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Preoperativeimplicationsofthephysiologicchangesofpregnancy
OrganSystem
Cardiovascular
PhysiologicChange
Increasedcardiacoutput
PreoperativeImplication
PossiblegradeIIsystolic
ejectionmurmur
Enlarginguterus
1. Displacedpointof
maximalcardiac
impulse
2. Supinehypotensive
Respiratory
Swellingoftheairway
syndrome
Increasedprobabilityof
MallampaticlassIIIorIV
airway
Enlarginguterus
1. Displaced
diaphragm
cephalad
2. Increasedlung
markingson
Increasedminute
Enlarginguterus
respiratoryrate
2. Possibledyspnea
3. DecreasedPaCO2
Fullstomachprecautions
Increasedplasmavolume
duringthirdtrimester
Anemia(Hemoglobin=11
andredcellmass
g/dL)
Increasedcoagulation
Deepvenousthrombosis
factors(exceptXIand
prophylaxis
XIII)
Increasedrenalplasma
postoperatively
Decreasedbloodurea
flowandglomerular
nitrogen(89g/dL)and
ventilation
Gastrointestinal
Hematologic
Renal
radiography
1. Increased
filtrationrate
creatinine(0,40,5g/dL)
In 1997, the National Institute of Child Health and Human Development
proposeddefinitionsfortheinterpretationoftheFHR.Thisgroupclassifiedvarious
decelerations in FHR during uterine contraction: Earlynadir with peak of the
contraction; lateonset and nadir after onset and peak of contraction; variablean
abruptdecreasedinFHR.Theotherimportantcriterionwasbaselinevariabilityorthe
amplitudeofpeaktotroughinbeatsperminute(Fig.14.3).Threedecadesearlier,
LeeandHonhaddemonstratedthatvariabledecelerationsofFHRwereassociated
with umbilical cord compression. In their study of babies delivered via cesarean
section,theumbilicalcordwasdeliveredfirstandthencompressed.FHRdropped
markedly with compression. The association of depressed neonates with late
decelerations in the FHR led to the proposed mechanism of uteroplacental
insufficiency.Pressureontheneonateshead,whichinducedadecreaseinheartrate,
ledtotheassociationofheadcompressionandearlydeceleration.
ThepurposeofFHRmonitoringistoensurethewellbeingofthefetus.A
normal tracing (i.e., a baseline of 110 to 160 bpm, regular rate, presence of
accelerations, presence of variability, and absence of periodic decelerations) is
associatedwithahealthy,welloxygenatedfetus.Aquestionariseswhenthetracingis
not perfect because FHR patterns that accurately predict asphyxia have not been
specified. A nonreassuring tracing as an indication of fetal hypoxia has a false
positiverate>99%.
The use of continuous FHR monitoring was compared to intermittent
auscultationduringlaborin504patients.Auscultationwasappliedevery15minutes
duringorimmediatelyfollowingauterinecontraction.Nosignificantdifferencewas
found between the two groups in neonatal deaths, Apgar scores, maternal and
neonatal morbidity, and cord blood gases. The only difference was the higher
cesareansectionrateinthecontinuouslymonitoredgroup.Certainfetalpatternswere
associatedwithfetalacidosis,decreaseduterineperfusion,andfetalhypoxemia.The
presence oflatedecelerations correlated withfetalacidosis.Finally, another FHR
parameter associated with acidosis is decreased baseline variability. In 186 term
gestations subjectedtocontinuous FHRmonitoring,decreasedvariabilityinthe1
hourbeforedeliverywassignificantlycorrelatedwithlowpH.Despitethesestrong
associationswithfetalacidosis,theroleofFHRmonitoringinreducingmorbidityand
mortalityremainstobeproven.
Pada tahun 1997, Institut Nasional Kesehatan Anak dan Pembangunan
ManusiamengusulkandefinisiuntukinterpretasiFHR.Kelompokinidiklasifikasikan