PENATALAKSANAAN PERSALINAN PENATALAKSANAAN PERSALINAN KALA TIGA, KALA EMPAT DAN KALA TIGA, KALA EMPAT DAN PERDARAHAN POST PARTUMPERDARAHAN POST PARTUM

WAWANG SETIAWAN SUKARYAWAWANG SETIAWAN SUKARYA

FAKULTAS KEDOKTERAN FAKULTAS KEDOKTERAN

UNIVERSITAS ISLAM BANDUNGUNIVERSITAS ISLAM BANDUNG

KEMATIAN MATERNAL

53% KEMATIAN DAPAT DICEGAH

DENGAN INTERVENSI TEKNOLOGI

SEDERHANA

KEMATIAN MATERNAL

PENYEBAB :PENYEBAB :

PERDARAHAN,SEPSIS

PREEKLAMPSI-EKLAMPSI

PARTUS MACETUNSAFE ABORTION”

60 - 80% POTENSIAL DAPAT DICEGAH

KEMATIAN MATERNAL

PENOLONG PERSALINAN YANG TERAMPIL

MERUPAKAN SALAH SATU INTERVENSI

YANG EFEKTIF DALAM MENURUNKAN KEMATIAN MATERNAL DAN

KECACATAN AKIBAT KEHAMILAN DAN PERSALINAN

PERSALINAN KALA TIGA

PADA KEHAMILAN ATERM ALIRAN DARAH KE UTERUS 500-800 ML/MENIT

JIKA UTERUS TIDAK SEGERA BERKONTRAKSI, PADA BEKAS TEMPAT IMPLANTASI PLASENTA TERJADI PERDARAHAN 350-560 ML/MENIT

PADA ATONIA UTERI DAPAT TERJADI KEHILANGAN SELURUH VOLUME DARAH DALAM 10-30 MENITIBU DENGAN PERDRAHAN KARENA ATONIA DAPAT MENINGGAL < 1 JAM

MEKANISME LAHIRNYA PLASENTAMEKANISME LAHIRNYA PLASENTA

1. FASE LATEN1. FASE LATEN

2. FASE KONTRAKSI2. FASE KONTRAKSI

3. FASE PELEPASAN PLASENTA3. FASE PELEPASAN PLASENTA

4. FASE PENGELUARAN4. FASE PENGELUARAN

KEUNTUNGAN MANAJEMEN AKTIF KEUNTUNGAN MANAJEMEN AKTIF KALA IIIKALA III

1. KALA III LEBIH SINGKAT1. KALA III LEBIH SINGKAT

2. PERDARAHAN BERKURANG2. PERDARAHAN BERKURANG

33. KEJADIAN RETENSIO PLASENTA . KEJADIAN RETENSIO PLASENTA BERKURANGBERKURANG

MANAJEMEN AKTIF vs EKSPEKTAN

AKTIF EKSPEKTANKEHILANGAN DARAH

< 500 ML 93,2% 83,5%500-1000 ML 5,1% 13,9%> 1000 ML 1,7% 2,6%

PLASENTA MANUAL 2 % 1,7%PLASENTA TERPERANGKAP 1,1% 0,9%LAMA KALA III 8 menit 15 menit

LANGKAH2 MANAJEMEN AKTIF KALA III

SEGERA JEPIT DAN POTONG SEGERA JEPIT DAN POTONG TALIPUSATTALIPUSAT

BERI OKSITOSIN 10 U IM BERI OKSITOSIN 10 U IM SEGERA SEGERA SETELAH BAYI LAHIRSETELAH BAYI LAHIR

PENEGANGAN TALIPUSAT PENEGANGAN TALIPUSAT TERKENDALITERKENDALI

SETELAH PLASENTA LAHIR SETELAH PLASENTA LAHIR SEGERA SEGERA MASASEMASASE FUNDUS UTERI FUNDUS UTERI

OKSITOSINOKSITOSIN

• PASTIKAN TIDAK ADA ANAK KEDUA PASTIKAN TIDAK ADA ANAK KEDUA (GEMELLI)(GEMELLI)

• DISUNTIKAN 10 UNIT OKSITOSIN (I.M) DISUNTIKAN 10 UNIT OKSITOSIN (I.M) SETELAH BAHU DEPAN LAHIR ATAU SEGERA SETELAH BAHU DEPAN LAHIR ATAU SEGERA SESUDAHNYA.SESUDAHNYA.

