F, 26 th, 74 kg

KU:Labour pain.
T : This has been experienced by the patient since 06.00 AM of SMRS. Abdominal pain
felt all over the abdomen, feels like creamping, which appears for 3-5 minutes and
elapsed. The patient is currently pregnant at 39 weeks' gestation.
Mucus drained out from the genitals (+). History of High blood pressure before
pregnancy (-). Headache (-). Cough(+), cough with phlegm (-) coughing up blood
(-), Dyspnoe (-) Fever (-), history leave the house without a mask (+), family and
neighbors positive covid (unknown), history of COVID vaccine 3x, history of
nausea vomitus (-), Urine output (+)N, Defecation(+)N, History of cigarrete smoking
(-), DM(-), HT(-)

HPHT : 26- 03 - 2020

TTP : 31 - 12 - 2022
:nothing
RPO
RPT :nothing
History of ANC: 4X to SpOG
 History of Pregnancy

1. This pregnant
A : Metals
M : NOT FOUND
P : NOT FOUND
L : 06.00 AM, 25/12/2022
E gravida 39 weeks
 25-12-2022, 03.00 PM
Arrived in RSHAM

25-12-2022
Consul Anesthesia at. 09.15 PM - ACC Anesthesia at. 09.25
PM

25-12-2021
AT 11.10 PM, SC operation
 Phisical diagnostic
-B1: Airway clear; S/G/C -/-/-; RR 20x/i; Sp ves/ves,
St -/- ; SpO2 98% Room Air, history of .
asthma/allergy/cough -/-/+, cough with phlegm (-).
-B2: Acral H/M/K; BP 137/93 mmHg; HR 98 x/I regular;
t/v strong/sufficient; CRT < 2 seconds.
-B3: Sens CM; Isocor pupil Φ 3 m m L = R; RC +/+.
-B4: Urine (+); catheter attached (-).
-B5: Asymmetrically enlarged abdomen, peristalsis (+) N, TFU
2 fingers bpx, fetal movement (+), FHR 150 x/minute, His(+),
-B6: Pretibial edema (-), Fracture (-)
 LABORATORIUM 25/12/2022
- Hb/ Ht/Leu/Tr : 12.8/36/8.790/259.000
- Na/K/Cl : 142/4.0/106
- PT/aPTT/INR : 15,6 (15,2)/57(39)/1,03

- swabs : Positive
- Hbsag : Non reactive
- Anti-HIV : Non reactive
Heart and lung size at normal
range
 Treatment in isolation Room
-bed rest

-applying iv line with cath 18 G, make sure the iv line is fluent,

take a blood sample, crossmatch
-Fasting since planned surgery
-Give something on the pelvis for raise right Pelvis
Preparation Steps:
-
-Patient preparation:
-Preparation for spinal anesthesia
-Preparation for Intubation
-Apply IV line with 18 G
-give O2 with nasal cannula 3 lpm
-Hemodynamic monitoring: awareness, BP, HR, T/V pulse,
UOP, FHR
-Informed consent + SIA

-Preparation of tools, medicine , and resuscitation equipment

-DIAGNOSIS : Susp Covid-19 + PG
+ IUP (38-39 weeks) + HP + FA + Inpartu+ CPD

-Procedure : Sectio Cesaria

-PS ASA : 2 E (susp Covid 19 + Pregnancy )

-ANESTHESIA : RA-SAB
-POSITION : Supine
-Blood preparation: Technical
 Technique of Anestesia
- Hemodynamic monitoring
- Preload 1000 cc RL
- Patient Position the sitting
- Identify L3-L4
- Disinfection with povidone iodine and 70% alcohol
- Spinal needle insertion No 25G penetrates the cutis - subcutis -
supraspinous ligament - interspinous ligament - ligamentum
flavum - Epidural space - durameter - sub-arachnoid space - CSF
(+), blood (-), inj. bupivacaine 12.5mg + fentanyl 25 mcg
- Return to supine position, set the block height to T4
 ACTUAL PROBLEM LIST
Problem Solving

• Emergency surgery patient - Fasting since the planned operation

• Fasting patient - Replace the fasting fluid and make sure the IV line is fluent, apply a
large bore (maintenance x fasting time)

• Pregnant patient under - Immediate termination of pregnancy

anesthesia Principle: safe
mother, safe baby, safe
uterus

Patients with pregnancies

where physiological changes
occur in pregnant women

1. Short neck, big • Prepare difficult intubation tools

chest, weight gain
during pregnancy, difficult
intubation
2. Patients with pregnant women, the

larynx is usually more edematous • Prepare ett 3 number 6, 6.5, and 7.0
 Problem Solving

