perdarahan intrapartum
DESCRIPTION
nbm,n,mTRANSCRIPT
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Perdarahan dalam ObstetriPerdarahan dalam Obstetri
Selly SeptinaSelly Septina, SpOG, SpOG
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PendahuluanPendahuluan
Perdarahan AntepartumPerdarahan Antepartum
Proses PersalinanProses Persalinan
Trauma Trauma
Perdarahan PostpartumPerdarahan Postpartum
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Proses PersalinanProses Persalinan
A. Perlukaan Vulva :A. Perlukaan Vulva :
Luka pada vulvaLuka pada vulva
Robekan perineum :Robekan perineum :
- Robekan derajat 1- Robekan derajat 1
- Robekan derajat 2- Robekan derajat 2
- Robekan derajat 3- Robekan derajat 3
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AnatomiAnatomi
Muscles of perineal body.
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Proses persalinanProses persalinan
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Robekan perineumRobekan perineum
• Derajat 1 :Derajat 1 :kulit perineum & mukosa vaginakulit perineum & mukosa vagina
• Derajat 2 :Derajat 2 :dinding belakang vagina & jaringan ikatdinding belakang vagina & jaringan ikat
• Derajat 3 :Derajat 3 :
m. sfingter ani externusm. sfingter ani externus
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Derajat 1Derajat 1
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Derajat 2Derajat 2
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Derajat 3Derajat 3
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Reparasi Reparasi
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Proses persalinanProses persalinan
B. Perlukaan vagina :B. Perlukaan vagina :
Sering berhubungan dengan robekan Sering berhubungan dengan robekan perineumperineum
ekstraksi cunamekstraksi cunamkolpaporeksis (robekan vagina atas)kolpaporeksis (robekan vagina atas)
persalinan CPDpersalinan CPD
laparatomilaparatomi
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Proses PersalinanProses Persalinan
C. Robekan ServiksC. Robekan ServiksSpekulumSpekulumPasca tindakan obstetri yang sulitPasca tindakan obstetri yang sulit
D. Ruptur UteriD. Ruptur UteriRobekan pada uterusRobekan pada uterus
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Reparasi robekan serviksReparasi robekan serviks
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Ruptur uteriRuptur uteri
Definisi : robeknya dinding uterusDefinisi : robeknya dinding uterus
Etiologi :Etiologi :- Spontan (kelainan letak, CPD, kontraksi Spontan (kelainan letak, CPD, kontraksi
>>>)>>>)- Traumatik (penggunaan alat bedah Traumatik (penggunaan alat bedah
obstetri, dorongan uterus >>>, plasenta obstetri, dorongan uterus >>>, plasenta manual, kecelakaan)manual, kecelakaan)
- Lokus minoris (bekas operasi)Lokus minoris (bekas operasi)
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Ruptur uteriRuptur uteri
Jenis :Jenis :
- Inkomplit (lapisan miometrium robek – Inkomplit (lapisan miometrium robek – lapisan serosa utuh)lapisan serosa utuh)
- Komplit (robekan sampai lapisan serosa)Komplit (robekan sampai lapisan serosa)
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Ruptur uteriRuptur uteri
Gejala :Gejala :
1.1. Awal : his kuat terus menerus, Awal : his kuat terus menerus, nyeri di abdomen bawah, gelisah, nyeri di abdomen bawah, gelisah,
2.2. Ruptur baru : akut abdomen Ruptur baru : akut abdomen shock + teraba janin di rongga shock + teraba janin di rongga abdomenabdomen
3.3. Ruptur lama : meteorismus + Ruptur lama : meteorismus + defans muskulardefans muskular
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Ruptur uteriRuptur uteri
PenangananPenanganan
- Laparatomi segeraLaparatomi segera- Infus + penanganan shockInfus + penanganan shock- TransfusiTransfusi
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Ruptur UteriRuptur Uteri
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Ruptur UteriRuptur Uteri
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Ruptur uteriRuptur uteri
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Perdarahan Pospartum (PPH)Perdarahan Pospartum (PPH)
Definisi :Definisi :
- Kehilangan darah > 500 ml (pervaginam)Kehilangan darah > 500 ml (pervaginam)- Kehilangan darah > 1000 ml (SC)Kehilangan darah > 1000 ml (SC)- 24 jam pertama (early PPH)24 jam pertama (early PPH)- > 24 jam (late PPH)> 24 jam (late PPH)
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Perdarahan Pospartum (PPH)Perdarahan Pospartum (PPH)
Faktor Predisposisi :Faktor Predisposisi :
- Atoni uteriAtoni uteri- Retensio plasenta / sisa plasenta Retensio plasenta / sisa plasenta - Trauma jalan lahirTrauma jalan lahir- Gangguan koagulasiGangguan koagulasi- IatrogenikIatrogenik
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Perdarahan PostpartumPerdarahan Postpartum
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Diagnosis PPHDiagnosis PPH
Perdarahan banyak dalam waktu pendekPerdarahan banyak dalam waktu pendek perdarahan perlahan (lama) sampai syokperdarahan perlahan (lama) sampai syok
FN FN ↑ , FP ↑, TD ↓↑ , FP ↑, TD ↓
Atoni : uterus besar dan lembekAtoni : uterus besar dan lembek
Perlukaan : uterus berkontraksiPerlukaan : uterus berkontraksi
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Diagnosis of vaginal bleeding after childbirth
Presenting Symptom and Other Presenting Symptom and Other Symptoms and Signs Typically PresentSymptoms and Signs Typically Present
Symptoms and Signs Sometimes Symptoms and Signs Sometimes PresentPresent
Probable DiagnosisProbable Diagnosis