• BILA TERPASANG INFUS DPT DITAMBAHKAN 20 BILA TERPASANG INFUS DPT DITAMBAHKAN 20 UNITUNIT

• EFEKTIF EFEKTIF 2 - 3 MENIT2 - 3 MENIT SETELAH PENYUNTIKAN SETELAH PENYUNTIKAN

BERIKAN OKSITOSIN 10 IU I.M.SETELAH BAHU DEPAN BAYI LAHIR

ATAU SEGERA SETELAH BAYI LAHIR

PASTIKAN DULU TIDAK

ADA KEHAMILAN KEMBAR /

GANDA

PENEGANGAN TALIPUSAT PENEGANGAN TALIPUSAT TERKENDALITERKENDALI

• JEPIT TALIPUSAT 5 CM DI DEPAN VULVA, PEGANG DENGAN TANGAN KANAN.

• LETAKAN TANGAN LAIN DI DEPAN KORPUS UTERI TEPAT DI ATAS SBU

• TEGANGKAN TALIPUSAT DGN RINGAN & HATI2, SEMENTARA TANGAN KIRI MENDORONG DORSOKRANIAL SP TANDA PLASENTA LEPAS

• TARIK KE BAWAH UNTUK LAHIRKAN PLASENTA

JANGAN TARIK TALI PUSAT JANGAN TARIK TALI PUSAT TANPA MENDORONG TANPA MENDORONG

DORSOKRANIAL DENGAN DORSOKRANIAL DENGAN TANGAN KIRI/KANANTANGAN KIRI/KANAN

Letakkan satu tangan diatas simfisis menahanbagian bawah uterus , sementara tangan lainmemegang tali pusat 5 - 10 cm dari perineum

Saat uterus kontraksitegangkan tali pusat kebawah

sementaratangan yanglain menekanuterus kearahatas dankranial (dorsocranial )

Bila terasa placenta mulai lepas , mulaitarik tali pusat kearah bawah kemudianke atas sesuai dengan lengkung vaginauntuk melahirkan plasenta .

Segera setelah plasenta lahir , masasefundus uteri hingga berkontraksi denganbaik (keras)

PERSALINAN KALA IV, TINDAKAN YANG PERSALINAN KALA IV, TINDAKAN YANG BAIKBAIK

IKAT TALI PUSATPEMERIKSAAN FUNDUS DAN MASASENUTRISI DAN HIDRASIBERSIHKAN IBUISTIRAHATMEMULAI MENYUSUIMENOLONG IBU KE KAMAR MANDIMENGAJARI IBU DAN KELUARGA

PERSALINAN KALA IV, TINDAKAN YANG PERSALINAN KALA IV, TINDAKAN YANG TIDAK BAIKTIDAK BAIK

TAMPON VAGINA

GURITA DAN SEJENISNYA

MEMISAHKAN IBU DAN BAYI

MANAJEMEN ATONIA UTERI UNTUK MENCEGAH HPP

IDENTIFIKASI RISIKO TINGGI

ADA PENOLONG TERLATIH SAAT PERSALINANUTEROTONIKACAIRAN INFUSTRANSPORTASI SETIAP SAAT

MEMBERDAYAKAN DAN MELATIH PENOLONG MEMBERDAYAKAN DAN MELATIH PENOLONG PERSALINAN PROAKTIF MENGAMBIL PERSALINAN PROAKTIF MENGAMBIL TINDAKAN SEDINI MUNGKINTINDAKAN SEDINI MUNGKIN

MENCEGAH PERDARAHAN POST PARTUM AKIBAT ATONIA UTERI

MENGIDENTIFIKASI IBU DGN RISIKO TINGGI UNTUK MELAHIRKAN DI RS.

