BEDAH CESAR

(SECTIO CESAREAN)

Oleh
Dr Kaswiyan SpAnK
 Problema
1. Tehnik Anestesia harus memenuhi kriteria
Analgesia cukup kuat
Trauma psikis pada ibu
Toksisitas rendah
Depresi janin
Relaksasi otot cukup, relaksasi uterus
2. Resiko yang mungkin timbul
Akibat lambung penuh Aspirasi
Sulit intubasijalan nafas sulit diatur
Kebutuhan oksigen
Adanya Supine Aorto Caval Syndrome
3. Adanya perubahan fisiologi pada wanita hamil
4. Adanya 3 individu yang dihadapi dengan
kepentingan berbeda :
Ibu
Anak/Janin
Ahli bedah (Obstetrikus)
 Indication for cesarean delivery
Previous cesarean section
Cephalopelvic disproportion
Failure to progress
Breech
Multiple gestation ; abnormal lie
Fetal macrosomia
Maternal disease, hemorrhage, Previa, Preeclampsia,
Herpes Genitalia
Fetal distress
 Management of maternal physiology and
uterine blood flow
Physiologic Alteration
Acute reduction in preload from
autocaval :
Compression resulting in maternal
hypotension or fetal hypoxia
Intervention
Uterine displacement :
LUD after 20 week EGA
Alternate uterine displacement if
unresponsive to LUD: Maternal
knee chest position allows
maximal caval and umbilical cord
unloading
Vasopressor
Ephedrine
Avoid 1 agonist when possible.
1 agonist are indicated with
profound maternal hypotension
 Physiologic Alteration
Uteroplacental perfusion directly correlates
with maternal MAP
More prone to hypoxemia
Decrease in FRC in the supine position
Closing capacity may inpinge on tidal
volume
Hypoxemia exaggregated by obesity and
underlying pulmonary pathology
Intervention
Intravascular volume expansion to increase
cardiac preload
Decreases in MAP should be treated
promply and aggressively to maintain
uterine perfusion and prevent fetal hypoxia
Treat as above
Maintain low therapeutic threshold for
propylactic oxygen administration during
regional anesthetics and prior to delivery
Pulmonary unloading by semisitting
position
 Physiologic Alteration
Propensity for development of diabetes
mellitius (DM) and gestational DM owing
to circulating placental hormones
Expansion of intravascular volume
and increase in red blood cell mass
Ample substrate for clot formating
owing to Overpriming of the clotting
cascade with clotting factors
Intervention
Rapid recovery fromdiabetic effects
of placental hormones postdelivery
Preoperative insulin requirements are
rapidly reduced and unpredictable; an
insulin sliding scale should be used post
operatively
Average blood loss of 500-1000 ml for
vaginal and cesarean delivery well
tolereted
 Physiologic Alteration Intervention

Increased GFR and renal plasma flow Glycosuria : often normal

Decrease BUN and creatinine Non pregnant normal values of

BUN and creatinine may represent
frank elevations during pregnancy
 ANESTESIA PADA KASUS
OBSTETRI
Keberhasilan anestesi
1. Keterampilan dan pengalaman
2. Memahami * Fisiologi / Patofisiologi wanita Hamil
* Farmakologi
3. Selalu mengikuti perkembangan ilmu

Pemilihan Tehnik Anestesi

1. Pengalaman Ahli Anestesi
2. Indikasi dan manfaat tindakan
3. Keinginan penderita
 REGIONAL ANESTHESIA : Advantage and
Disadvantage
Advantages : Disadvantages:

Awake Patient Potential for inadequat block

Avoidance of airway emergent,intraoperative,general
manipulation anesth
Minimal fetal effects High/total spinal ; IV
administration
Possible seizure and cardiac
arrest
Hypotension
Postdural puncture headache
Neurologic sequelae
 General Anesthesia : Advantages and Disadvantages

Advantages : Disadvantages :

Rapid, relaible induction of Unconscious patient

anesthesia Potential for difficult or failed
Excellent surgical conditions intubation
Administration possible in the Aspiration
presence of coagulopathy, Fetal effects
Hemorrhage, sepsis
Anesthetist familiarity with
technique
 Implikasi Maternal Perubahan Physiologic pada Pemberian
Anesthesia Regional

