Scenario C blok 24 tahun 2017

Mrs. Sukinem, a 38 years old women in her fifth pregnancy delivered her son
spontaneously 4 hours ago. She was helped by birth attendant in her village, about
1,5 hours away from referral hospital. She lived with her husband who is a farmer
and her mother in law who is a birth attendant. She gave birth a male baby, weighed
4000 grams. The placenta was delivered by birth attendant, she clamed it was
delivered completely.
1. Suddenly after placenta was delivered, massive blood was came out from vagina.
The birth attendant called midwife and according to midwife, uterine contraction was
poor and uterine fundal could not be palpated at that time.
2. She gave the mother intramuscular oxytocin injection 10 IU and reffered her to
primary public health service (Puskesmas) which already got PONED certification.
3. Her antenatal care history was 2 times with midwife in this public health and already
diagnosed with mild anemia due to Fe serum deficiency (her last month Hb count
was 9 g/dl).
4. On arrival, as general practitioner public health service, you find the patient is
consciousness but drowsy and pale. You also find approximately 1000 ml of blood
clot in her pants.
In the examination findings:
Height 155 cm, weight 50 kg. blood pressure 60/40 mmHg, heart rate 140x/minute,
RR 36x/minute, temperature 35C. the peripheral extremities are cold. The abdomen
is otherwise soft and non tender. The uterus fundal can not be palpated, no uterine
contraction. On vaginal inspection there is blood colt in vagina and no portio
laceration or vaginal/perineal laceration are identified.
5. You do resuscitation on her, made her to become in Tredenlenburg position, gave her
oxygen 6-8 L/minute, insert 2 venous line and folley catheter, do blood examination
including routine blood analysis, hemostatic analysis, and serum blood analysis. You
gave 2000 ml crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500
ml crystalloid fluid.
6. After 30 minutes, she become conciouness and not drowsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, RR 22x/minute, temperature 35,8 C, urine
output 100 cc. you reexamine the patient again, uterine fundal still can not be
 palpated, uterine contraction is poor, and vaginal bleeding is still coming out. You do
bimanual interna compression but still no uterine contraction. You gave her
misoprostol 600g vaginally and do abdominal aorta compression, but uterine
contraction wont get better. You insert uterine tamponade using Sayeba condom
method, and plan reffer her to RSMH, hospital nearby.
7. The laboratory result come out:
Hb: 4,2 g/dl
White cell count : 3.200/mm3
Platelet : 115.000/mm3
INR : 1,3
APTT : 39
8. You finally reffer this patient after 1 hours treatment in your public health service to
RSMH.

Klarifikasi istilah

1 Birth Bidan tradisional (dukun beranak)

attendant
2 oxytosin Hormon alami yang digunakan untuk menginduksi
persalinan atau memperkuat kontraksi persalinan ketika
melahirkan, dan untuk mengendalikan perdarahan
setelah melahirkan
3 PONED Suatu sertifikasi dari SK Bupati berisi serangkaian
Certification langkah dalam membangun dan mempertahankan
kapasitas puskesmas dalam memberikan pelayanan
obstetric dan ginekologi emergensi dasar.
4 Drowsy
5 Vaginal/perin Luka di vagina atau di lapisan kulit dan otot di sekitar
eal vulva. Biasanya paling banyak di perineum
laceration
6 Tredelenburg Posisi berbaring pada tempat yang mendatar dimana
position kepala berada lebih rendah daripada pelvis.
7 Folley Kateter dengan balon yang dikembangkan dengan
Catheter udara atau cairan untuk menahan posisi uterus pada
vesica urinaria.
8 Crystalloid Larutan air dengan elektrolit dan atau dekstrosa, tidak
Fluid mengandung molekul besar.
9 Packed red Sel darah merah yang telah dipisahkan untuk transfuse
cell darah.
10 Bimanual Tangan kiri penolong dimasukkan ke dalam vagina dan
interna sambil membuat kepalan diletakkan pada fornix
compression anterior vagina. Tangan kanan diletakkan pada perut
 penderita dengan memegang fundus uteri dengan
telapak tangan dan ibu jari di depan serta jari jari lain di
belakang uterus.
11 Misoprostol Analog prostaglandin E1 yang sintetik yang dipakai
untuk mengobati iritasi lambung dengan pemakaian
obat anti inflamasi non steroid dalam jangka panjang
12 Abdominal Suatu tehnik kompresi eksternal aorta abdomen
aorta sebagai bentuk maneuver emergensi untuk mengurasi
compression perdarahan postpartum dan memberikan waktu untuk
resusitasi dan control perdarahan.
13 Uterin Suatu tindakan untuk menghentikan perdarahan
tamponade postpartum apabila metode uteritonik gagal.
14 Sayeba Pemasangan tampon berupa kondom yang diikatkan
condom pada kateter dan dimasukkan ke kavum uteri secara
method aseptic untuk menghantikan PPH.
15 INR International Normalized Ratio. Indikator
kecenderungan pembekuan darah untuk membantu
menentukan dosis pasien selama pemberian terapi anti
koagulan oral.
16 APTT Activated partial thromboplastin time, adalah uji
laboratorium untuk menilai aktivitas faktor koagulasi
jalur intrinsic dan jalur bersama.