• GRANDEMULTIPARA• PARTUS LAMA

• KEHAMILAN GANDA• IBU TUA

MISOPROSTOL• EFEK UTEROTONIKA KUAT

• TIDAK MENINGKATKAN TEKANAN DARAH

• CEPAT DISERAP

• TIDAK PERLU PENYIMPANAN KHUSUS

SEGERA MASASE FUNDUS UTERISESUDAH PLASENTA LAHIR(MAKSIMAL 15 DETIK)

UTERUS KONTRAKSI ?

TIDAK

EVALUASI / BERSIHKAN BEKUAN DARAH / SELAPUT KETUBAN

KOMPRESI BIMANUAL INTERNA (KBI) MAKS. 5 MENIT

UTERUS KONTRAKSI ?

AJAR KELUARGA MELAKUKAN KOMPRESI BIMANUAL EKSTERNA (KBE)

KELUARKAN TANGAN (KBI) SECARA HATI2

SUNTIK METHYL ERGOMETRIN 0,2 MG I.M PASANG INFUS RL + 20 IU OKSITOSIN, GUYUR LAKUKAN LAGI KBI

PERTAHANKAN KBI SELAMA 1-2 MENIT KELUARKAN TANGAN SECARA HATI-

HATI LAKUKAN PENGAWASAN KALA IV

EVALUASI RUTINYA

YA

TIDAK

UTERUS KONTRAKSI ?

LIGASI ARTERI UTERINA DAN / ATAU HIPOGASTRIKA

B-LYNCH METHOD

RUJUK SIAPKAN LAPAROTOMI LANJUTKAN PEMBERIAN INFUS + 20 IU

OKSITOSIN MINIMAL 500 CC/JAM HINGGA MENCAPAI TEMPAT RUJUKAN

SELAMA PERJALANAN DAPAT DILAKUKAN KOMPRESI AORTA

ABDOMINALIS/KBE

HISTEREKTOMI

PERDARAHAN BERLANJUT

TIDAK

PENGAWASAN KALA IV

YA

PERTAHANKAN UTERUS

PERDARAHAN BERHENTI

KOMPRESI BIMANUAL INTERNALKOMPRESI BIMANUAL INTERNALKOMPRESI BIMANUAL INTERNALKOMPRESI BIMANUAL INTERNAL

KOMPRESI BIMANUAL KOMPRESI BIMANUAL EKSTERNALEKSTERNAL

KOMPRESI AORTA KOMPRESI AORTA ABDOMINALISABDOMINALIS

SISA PLASENTASISA PLASENTA

SISA PLASENTA DAPAT NYEBABKAN PERDARAHAN POST PARTUM AWAL (EARLY)/LAMBAT (DELAYED).

LAKUKAN PENGAMBILAN SECARA MANUAL DGN ANESTESI UMUM (VOLATILE,1.5 – 2 MERUPAKAN KONSENTRASI ALVEOLAR MINIMAL YG MGK PERLU UNTUK RELAKSASI UTERUS)

KADANG2 WAKTU SISA PLASENTA DIKELUARKAN SECARA MANUAL, TERJADI PERDARAHAN HEBAT KARENA PLASENTA AKRETA YG TIDAK TERDIAGNOSA (JARANG)

MANUAL REMOVAL Of THE PLACEMTA MANUAL REMOVAL Of THE PLACEMTA Preparation of patientPreparation of patient Explain the intervention to the woman and reassure her § Take Explain the intervention to the woman and reassure her § Take

blood for typing and cross-matching and for haemoglobin blood for typing and cross-matching and for haemoglobin level if it has not already been done § Start IV infusion,level if it has not already been done § Start IV infusion,

if not already established, and infuse either Ringer’s lactate or if not already established, and infuse either Ringer’s lactate or normal saline. normal saline.

Run it fast if hypovolaemia has not yet been corrected. Blood Run it fast if hypovolaemia has not yet been corrected. Blood transfusion may be needed if haemorrhage is severe. transfusion may be needed if haemorrhage is severe.