•Patients with - Prevent the spread of infection with Level

swab suspect 3 Personal Protective Equipment (PPE).
Covid19(+) - Preparation of negative pressure OR
- The patient continues to wear a mask to
prevent the spread of aerosols
 Problem Solving
• Pregnant woman with changes in • Due to changes in the anatomy and
anatomy and physiology
physiology of the GIT in pregnant women,
• As a result of enlargement of the fundus
and antrum - increased intragastric pregnant women should always be suspect
pressure. with a full stomach, ensure fasting
enough - prevent Mendelson Syndrome.
. Changes in GIT Physiology A gravid uterus
causes; prolonged gastric emptying time. •- Give antacids non particulate 30 cc ½ hour
-there is an increase in the secretion before surgery Because the molecule is small it
of the hormone gastrin - it increases prevents aspiration; inj ranitidine 50 mg,
the secretion of acid gaster.
- due to increased plasma progesterone
levels, GIT motility - food absorption and
pressure
sphincter distal oesophageal decreased
-presence of analgesic drugs - can
slow gastric emptying.
PROBLEM LIST

Problem Solving
Pre operation
Changes in Respiratory Anatomy and Physiology
- Term pregnancy: FRC decreases due to the
anatomical diaphragm being pushed by the gravid
uterus
-Prepare oxygen  oxygenate with O2 nasal cannula 2
- FRC decreases  oxygen reserves decrease
- Term pregnancy causes an increase in oxygen l/min.
demand of 30-40% due to increased metabolism for
- Monitoring airways.
the fetus, uterus, placenta.
 Problem Solving
Cardiovascular Changes
− Term pregnancy with gravis enlargement can cause •Right hip pad, fluid preloading, prepare colloid,
aortocaval compression when in supine position  prepare ephedrine
SUPINE HYPOTENSIVE SYNDROME
 Problem List
Problems Solving

Durante op:
Patients under regional anesthesia
•Ensure adequate patient fluids (euvolume)
•Make sure infusion is free flow
•Prepare ephedrine  dilute 1ml of
ephedrine become 10cc with nacl 0,9%

High block or total block •Head up position to prevent further

upward spread local anaesthetic
•Deliver high flow oxygen

Bleeding risk  Calculate EBV (Estimated •Calculate need for resuscitation fluids and
Blood Volume) evaporation fluids. Monitoring HR, UOP,
warm fluids, turn off air conditioning, put
blankets on.

•EBV = 90 x 74 = 6660cc
•EBL = 10 % = 660 cc
• 20% = 1.332 cc
• 30% = 1.998 cc
 Problem List Potential (cont..)
Problem Solving
Durante op:
• The potential for a baby to be • Prepare for newborn
born with a low APGAR score resuscitation equipments and
drugs
 Problem List Post Operation
Problem Solving

Post op: • Strict monitoring of hemodynamics and fluid

• Post op pain  triggers blood balance
pressure to rise • Gives strong analgesics

• Adequate antibiotics

• Post operation infection • Prepare an isolation room for the mother and
baby

• Patient with suspected Covid 19

DURING OPERATION
• BP : 110-130 /70-90 mmHg
• HR : 82-100 x/minute
• Fluid : PO RL 1000 cc,
DO RL 1500 cc
• Bleeding : + 600 cc
• Maintenance : (4.10)+(2.10)+(1.54) = 114cc/hour, +
evaporation = 6 x 74 kg = 444 cc/hour
• UOP : 1000 cc, clear yellow
• APGAR SCORE : 3/8
• Operating time : + 2 hour 30 minutes
Baby clinical presentation
• APGAR SCORE: 3/8

• Weight : 3200 gr
 Post operation
• B1: Airway: clear, BS: vesicular +/+, AS -/-, RR: 18 x/i. SpO2: 98%. NC
3LPM
• B2: Acral: W/R/D, BP : 111/87 mmHg, HR: 79 x/i, reg, t/v: strong
and sufficient
• B3: Sens: CM, pupil isocoria Φ3mm, LR +/+, convulsion(-)
• B4: Urine (+), color: clear yellow
• B5: Abdomen, peristaltic (+), bandaged surgical wound .
• B6: Pretibial edema (-), Fracture(-)
 Planning post operation
• Bed rest + Head up 30
• IVFD RL 30 gtt/i
• Inj. Ceftriaxone 1 gr/12 hour
• Paracetamol 3x1000mg
• Inj. Ketorolac 30 mg/8 hour
• Inj. Ranitidine 50 mg/12 hour
• Prepare transport to isolation room
 THANK YOU
Terima Kasih
TIm Jaga
 PROBLEM SOLUTION
PRE OPERATION • Due to anatomical changes
• Pregnant woman with changes in anatomy
and physiology and GIT physiology in pregnant women, pregnant

women must always be taken into account

AChanges to the Anatomy of the GIT
•As a result of enlargement of the fundus full stomach, ensure fasting
and antrum - increased intragastric tek. enough - prevent Mendelson Syndrome.