• • Immediate PPHImmediate PPHaa • • Uterus soft and not contractedUterus soft and not contracted
• • ShockShock Atonic uterus
• • Immediate PPHImmediate PPHaa
• • Complete placenta Complete placenta • • Uterus contractedUterus contracted
Tears of cervix, vagina or perineumTears of cervix, vagina or perineum
• • Placenta not delivered within 30 minutes Placenta not delivered within 30 minutes after deliveryafter delivery
• • Immediate PPHImmediate PPHaa • • Uterus contractedUterus contracted
Retained placentaRetained placenta
• • Portion of maternal surface of placenta Portion of maternal surface of placenta missing or torn membranes with vesselsmissing or torn membranes with vessels
• • Immediate PPHImmediate PPHaa • • Uterus contractedUterus contracted
Retained placental fragmentsRetained placental fragments
• • Uterine fundus not felt on abdominal Uterine fundus not felt on abdominal palpation palpation • • Slight or intense painSlight or intense pain
• • Inverted uterus apparent at vulva Inverted uterus apparent at vulva • • Immediate PPHImmediate PPHbb
Inverted uterusInverted uterus
• • Bleeding occurs more than 24 hours Bleeding occurs more than 24 hours after delivery after delivery • • Uterus softer and larger than expected Uterus softer and larger than expected for elapsed time since deliveryfor elapsed time since delivery
• • Bleeding is variable (light or heavy, Bleeding is variable (light or heavy, continuous or irregular) and foul-smelling continuous or irregular) and foul-smelling • • AnaemiaAnaemia
Delayed PPHDelayed PPH
• • Immediate PPHImmediate PPHaa (bleeding is intra- (bleeding is intra-abdominal and/or vaginal) abdominal and/or vaginal) • • Severe abdominal pain (may decrease Severe abdominal pain (may decrease after rupture)after rupture)
• • Shock Shock • • Tender abdomenTender abdomen• • Rapid maternal pulseRapid maternal pulse
Ruptured uterusRuptured uterus
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Komplikasi PPHKomplikasi PPH
KematianKematian
InfeksiInfeksi
Sindrom SheehanSindrom Sheehan
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PencegahanPencegahan
Anemia Anemia Kala III hindari manipulasi uterus sebelum Kala III hindari manipulasi uterus sebelum
plasenta lahirplasenta lahirManajemen aktif kala IIIManajemen aktif kala IIIOksitosin 10 unitOksitosin 10 unitErgometrin 0,2 mgErgometrin 0,2 mg
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PenangananPenangananMinta bantuan (shout for help) Minta bantuan (shout for help) Buat penilaian keadaan umumBuat penilaian keadaan umum
TD, FN, FP, STD, FN, FP, SJika shock Jika shock tatalaksana segera tatalaksana segeraMasase uterus (+ oksitosin 10 U IM Masase uterus (+ oksitosin 10 U IM
+ ergometrin 0,2 mg IM)+ ergometrin 0,2 mg IM) InfusInfusPasang kateterPasang kateterCek plasenta telah lahir (komplit / Cek plasenta telah lahir (komplit /
tidak)tidak)
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PenangananPenanganan
Cek robekan serviks, vagina & perineumCek robekan serviks, vagina & perineumKompresi bimanualKompresi bimanualPerasat Dickinson (multipara)Perasat Dickinson (multipara)Tamponade utero vaginaTamponade utero vaginaLigasi arteri hipogastrika Ligasi arteri hipogastrika histerektomi histerektomi Setelah perdarahan teratasi (24 jam) Setelah perdarahan teratasi (24 jam)
cek Hb dan Htcek Hb dan Ht
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Perdarahan PosPerdarahan Posttpartum (PPH)partum (PPH)
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Kompresi BimanualKompresi Bimanual
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Atoni UteriAtoni Uteri
Sebab : Sebab :
-- Partus lamaPartus lama
-- Pembesaran uterus berlebihanPembesaran uterus berlebihan
-- MultiparitasMultiparitas
-- Anastesi yang dalamAnastesi yang dalam
-- Anastesi LumbalAnastesi Lumbal
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AtoniAtoni
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Retensio PlasentaRetensio Plasenta
Plasenta belum lahir ½ jam setelah janin Plasenta belum lahir ½ jam setelah janin lahirlahir
Plasenta belum lepas :Plasenta belum lepas :
-- Plasenta adhesivaPlasenta adhesiva
-- Plasenta akreta – perkretaPlasenta akreta – perkretaPlasenta InkarserasioPlasenta Inkarserasio
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Penanganan Retensio Plasenta Penanganan Retensio Plasenta
Perasat CredePerasat Crede
Hati-hati : Inversio uteriHati-hati : Inversio uteriPerasat BrandtPerasat BrandtManualManualPlasenta Inkreta Plasenta Inkreta Histerektomi Histerektomi Inkarserasio plasenta Inkarserasio plasenta Anastesi Umum Anastesi Umum
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Plasenta ManualPlasenta Manual
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Inversio UteriInversio Uteri
Bagian atas uterus masuk kavum Bagian atas uterus masuk kavum uteriuteri
Spontan atau akibat tindakanSpontan atau akibat tindakanGejala klinikGejala klinik
Nyeri hebat Nyeri hebat syok syokTarikan ligamentum ke dalam Tarikan ligamentum ke dalam terowongan inversioterowongan inversio
DiagnosisDiagnosis
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Penanganan Inversio uteriPenanganan Inversio uteri
Hindari tindakan yang dapat Hindari tindakan yang dapat menyebabkan inversiomenyebabkan inversio
Cairan (elektrolit + transfusi)Cairan (elektrolit + transfusi)Reposisi (anastesi)Reposisi (anastesi)Laparotomi (Haultein)Laparotomi (Haultein)
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Inversio UteriInversio Uteri
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