Perubahan Physiologic Intervensi

Peningkatan sensitivitas neuron pada Dosis titrasi pada Epidural menimbulkan

anestesia lokal atau penurunan voulume
pada ruang epidura.
Penekanan Aortocaval menghasilkan
penigkatan tekanan ruang epidural.
efek. Kebutuhan dosis diturunkan. Dosis
SAB (Subarachnoid Bock) perlu
diturunkan. Perubahan posisi lumbal
lordosis akan menimbulkan penyebaran
obat ke kepala dan leher sehingga setelah
penyuntikan, leher dan kepala harus
ditinggikan.
Pemasangan epidural chateter dapat
membantu dalam pemberian obat
tambahan selama prosedur operasi.

Penekanan Aortocaval menyebabkan PRELOAD IV kristaloid sebelum

penurunan preload dan meningkatkan anesthesia regional sebanyak 10-15
respon hypotensi simpatis. ml/kg. Menjaga kebutuhan cairan
pengganti setiap saat.
Created by Z
 Keuntungan Dan Kerugian Spinal Anestesi

Keuntungan Kerugian
Pada umumnya lebih cepat dan Jangka waktu terbatas.
mudah dilakukan. Postdural : kebocoran, sakit kepala.
Dapat diandalkan. Resiko lebih besar terhadap
Memberikan efek minimal pada hypotensi
janin.
Dosis Spinal Anestesi pada Bedah Cesar

Onset
Anestesi Lokal Dosis (mg) Durasi (min)
(min)

Lidocaine 5% /D 7,5% 60 80 45 60 -90

Bupivacaine 0,75% /D 8,25% 12 15 48 90 - 120

Tetracain 1% /D 10% 7 - 11 4 15 120 - 180

Created by Z
 Implication of Maternal Physiologic Alterations on the Administrasion of the
General ANESTHESIA
PHYSIOLOGIC ALTERATION INTERVENTIONS

Increased difficulty of endotracheal Short handle laringoscope

intubation Smaller endotracheal tube
Airway edema Failed intubation protocol and emergency airway
Venous engorgement equipment
Soft tissue obstruction (breasts, chest
shape)
Rapid arterial oxygen desaturation Preoxygenation for 3 5 min
Increased metabolic need and O2 Titrate N20 to keep SpO2 >96 %
consumption More rapid denitrogenation possibquenle owing to
Maternal or fetal decreased FRC
Decreased FRC

Increased risk of aspiration of pulmonary Rapid squence induction with cricoid pressure or
Increased intragastric pressure awake Intubation
Decreased intragastric PH Prophylactic nonparticulate antacid
Possible decreased LES tone
 PHYSIOLOGIC ALTERATION
Altered response to volatile
anesthetics
Decreased MAC
More rapid uptake : decreased FRC
and
more rapid Fa/F1 rate of risk
Muscular effects of Progesteron
Decresed post operative myalgia
FRC: functional residual capacity
LES:Lower esophageal sphincter
INTERVENTIONS
Reduced volatile anesthetic
requirements and careful titration
required compared with nonpregnant
patients
Desfasciculation with nondepolarizing
muscle relaxans not routinely
necessary
MAC:minimum alveolar concentration
Gambaran umum penderita Obstetri
1. Datang mendadak
2. Ratarata Sehat
3. Keadaan umum cukup Optimal
 Table 12-4
Treatment of Amniotic Fluid Embolus

Treat airway, breathing, circulation

Intubate and ventilate with 100% Oxygen
Support circulation with basic CPR and
vasoactive drugs
Consider early delivery of vetus
Continue fetal monitoring
Improve cardiac preload and contractility
Initiate fluid challenge with crystalloid
Consider Dopamine, digitalization
Install pulmonary artery catheter
Obtain distal heparinized sample for buffy
coat examination
Examine ventricular function curves to
optimize preload, prevent overzealous fluid
administration (pulmonary edema)

Treat disseminated intravascular coagulation

with fresh frozen plasma and packed red blood cells and
monitor coagulation parameters until underlying
cause is reversed
 STANDARD FOR
POSTANESTHESIA
CARE
(TABLE 13 1)
 LOKAL ANESTHRTIC AGENT
COMMONLY USED FOR SPINAL
AND EPIDURAL ANESTHESIA
 SPINAL
T10 SENSORY LEVEL T 4 SENSORY LEVEL (
AGEN % (OUTLET MID FORCEPS ) (MG)
FORCEFS)(MG)