B. Changes in GIT Physiology

• A gravid uterus causes; •Give antacids 30 cc ½ hour before
- Increased intra-gastric -
prolonged gastric emptying time. surgery, preferably non-particulate,
- there is an increase in the secretion of the because the molecule is small prevent
hormone gastrin - increases the secretion of
aspirations.
stomach acid.
- due to increased plasma progesterone
levels, GIT motility - food absorption and
pressure oesophageal sphincterdistal bgn • Reduce the dose of anesthetic drug administration
decreased. local
- presence of analgesic drugs - can
slow gastric emptying.
 Problem Solving
Pre operation
C. Changes in Respiratory Anatomy
and Physiology

- Term pregnancy: FRC decreased because - Prepare oxygen - oxygenate with O2

of the anatomy of the diaphragm
pushed by the gravid uterus nasal cannula 2 l/minute,.
-FRC decreased - oxygen reserve - Monitoring airways.
decreased ,,.
- Term pregnancy causes oxygen
demand to increase by 30-40% due to
increased metabolism for the fetus,
uterus, placenta.
- MAC decreased will cause

- MAC decreased - due to increased pregnant women more anesthetic

hormone progesterone gas that
get into the alveoli - then preferably choice

anesthesia is the less use of inhalation

drugs, the th
Regional Anesthesia.
 Problem Solving
D. Cardiovascular changes
- Term pregnancy with enlarged gravid •Right hip pad, fluid preloading, prepare
can cause compression of the aorta colloid, prepare ephedrine
cava when in supine position -
SUPINE HYPOTENSIVE SYNDROME
 score 0 1 2
color pale pinkbody, Pink
peripherals
acrocyanosis
HR absences <100 >100
Respond to none grimace Cough, sneeze
stimulation
muscle tone flaccid Some movements moving
Respiration none Weak, irregular Crying, regular

Normal : 7-10
Moderate impairment : 4-6
Needs resuscitation :0-3
- Mendelson's syndrome is a collection of symptoms caused by aspiration of
gastric juices during general anesthesia. This can happen if:
- Intake fluid pH <2.5 aspirated volume greater than 0.3 ml/kg body weight (20-25 ml
in adults)
- Clinical symptoms:
- Tachypnea
- Tachycardia
- Wheezing / crackles
- cyanosis

-Complications:

1. Pulmonary oedema

2. Shock
3. Pneumonia
4. ARDS
5. Bronchiectasis
-Full movement of the limbs, 0
-Unable to extend leg, 1
-Unable to flex the knee, 2
-Unable to flex ankle 3
• Patient position
• For the barity of the solution, it is recommended to use a hyperbaric
solution (the drug is heavier than the CSF so that it remains
precipitated below, reducing the possibility of high spinal pressure),
compared to hypo or isobaric solutions.
• Total volume dose of local anesthetic drug.
• Injection site
• Injecting speed (barbotage)
• Large spinal needle
• Physical state
• Intra-abdominal pressure
- Drugs used
-The dose given
- Administration of a vasoconstrictor

- Spread/height of the blocks

- Until now there is no strong clinical evidence
recommending one method of delivery, so delivery is
based on obstetric indications by taking into
account the wishes of the mother and family,
except for mothers with respiratory problems who
require immediate delivery in the form of SC or
vaginal surgery.
-Anesthesia. Give epidural or spinal anesthesia as
indicated and avoid general anesthesia unless
absolutely necessary.
- Until now, there is no evidence of mother-to-child
transmission and increased worsening of outcomes
in mothers and neonates
-The SARS-Cov-2 RNA virus has not been detected in breast milk and
there is no transmission through breast milk
-Children at low risk of COVID-19 infection
19. Out of a total of 72,314 people with confirmed COVID-19,
only 1% were children aged
-Care and feeding recommendations for infants of mothers
with suspected or confirmed COVID-19 improve the
health and well-being of mothers and babies
- Recommendations should consider not only the risk
of infection in infants with COVID19, but also the
risk of serious morbidity and mortality associated
with not breastfeeding or using inappropriate
•breastmilk substitutes.
- Breastfeeding and breastfeeding protect against
morbidity and mortality during infancy and childhood.
• -Formothers, breastfeeding protects against
breast cancer and increases birth spacing, and
may protect against ovarian cancer and type 2
diabetes
• -Skincontact and KMC improve thermoregulation and
several other physiological outcomes and are associated
with reduced neonatal mortality
-All
babies born to mothers with PDP or
confirmed COVID-19 also need to be tested for
COVID-19.