Give one dose of prophylactic antibiotics: Give one dose of prophylactic antibiotics:

Ampicillin 2 g IV, and -metronidazole 500 mg IV, Ampicillin 2 g IV, and -metronidazole 500 mg IV,

or -cefazolin 1 g IV, plus metronidazole 500 mg IV. or -cefazolin 1 g IV, plus metronidazole 500 mg IV.

EQUIPMENT & SUPPLIES NEEDED: EQUIPMENT & SUPPLIES NEEDED: antiseptic solution antiseptic solution sterile glovessterile gloves one long sterile gloveone long sterile glove sterile swabs sterile swabs sterile vulval pad sterile vulval pad clamp, e.g. sponge-holding forceps clamp, e.g. sponge-holding forceps receiver for placentareceiver for placenta drugs: -analgesia -ergometrine -oxytocin -drugs: -analgesia -ergometrine -oxytocin -

antibiotics antibiotics syringes and needles. syringes and needles.

ANALGESIAANALGESIA Use an analgesic such as pethidine 25 Use an analgesic such as pethidine 25

mg IV, and a sedative such as diazepam mg IV, and a sedative such as diazepam 10 mg IV. 10 mg IV.

If the pethidine and diazepam are not If the pethidine and diazepam are not available, use another appropriate available, use another appropriate analgesic, if available, and continue analgesic, if available, and continue gently with the manual removal of the gently with the manual removal of the placenta as it is a life saving procedure. placenta as it is a life saving procedure.

ProcedureProcedure 11Provide emotional support to the woman throughout. Provide emotional support to the woman throughout. 2.2. Help the woman lie on her back with knees bent. If she is unable to void urine, catheterize and empty the bladder. A full bladder can prevent the delivery of the placenta. Help the woman lie on her back with knees bent. If she is unable to void urine, catheterize and empty the bladder. A full bladder can prevent the delivery of the placenta. 3.3. Administer analgesic. Administer analgesic. 4.4. Wash and scrub your hands and arms well. Wash and scrub your hands and arms well. 5.5. Clean around the vagina and the perineal area with an antiseptic solution. Clean around the vagina and the perineal area with an antiseptic solution. 6.6. Put on short sterile gloves first. Part the labia and clean the vestibule, i.e. the area inside the labia minora. Then, on the hand that will be inserted into the vagina, put on a long Put on short sterile gloves first. Part the labia and clean the vestibule, i.e. the area inside the labia minora. Then, on the hand that will be inserted into the vagina, put on a long

sterile glove on top of the short one. This will prevent the introduction of bacteria from the arm. (If no long glove is available, use a second short glove, cut off the part for the fingers and use the sterile glove on top of the short one. This will prevent the introduction of bacteria from the arm. (If no long glove is available, use a second short glove, cut off the part for the fingers and use the rest to lengthen the first glove) rest to lengthen the first glove)

7.7. Hold the umbilical cord with a clamp and pull cord gently until it is taut and parallel with the floor. Hold the umbilical cord with a clamp and pull cord gently until it is taut and parallel with the floor. 8.8. Introduce the other, long-gloved hand into the vagina with the fingers and thumb straight but close together and follow the cord, using a gentle rotation movement to go Introduce the other, long-gloved hand into the vagina with the fingers and thumb straight but close together and follow the cord, using a gentle rotation movement to go

through the cervical os into the uterine cavity (through the cervical os into the uterine cavity (Figure 9.1Figure 9.1). Follow the cord until you find the placenta. (Once you have put your hand into the uterus, do not bring your hand out until you have ). Follow the cord until you find the placenta. (Once you have put your hand into the uterus, do not bring your hand out until you have separated the placenta and are bringing it out of the uterus. Do not go in and out of the uterus as this increases the risk of infection). separated the placenta and are bringing it out of the uterus. Do not go in and out of the uterus as this increases the risk of infection).

9.9. Let go of the cord with your external hand and grasp the fundus of the uterus through the abdomen. This supports the uterus and provides counter traction during the manual Let go of the cord with your external hand and grasp the fundus of the uterus through the abdomen. This supports the uterus and provides counter traction during the manual removal to prevent inversion of the uterus. (removal to prevent inversion of the uterus. (Figure 9.2Figure 9.2). ).