Identifikasi Masalah

1. Mrs. Sukinem, a 38 years old women in her fifth pregnancy delivered her son
spontaneously 4 hours ago. She was helped by birth attendant in her village, about
1,5 hours away from referral hospital. She lived with her husband who is a farmer
and her mother in law who is a birth attendant. She gave birth a male baby, weighed
4000 grams. The placenta was delivered by birth attendant, she clamed it was
delivered completely.
2. Suddenly after placenta was delivered, massive blood was came out from vagina.
The birth attendant called midwife and according to midwife, uterine contraction was
poor and uterine fundal could not be palpated at that time.
3. She gave the mother intramuscular oxytocin injection 10 IU and reffered her to
primary public health service (Puskesmas) which already got PONED certification.
4. Her antenatal care history was 2 times with midwife in this public health and already
diagnosed with mild anemia due to Fe serum deficiency (her last month Hb count
was 9 g/dl).
 5. On arrival, as general practitioner public health service, you find the patient is
consciousness but drowsy and pale. You also find approximately 1000 ml of blood
clot in her pants.
In the examination findings:
Height 155 cm, weight 50 kg. blood pressure 60/40 mmHg, heart rate 140x/minute,
RR 36x/minute, temperature 35C. the peripheral extremities are cold. The abdomen
is otherwise soft and non tender. The uterus fundal can not be palpated, no uterine
contraction. On vaginal inspection there is blood colt in vagina and no portio
laceration or vaginal/perineal laceration are identified.
6. You do resuscitation on her, made her to become in Tredenlenburg position, gave her
oxygen 6-8 L/minute, insert 2 venous line and folley catheter, do blood examination
including routine blood analysis, hemostatic analysis, and serum blood analysis. You
gave 2000 ml crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500
ml crystalloid fluid.
7. After 30 minutes, she become conciouness and not drowsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, RR 22x/minute, temperature 35,8 C, urine
output 100 cc. you reexamine the patient again, uterine fundal still can not be
palpated, uterine contraction is poor, and vaginal bleeding is still coming out. You do
bimanual interna compression but still no uterine contraction. You gave her
misoprostol 600g vaginally and do abdominal aorta compression, but uterine
contraction wont get better. You insert uterine tamponade using Sayeba condom
method, and plan reffer her to RSMH, hospital nearby.
8. The laboratory result come out:
Hb: 4,2 g/dl
White cell count : 3.200/mm3
Platelet : 115.000/mm3
INR : 1,3
APTT : 39
9. You finally reffer this patient after 1 hours treatment in your public health service to
RSMH.

Analisis Masalah

1. Mrs. Sukinem, a 38 years old women in her fifth pregnancy delivered her son
spontaneously 4 hours ago. She was helped by birth attendant in her village, about
 1,5 hours away from referral hospital. She lived with her husband who is a farmer
and her mother in law who is a birth attendant. She gave birth a male baby, weighed
4000 grams. The placenta was delivered by birth attendant, she clamed it was
delivered completely.
a. Bagaimana hubungan usia ibu dengan status obstetric (kelahiran yang
kelima)? 1,3,5
b. Bagaimana pengaruh persalinan spontan pada kelahiran yang kelima? 7,9,2
c. Bagaimana pengaruh berat badan bayi lahir terhadap proses persalinan? 4,6,8
d. Bagaimana cara persalinan plasenta yang benar? 1, 2,7
e. Bagaimana cara mengetahui jika plasenta telah dilahirkan sempurna? 2,5,8
f. Apa komplikasi persalinan plasenta yang tidak sempurna? 3,6,9

2. Suddenly after placenta was delivered, massive blood was came out from vagina.
The birth attendant called midwife and according to midwife, uterine contraction was
poor and uterine fundal could not be palpated at that time.
a. Bagaimana pengaruh lahir per vaginam, berat badan bayi lahir dan usia ibu
dengan perdarahan postpartum? 9, 5,1
b. Apa saja penyebab dan mekanisme perdarahan postpartum pada kasus? 8, 4,
2
c. Apa penyebab dan mekanisme kontraksi uterus lemah dan fundus uteri tidak
teraba? 7, 3,4
d. Apa dampak perdarahan masif pada ibu? 6, 2, 3

