKUKAN DI TEMPAT, PENUNDAAN TINDAKAN DI
EMERGENSI, PERSIAPAN AKAN MEMAKAN WAKTU YANG
BERHARGA DALAM MENYELAMATKAN BAYI
PMCD ACT AS RECUSTITATION
• Adequate chest compressions and displacement of the gravid uterus off
the venous return from the lower extremities are both proven to improve
maternal oxygenation.
• Resuscitative efforts also must include postcesarean infant resuscitation.
• This means the decision to operate must be made and surgery begun by 4
minutes into the arrest.
Uteroplacental blood flow may require up to 30% of a
woman's cardiac output during pregnancy7 , and this may
be recruited for perfusion of other visceral organs after
delivery.
Several animal and laboratory models and a growing body
of clinical evidence suggest that cardiac compressions are
more effective after delivery.5
A decrease of 30% occurs in stroke volume and cardiac
output in a pregnant woman who lies supine, largely
because the inferior vena cava is completely occluded
(which occurs in 90% of women in late pregnancy).
In addition, a 20% reduction in functional residual capacity
occurs at term and the metabolic rate is faster, which lead
to decreased oxygen reserves and a more rapid onset of
anoxia following apnea.4
TEKNIS PELAKSANAAN PMCD
• Full CPR measures should continue during the delivery
• Most young obstetricians perform Pfannenstiel incisions
• The available equipment is likely to be minimal, the equipment is generally
not neatly arranged, and a scrub technician probably will not be standing
at the ready.
• While many spectators may be present, none is likely to be of value as an
assistant.
• Lighting may be poor and not deployable where needed within the
incision.
Resusitasi jantung paru dan ACLS
ALGORITMA SC PERIMORTEM
• Generally, PMCD is deemed an emergency procedure for which consent
is not possible. When maternal consent is not an issue, no other opinion
should be deemed as legally binding in the emergency setting.
• When the situation involves a ventilator‐dependent, brain‐dead patient
being kept alive solely as a nursery, next‐of‐kin decisions become
relevant, and legal and, possibly, spiritual, counsel should be sought.
Perimortem Cesarean Section
The emergency physician has the legal right and responsibility
to provide the unborn fetus with every possible chance of
survival when there is no hope of maternal survival.
• Perimortem cesarean section is an emotionally charged procedure,
even for the skilled and experienced practitioner.
• Although medicolegal issues about poor fetal outcome or intraoperative
injury to the newborn remain a concern
• Katz et al. state that no physician in the United States has been found
liable for performing a perimortem cesarean section against the will of
the family or the patient
Luaran SC
Perimortem
pada ibu dan bayi
Vern Katz; Keith Balderstone; Perimortem
Cesarean Delivery: Were our assumption
Correct?, American Journal Obs and Gyne,
2005,192:1916‐21
SC perimortem dilakukan pada keadaan…
Vern Katz; Keith Balderstone; Perimortem
Cesarean Delivery: Were our assumption
Correct?, American Journal Obs and
Gyne, 2005,192:1916‐21
OVERVIEW PELAYANAN NEONATAL
DI RSUPN DR. CIPTO
MANGUNKUSUMO
SURVIVAL RATE BERDASARKAN BERAT LAHIR
JANUARI‐APRIL 2012
120,00%
80,00% 78,13%
60,00%
Survival rate per BBL
53,13%
40,00%
20,00%
0,00%
< 1000 g 1000 ‐ 1499 g 1500 ‐ 1999 g 2000 ‐ 2499 g 2500 ‐ 2999 g 3000 ‐ 3499 g 3500 ‐ 3999 g > 4000 g
PERFORMANCE OF NEONATAL UNIT RSCM JAN-APR 2012
< 28 w 28‐30 w 31‐32 w 33‐34 w 35‐36 w 37‐41 w
Mean birth
weight (g) 920 1355 2081 2150 2423 3019
Survival rate at
RSCM 33% 82% 94% 98% 97% 99%
Incidence of BPD
0% 0% 2% 0% 0% 0%
Incidence of NEC
0% 3,57% 2% 0% 0,7% 0%
IVH grade I
incidence 0% 0% 0% 0% 0% 0%
IVH grade II
incidence 28% 7% 0% 0% 0% 0%
IVH grade IIII
incidence 0% 0% 0% 0% 0% 0%
IVH grade IV
incidence 0% 0% 0% 0% 0% 0%
ROP grade 3/4
4,76% 4,3% 2% 0% 0% 0%
RCOG Green Top Guideline
No 56 January 2011
Dijkman A, Huisman C, Smit M, Schutte J, Zwart J, van Roosmalen J, Oepkes D. Cardiac arrest in pregnancy: increasing
use of perimortem caesarean section due to emergency skills training? BJOG 2010;117:282–287.
Suresh et al. Cardiopulmonary resuscitation and parturient. Best Practice & Research Clinical Obstetrics and Gynaecology
24(2010)383e400
Postmortem cesarean ekstraksi
bayi pada wanita hamil yang sudah
meninggal
SVR Menurun
• Kompresi dada tidak efektif
setelah kehamilan 20 minggu
kehamilan oleh karena itu perlu
tindakan melahirkan bayi dan
plasenta dengan segera.
RCOG Green Top Guideline
No 56 January 2011
• Jika tidak ada respon setelah
dilakukan CPR dalam waktu 4
menit pada kehamilan di atas
usia 20 minggu kehamilan SC
harus dilakukan untuk
membantu resusitasi maternal.
• American Heart Association (AHA) guidelines
(2010) rekomendasi SC dilakukan setelah
4 menit usaha resusitasi gagal.
Hill CC, Pickinpaugh J. Trauma and surgical emergencies in the obstetric patient.
AHA Guidelines 2010
Tindakan Jumlah kasus Keberhasilan
SC 12 2 (17%)
Dijkman A, Huisman C, Smit M, Schutte J, Zwart J, van Roosmalen J, Oepkes D. Cardiac arrest in
pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG
2010;117:282–287.