10. Reach the placenta and find its edge. Slip the fingers of your hand between the edge of the placenta and the uterine wall. With your palm facing the placenta and fingers held tightly together, 10. Reach the placenta and find its edge. Slip the fingers of your hand between the edge of the placenta and the uterine wall. With your palm facing the placenta and fingers held tightly together, use a sideways slicing movement to gently detach the placenta. Go all around the placental bed until all the placenta is detached from the uterine wall. use a sideways slicing movement to gently detach the placenta. Go all around the placental bed until all the placenta is detached from the uterine wall.

11. When all of the placenta is separated and in the palm of your hand, (11. When all of the placenta is separated and in the palm of your hand, (Figure 9.3Figure 9.3) gently withdraw the placenta from the uterus. Do not pull on just a piece of placenta for it may tear from the ) gently withdraw the placenta from the uterus. Do not pull on just a piece of placenta for it may tear from the rest of the placenta. The membranes will follow the delivered placenta. Pull them out slowly and carefully as they might tear off and be left in the uterus giving rise to haemorrhage or infection. rest of the placenta. The membranes will follow the delivered placenta. Pull them out slowly and carefully as they might tear off and be left in the uterus giving rise to haemorrhage or infection.

12. Continue to provide counter-traction to the uterus with the other hand to prevent uterine inversion. 12. Continue to provide counter-traction to the uterus with the other hand to prevent uterine inversion. 13. Insert your hand again to palpate the uterine cavity for any 13. Insert your hand again to palpate the uterine cavity for any remaining placental tissue. remaining placental tissue.

14. Add oxytocin 20 IU to 1 litre of IV fluid (either Ringer’s lactate or normal saline) and give by intravenous infusion. Give rapidly if bleeding. 14. Add oxytocin 20 IU to 1 litre of IV fluid (either Ringer’s lactate or normal saline) and give by intravenous infusion. Give rapidly if bleeding. 15. Have an assistant massage the uterus to encourage contraction. 15. Have an assistant massage the uterus to encourage contraction.

16. If there is continued heavy bleeding, give ergometrine 16. If there is continued heavy bleeding, give ergometrine 0.2 mg IM to help the uterus contract, or prostaglandins depending on national policy (prostaglandins should not be given intravenously as this may be fatal). 0.2 mg IM to help the uterus contract, or prostaglandins depending on national policy (prostaglandins should not be given intravenously as this may be fatal).

17. Examine the removed placenta and check for completeness (17. Examine the removed placenta and check for completeness (Figure 9.4Figure 9.4). ). 18. Check for tears in the birth canal and repair, as required. 18. Check for tears in the birth canal and repair, as required.    Problems in the removal of the placenta. Problems in the removal of the placenta. §§ If the placenta does not separate from the uterine wall by gentle lateral movements of the finger tips at the line of cleavage, suspect placenta accreta and refer the woman to a If the placenta does not separate from the uterine wall by gentle lateral movements of the finger tips at the line of cleavage, suspect placenta accreta and refer the woman to a

higher level health facility for laparotomy and possible sub-total hysterectomy. No bleeding will occur from the uterine wall if the placenta is attached, only from areas where the placenta has higher level health facility for laparotomy and possible sub-total hysterectomy. No bleeding will occur from the uterine wall if the placenta is attached, only from areas where the placenta has separated separated

§§ If the placenta is retained due to a constriction ring, or if hours or days have passed since the birth of the baby, it may not be possible to get the whole hand into the uterus. If the placenta is retained due to a constriction ring, or if hours or days have passed since the birth of the baby, it may not be possible to get the whole hand into the uterus. Remove the placenta in fragments using two fingers, ovum forceps or a wide, blunt curette. Referral for exploration of the uterus under anaesthetic may be required because of the danger of Remove the placenta in fragments using two fingers, ovum forceps or a wide, blunt curette. Referral for exploration of the uterus under anaesthetic may be required because of the danger of retained placental tissue retained placental tissue

§§ If postpartum haemorrhage occurs before, during, or after the manual removal, follow the management as described in Session 5. If postpartum haemorrhage occurs before, during, or after the manual removal, follow the management as described in Session 5.