3. She gave the mother intramuscular oxytocin injection 10 IU and reffered her to
primary public health service (Puskesmas) which already got PONED certification.
a. Apa saja indikasi pemberian oksitosin pada kasus? 5, 8, 2
b. Bagaimana mekanisme kerja oksitosin? 6, 9, 3
c. Apa indikasi rujuk pada kasus? 7, 1, 4
4. Her antenatal care history was 2 times with midwife in this public health and already
diagnosed with mild anemia due to Fe serum deficiency (her last month Hb count
was 9 g/dl).
a. Bagaimana hubungan anemia dengan kejadian perdarahan pada kasus? 5, 6,7
b. Bagaimana tatalaksana anemia dan manajemen persalinan pada ibu hamil
dengan anemia? 8,9, 1

5. On arrival, as general practitioner public health service, you find the patient is
consciousness but drowsy and pale. You also find approximately 1000 ml of blood
clot in her pants.
In the examination findings:
 Height 155 cm, weight 50 kg. blood pressure 60/40 mmHg, heart rate 140x/minute,
RR 36x/minute, temperature 35C. the peripheral extremities are cold. The abdomen
is otherwise soft and non tender. The uterus fundal can not be palpated, no uterine
contraction. On vaginal inspection there is blood clot in vagina and no portio
laceration or vaginal/perineal laceration are identified.
a. Bagaimana interpretasi dan mekanisme abnormal dari hasil pemeriksaan
fisik? 2, 7, 3
b. Bagaimana interpretasi dan mekanisme abnormal dari hasil pemeriksaan
obstetrik? 3, 8,4
c. Berapa banyak volume darah yang hilang pada persalinan normal? 4,9,5
d. Apa kriteria diagnostik syok hemoragik? 5, 1, 6
e. Apa makna klinis pada inspeksi vagina tidak ditemukan laserasi di portio atau
vagina/perineum? 6, 2,7

6. You do resuscitation on her, made her to become in Trendelenburg position, gave her
oxygen 6-8 L/minute, insert 2 venous line and folley catheter, do blood examination
including routine blood analysis, hemostatic analysis, and serum blood analysis. You
gave 2000 ml crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500
ml crystalloid fluid.
a. Bagaimana gambaran posisi trendelenburg dan apa tujuannya? 8, 2, 5
b. Apa indikasi dan tujuan resusitasi? 9, 3, 6
c. Bagaimana prosedur resusitasi pada PPH? 1, 4,7

7. After 30 minutes, she become conciouness and not drowsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, RR 22x/minute, temperature 35,8 C, urine
output 100 cc. you reexamine the patient again, uterine fundal still can not be
palpated, uterine contraction is poor, and vaginal bleeding is still coming out. You do
bimanual interna compression but still no uterine contraction. You gave her
misoprostol 600g vaginally and do abdominal aorta compression, but uterine
contraction wont get better. You insert uterine tamponade using Sayeba condom
method, and plan reffer her to RSMH, hospital nearby.
a. Mengapa pada kasus kontraksi uterus masih buruk dan masih ada
perdarahan? 8, 5, 2
b. Bagaimana cara bimanual interna compression dan apa tujuannya? 9,6,3
c. Apa indikasi pemberian misoprostol? 1,7, 4
d. Bagaimana cara abdominal aorta compression dan apa tujuannya? 2, 8, 5
e. Apa indikasi tamponade uteri dengan metode kondom Sayeba? 3, 9, 6
 f. Bagaimana metode kondom Sayeba? 4, 1, 7
8. The laboratory result come out:
Hb: 4,2 g/dl
White cell count : 3.200/mm3
Platelet : 115.000/mm3
INR : 1,3
APTT : 39
You finally refer this patient after 1 hours treatment in your public health service to
RSMH.
a. Bagaimana interpretasi dan mekanisme abnormal dari hasil pemeriksaan
laboratorium? 8, 4, 9
b. Apa indikasi rujuk ke RS tipe A? 9, 5, 1
c. Bagaimana sistem rujukan yang benar pada kasus? 1, 6 , 2
d. Bagaimana prosedur yang dilakukan sesuai kompetensi dokter umum? 2,
7, 3
e. Tindakan apa yang dilakukan pasca rujukan ke rumah sakit? 3, 8, 4
10. Aspek Klinis
a. DD 5, 7, 9
b. Algoritma diagnosis 6, 1,3
c. DK SEMUA
d. Etiologi 8, 2,4
e. Epidemiologi 9, 3, 5
f. Faktor resiko 1,4, 6
g. Patogenesis dan patofisiologi 2,5,7
h. Manifestasi klinis 3,6,8
i. Pemeriksaan penunjang 4,7,9
j. Tatalaksana dan follow-up 5,8,1
k. Edukasi dan pencegahan 6,9,2
l. Komplikasi 7,1,3
m. Prognosis 8,2,4
n. SKDI SEMUA

HIPOTESIS

Ny. Sukinem 38 tahun mengalami perdarahan postpartum akibat atonia uteri.

Learning Issues

1. Fisiologi kelahiran normal 1, 3, 5

2. Perdarahan Postpartum SEMUA
3. Atonia Uteri 2,4,6
4. Penanganan syok hemoragik 8,7,9