LIDOCAIN 5 30 - 50 60 - 100

BUPIVACAIN 0,75 5 - 7,5 12,5 - 15

TETRACAIN 1 5 - 6 8 - 12
 EPIDURAL
OUTLET MID RECOMMENDED. MAXIMAL
AGEN FORCEFS FORCEFS
(%)
INITIAL DOSE (
ML )
INIYIAL DOSE
( MG/ KG )
(%)

LIDOCAIN 1 - 2 2 10 - 15 7.0

CLOROPROCAINE 2 3 10 _ 15 15

BUPIVACAIN O.25- 0.5 10 _ 15 2.5

0,5
 TABEL 3 - 13
STANDARDS FOR
POSTANESTHESIA CARE
 STANDARD I
ALL PATIENS WHO HAVE RECEIVE
GENERAL ANASTHESIA
REGIONAL ANASTHESIA
MONITORED ANASTHESIA CARE
SHELL RECEIVE APPROPRIATE POST
ANASTHESIA MANAGEMENT.
 STANDARD II
A PATIENT TRANSPORTED TO THE PACU
SHALL BE ACCOMPANIED BY A MEMBER
OF THE ANASTHESIA CARE TEAM WHO IS
KNOWLEDGEABLE ABOUT THE PATIENTS
CONDITION. THE PATIENT SHALL BE
CONTINUALLY EVALUATED AND TREATED
DURING TRANSPORT WITH MONITORING
AND SUPPORT APPROPRIATE TO THE
PATIENTS CONDITION.
 STANDARD III
UPPON ARRIVAL IN THE PACU, THE
PATIENT SHALL BE REEVALUATED
AND A VERVAL REPORT PROVIDED
TO THE RESPONSIBLE PACU NURSE
BY THE MEMBER OF HE ANESTHESIA
CARE TEAM WHO ACCOMPANIES THE
PATIENT.
 STANDARD IV
THE PARENTS CONDITION SHALL BE
EVALUATED CONTINUALLY IN THE
PACU
 STANDARD V
A PHYSICIAN IS RESPONSIBLE FOR
THE DISCHARGE OF THE PATIENT
FROM THE PACU.
 SIDE EFFECTS OF INTRATHECAL
OPIOID AND THE TREATMENT
ITCHING
NAUSEA AND VOMITING
HYPOTENSION
URINARY RETENTION
 ITCHING
TREATMENT
DIPHENHYDRAMINE 25 MG IV,
NALBUPHINE 5 10 IV, PROPOFOL 10 MG,
NALOXONE 40 MG IV(LAST RESORT)
NALTROXON 25 MG P.O ( AFTER DELIVERY,
MORPHINE ONLY )
COMMENTS
ITCHING USUALLY MLD AD OF LIMITED
DURATION: MORPHINE CAN CAUSE
SEVERE, PROLONGED ITCHING.
 NAUSEA AND VOMITING
TREATMENT
METOKLORPROPAMIDE 5 10 MG IV, NALBUPHINE
5 10 MG IV, PROPOFOL 10 MG IV
NALOXONE 40 G IV(LAST REPORT)
NALOXONE 25 MG P.O (AFTER DELIVERY,
MORPHINE ONLY)
COMMENTS
NAUSEA AFTER INTRATHECAL MEPERIDINE IS
USUALLY SELF LIMITED AND RESOLVES WITHOUT
TREATMENT : MORPHINE CAN CAUSE
SIGNIFICANT NAUSEA BOTH DURING AND AFTER
DELIVERY
 HYPOTENSION

TREATMENT
IV FLUIDS, EPHEDRINE
COMMENTS
MINOR DECREASE IN BLOOD
PRESSURE ARE COMMON WITH ALL
INTRATHECAL OPIOID SIGNIFICANT
HYPOTENSION ( SYSTOLIC BP < 90
mmHG ) IS RARE BUT MAY OCCUR
 URINARY RETENTION
TREATMENT
CATHETERIZATION
NALOXON 400 Mg iv ( MAY HAVE TO
REPEAT )
COMMENTS
OCCASIONALLY A PROBLEM AFTER
DELIVERY WITH MORPHINE