IMPORTANCE POINTS: IMPORTANCE POINTS: As much as possible, use aseptic As much as possible, use aseptic

precautions during the procedureprecautions during the procedure All intrauterine manipulations should be All intrauterine manipulations should be

carried out slowly, smoothly and gently carried out slowly, smoothly and gently It is very easy to perforate the lower It is very easy to perforate the lower

uterine segment if the hand is forced uterine segment if the hand is forced through the os through the os

It is also easy to perforate the uterine wall It is also easy to perforate the uterine wall if forceful if forceful

MANUAL PLASENTAMANUAL PLASENTA

DISTOSIDISTOSIA BAHUA BAHU

INSIDENSINSIDENS DISTOSIA BAHU : KEGAWAT DARURATAN OBSTETRIK

Kegagalan untuk melahirkan bahu secara spontan menempatkan ibu dan bayi berisiko untuk terjadinya trauma

ANTARA 0.3-1%BAYI > 4,000 gram 5-7%BAYI > 4,500 gram 8-10%.

DISTOSIA BAHUDISTOSIA BAHU TERUTAMA TERUTAMA DISEBABKAN :DISEBABKAN :

- Deformitas panggul Deformitas panggul - Kegagalan melipatnya bahu kedalam Kegagalan melipatnya bahu kedalam

panggul (pada makrosomia)panggul (pada makrosomia)- Pada multipara karena fase aktif & Pada multipara karena fase aktif &

persalinan kala II yang pendek persalinan kala II yang pendek Kepala turun terlalu cepatKepala turun terlalu cepat

menyebabkan bahu tidak melipat pada menyebabkan bahu tidak melipat pada saat melalui jalan lahir atau kepala saat melalui jalan lahir atau kepala telah melalui pintu tengah panggul telah melalui pintu tengah panggul setelah mengalami pemanjangan kala II setelah mengalami pemanjangan kala II sebelum bahu berhasil melipat masuk sebelum bahu berhasil melipat masuk ke dalam panggul.ke dalam panggul.

DISTOSIA BAHUDISTOSIA BAHU TERUTAMA TERUTAMA DISEBABKAN :DISEBABKAN :

- Deformitas panggul Deformitas panggul - Kegagalan melipatnya bahu kedalam Kegagalan melipatnya bahu kedalam

panggul (pada makrosomia)panggul (pada makrosomia)- Pada multipara karena fase aktif & Pada multipara karena fase aktif &

persalinan kala II yang pendek persalinan kala II yang pendek Kepala turun terlalu cepatKepala turun terlalu cepat

menyebabkan bahu tidak melipat pada menyebabkan bahu tidak melipat pada saat melalui jalan lahir atau kepala saat melalui jalan lahir atau kepala telah melalui pintu tengah panggul telah melalui pintu tengah panggul setelah mengalami pemanjangan kala II setelah mengalami pemanjangan kala II sebelum bahu berhasil melipat masuk sebelum bahu berhasil melipat masuk ke dalam panggul.ke dalam panggul.

FAKTOR RISIKOFAKTOR RISIKO

MAKROSOMIA > 4,000 gTaksiran berat janin kehamilan

sekarang Riwayat persalinan bayi makrosomia Riwayat keluarga dengan Makrosomia

DIABETES GESTASIONAL MULTIPARITAS PERSALINAN LEWAT BULAN

(serotinus)

MAKROSOMIA > 4,000 gTaksiran berat janin kehamilan

sekarang Riwayat persalinan bayi makrosomia Riwayat keluarga dengan Makrosomia

DIABETES GESTASIONAL MULTIPARITAS PERSALINAN LEWAT BULAN

(serotinus)

