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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
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 .
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
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
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
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
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
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:
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“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
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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
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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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