KOMPRESI TALI PUSAT KERUSAKAN PLEXUS BRACHIALIS ERB-DUCHENE PALSY PARALISIS KLUMPKE PATAH TULANG

FRAKTUR KLAVIKULA FRAKTUR HUMERUS

ASFIKSIA JANIN KEMATIAN BAYI

KOMPRESI TALI PUSAT KERUSAKAN PLEXUS BRACHIALIS ERB-DUCHENE PALSY PARALISIS KLUMPKE PATAH TULANG

FRAKTUR KLAVIKULA FRAKTUR HUMERUS

ASFIKSIA JANIN KEMATIAN BAYI

PROGNOSISPROGNOSIS

KEPALA BAYI SUDAH LAHIR TETAPI BAHU TERHAMBAT DAN TIDAK DAPAT DILAHIRKAN

KEPALA BAYI SUDAH LAHIR TETAPI BAHU TERHAMBAT DAN TIDAK DAPAT DILAHIRKAN

WASPADAI DISTOSIA BAHU PADA SETIAP PERSALINAN

DETEKSI DINI MAKROSOMIA PROAKTIF BEDAH CAESAR PADA MAKROSOMIA

WASPADAI DISTOSIA BAHU PADA SETIAP PERSALINAN

DETEKSI DINI MAKROSOMIA PROAKTIF BEDAH CAESAR PADA MAKROSOMIA

MASALAHMASALAH

PENGELOLAAN UMUMPENGELOLAAN UMUM

KONDISI VITAL IBU DAPAT BEKERJA SAMA

MASIH MEMILIKI KEMAMPUAN MENGEDAN

JALAN LAHIR & PINTU BAWAH PANGGUL NORMAL BAYI HIDUP BUKAN MONSTRUM / KELAINAN

CONGENITAL

KONDISI VITAL IBU DAPAT BEKERJA SAMA

MASIH MEMILIKI KEMAMPUAN MENGEDAN

JALAN LAHIR & PINTU BAWAH PANGGUL NORMAL BAYI HIDUP BUKAN MONSTRUM / KELAINAN

CONGENITAL

SYARATSYARAT

MANUVER MANUVER McROBERTSMcROBERTS

ANTERIOR ANTERIOR DISIMPACTIONDISIMPACTION

- MASSANTI MANUVER MASSANTI MANUVER (SUPRA PUBIC (SUPRA PUBIC PRESSURE)PRESSURE)

- RUBIN MANUVERRUBIN MANUVER

TIDAK BOLEH MENEKAN F.U. :TIDAK BOLEH MENEKAN F.U. :

- LAKUKAN TEKAN SUPRA PUBISLAKUKAN TEKAN SUPRA PUBIS

- TANGAN DIKEPAL, MENEKANTANGAN DIKEPAL, MENEKAN

DARI ASPEK POSTERIOR AGARDARI ASPEK POSTERIOR AGAR

BAHU DEPAN AGAR LEPASBAHU DEPAN AGAR LEPAS

MANUVER “CORKSCREW

”

(WOODS)

MANUVER “CORKSCREW

”

(WOODS)

ROTATION OF POSTERIOR ROTATION OF POSTERIOR SHOULDERSHOULDER

Step 1Step 1

● Pressure on anterior aspect of posterior shoulder

● May be combined with anterior disimpaction manoeuvers

● NO fundal pressure

ROTATION OF POSTERIOR ROTATION OF POSTERIOR SHOULDERSHOULDER Step 2Step 2

Wood’s screw manoeuvre

can be done simultaneously with anterior dissimpaction

Rotation of Posterior ShoulderRotation of Posterior Shoulder Step 3Step 3

may be repeated if delivery not accomplished by Steps 1 & 2

Rotation of Posterior ShoulderRotation of Posterior ShoulderStep 4Step 4

MELAHIRKAN MELAHIRKAN BAHU PADA BAHU PADA

DISTOSIA DISTOSIA BAHUBAHU

MANUVER “CORKSCREW

”(WOODS)

MANUVER “CORKSCREW

”(WOODS)

MELAHIRKAN BAHU BELAKANG (SCHWARTZ & DIXON)

MELAHIRKAN BAHU BELAKANG (SCHWARTZ & DIXON)

Magnesium sulphate regimens for women with pre-eclampsia and eclampsia

For more than 75 years the anticonvulsant agent for treating eclampsia and whether to use an anti-convulsant or not for

women with pre-eclampsia have been controversial.

Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate?

The Magpie trial: a randomised placebo-controlled trial. Lancet 2002;1:359(9321):1877-1890

Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial.

Lancet 1995;345:1455-1463

This situation changed with two recent multicentre trials:

Next slide

“Magnesium sulphate Boxes”

Treatment packs in cardboard boxes containing magnesium sulphate for the loading dose, 24h maintenance

therapy and treatment of one (recurrent) convulsion as well as syringes, swabs, drip sets and fluids make the application of

magnesium sulphate treatment quick and easy in emergencies.

Magnesium sulphate BOX

Source: Duley L. Magnesium Sulphate regimens for women with Eclampsia: Messages from the Collaborative Eclampsia Trial. British Journal of Obstetrics and Gynaecology. 1996;103:103-105

Next slide

Calcium gluconate1 g (for toxicity)

Charts

Contents of the magnesium sulphate pack (intramuscular regimen)

IV infusion set Magnesium sulphate

Syringes and needles

500 ml normal salineDrip set (tubes)Intravenous cannulaTape (to secure cannula)Swab (to clean skin for cannula)

14 g (for loading dose)5 x 5 g (for maintenance therapy)5 g (for recurrent convulsions)

(For loading, maintenancedoses and calcium gluconate)

Fluid balance Observations

ProtocolSummary flow chart (on lid of the box)Detailed regimenGuidelines for other aspects of care

The treatments packs

A flow chart summarising how to administer magnesium sulphate

ampoules

syringesand needles

Next slide

The intravenous (IV) magnesium sulphate regimen

Continue for 24 hours after last convulsion, or delivery

Magnesium sulphate (4g) INTRAVENOUS

Slow intravenous injection over a period not less than 5 minutes preferably 10-15 minutes

Magnesium sulphate (10g)in 1000 ml normal Saline IV infusion

Rate of infusion 1g per hour

LOADING DOSE

MAINTENANCETHERAPY

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The intramuscular magnesium sulphate regimen

MAINTENANCE THERAPY

Deep intramuscular injection, 2.5g in each buttock every 4 hours. Continue for 24 hours after last convulsion, or delivery

Magnesium sulphate (4g) INTRAVENOUS

Slow intravenous injection over a period not less than 5 minutes

Magnesium sulphate (10g)INTRAMUSCULAR

Magnesium sulphate (5g)INTRAMUSCULAR

Deep intramuscular injection, 5g in each buttock

LOADING DOSE

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Recurrent convulsions

Give lower dose (2g) if the patient is small and/ or weight is less than 70 kgs

Magnesium sulphate 2-4 g IV over 5 minutes

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Monitoring during magnesium sulphate therapy

• Continue with IV infusion or give the next IM dose only if:

Respiratory rate >16/min

Urine output >25 ml/h (or >100 ml in 4h)

• With IV regimen monitor more frequently in the first 2 hours • Consider reducing the dose if renal function is impaired

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In case of magnesium toxicity

• Absent patellar reflexes

-Stop magnesium sulphate treatment-Oxygen by mask -1g IV calcium gluconate

-If respiration rateabnormal, withhold further magnesium sulphate

-If there are no respiratory or patellar signs mentioned reduce the dose by half (IV infusion 0.5g/1h, IM 2.5g 4 hourly)

• Respiratory arrest

-Stop magnesium sulphate treatment-Intubate and ensure ventilation -1g IV calcium gluconate

• Respiratory depression • Urine output < 100 ml in 4h

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For more information go to Cochrane Reviews andCommentaries on prevention and treatment of eclampsiain WHO Reproductive Health Library

• Magnesium sulphate versus diazepam for eclampsia

• Magnesium sulphate versus phenytoin for eclampsia

• Magnesium sulphate versus lytic cocktail for eclampsia

• Drugs for rapid treatment of very high blood pressure during pregnancy

• Antihypertensive drug therapy for mild to moderate hypertension during pregnancy

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For more information, please see Cochrane Reviews and Commentaries in RHL