Skenario C Blok 24

Kelompok A2
 Anggota
• Reza Nurdesni 04011381419148
• Wulan Purnama Sari 04011381419160
• Fidella Ayu Aldora 04011381419163
• Muhammad Alif Prizarky 04011381419173
• Ulfa Mutia 04011381419177
• Ahmad Reiman 04011381419179
• N.P. Ayu Oka Shinta 04011381419188
• Ridho Surya Putra 04011381419199
• Angelina Hendesa 04011381419200
• Masayu Shavira R.S. 04011381419213
• Vejitha Raja Kumar 04011381419222
• Pavitra Subramaniam 04011381419225
 Outline
1. Skenario
2. Klarifikasi Istilah
3. Identifikasi Masalah
4. Analisis Masalah
5. Learning Issues
6. Kerangka Konsep
7. Kesimpulan
 Skenario
Mrs Sukinem, 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 4000grams. The placenta was delivered by birth
attendant, she claimed it was delivered completely. Suddenly after placenta
was delivered, massive blood came out from the vagina. The birth attendant
called midwife and according to midwife, uterine contraction was poor and
uterine fundal could not be palpated at that time. She gave the mother
intramuscular oxytocin injection 10 IU and referred her to primary health
service (Puskesmas) which already got PONED certification. 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 9g/dl)
On arrival, as general practitioner public health service, you find the patient is
consciousness but drowsy and pale. You also find approximately 1000ml of
blood clots in her pants.
In the examination findings:
Height 155cm, weight 50kg, Blood pressure 60/40mmHg, heart rate 140x/min,
respiratory rate 36x/min, temperature 35 C. 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.
You do resuscitation on her, made her to become in Trendelenburg position, gave her
oxygen 6-8L/min , insert 2 venous line and folley catheter, do blood examination
including routine blood analysis, hemostatic analysis and serum blood analysis. You
gave 2000ml crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500 ml
crystalloid fluid.
After 30 min, she became consciousness and not drowsy anymore. Blood pressure
become 100/70mmHg, pulse 92x/min, respiratory rate 22x/min, temperature 35,8 C,
urine output 100cc. You re-examine the patient again, uterine fundal still cannot 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 600ug vaginally and do abdominal aorta compression but uterine
contraction wont get better. You insert uterine tamponade using Sayeba condom
method and plan to refer her to RSMH, hospital nearby.
The laboratory result:
Hb: 4,2g/dl
WBC: 3,200/mm
Platelet: 115 000/mm
INR: 1,3
APTT: 39’
You finally refer this patient after 1 hour treatment in you public health
service to RSMH.
 Klarifikasi Istilah
• Tredelenburg: posisi berbaring pada tempat yang datar dimana
kepala berada lebih rendah daripada pelvis.
• PONED certification: pelayanan obstetrik neonatus esensial dasar
untuk puskesmas yang mempunyai fasilitas/kemampuan utk
penanganan kegawat daruratan obstetrik dan neonatus dasar
• Placenta: organ yang tumbuh dalam rahim selama kehamilan yang
memiliki fungsi untuk menghubungkan calon bayi denganibu utk
transfer oksigen dan nutrisi
• Resuccitation: proses pertolongan pembaikan kelainan fisiologis
pada pasien akut
• Foley catheter: tabung kecil steril yang dimasukkan ke kantung
kemih untuk drainase urin
• Bimanual interna compression: dilakukan pada kasus perdarahan
primer posrtpartum dilakukan ketika semua usaha sudah gagal
untuk menyelamatkan hidup dari ibu.
 Klarifikasi Istilah
• Misoprostol: obat yg digunakan utk mencegah dan mengobati
tukak lambung.
• Oxytocin: hormon hipatalamus yg tersimpan di hipofisis posterior,
memiliki aktivitas untuk kontraksi uterus dan mengeluarkan air
susu.
• INR: international normalise ratio. Pengukuran labratorium utk
mengetahui berapa lama darah membentuk clot. Normalnya 0,9-
1,3.
• APTT: activated parsial thromboplastin time adalah pemeriksaan
untuk mengetahui pembekuan darah.
• Uterine tamponade: adalah tampon berbentuk balon yang diinsersi
ke uterus dan dikembangkan dengan tujuan untuk meghentikan
perdarahan.
• Abdominal aorta compression: adalah manuver emergensi yang
digunakan untuk menghentikan dan megontrol perdarahan
postpartum dan memungkinkan resusitasi.
 Identifikasi Masalah
No Identifikasi masalah Problem Concern

1 Mrs. Sukinem,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 gave birth a male baby, weighed 4000grams.

2 She lived her husband who is a farmer and her

✓ ★
mother in law who is a burth attendant.

3 The placenta was delivered by birth attendant, she

claimed it was delivered completely. Suddenly after
placenta was delivered, massive blood came out ✓ ★★★
from the vagina.

4 The birth attendant called midwife and according to

midwife, uterine contraction was poor and uterine
✓ ★★
fundal could not be palpated at that time.
5 She gave the mother intramuscular oxytocin injection
10IU and reffered her to primary health service( ✓ ★★
Puskesmas) which already got PONED certification.

6 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 9g/dl)
7 On arrival , as general practitioner public health service,
you find the patient is consciousness but drowsy and
✓ ★
pale. You also find approximately 1000ml of blood clots in
her pants.
8 In the examination findings:

Height 155cm, weight 50kg, Blood pressure

60/40mmHg, heart rate 140x/min, respiratory rate
36x/min, temperature 35 C. 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.
9 You do resuscitation on her, made her to become in Trendelenburg
position, gave her oxygen 6-8L/min , insert 2 venous line and folley
catheter, do blood examination including routine blood analysis,
✓ ★
hemostatic hemolysis and serum blood analysis. You gave 2000ml
crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500 ml
crystalloid fluid.
10 After 30 min, she became consciousness and not drowsy anymore.Blood
pressure become 100/70mmHg, pulse 92x/min,respiratory rate ✓ ★
22x/min, temperature 35,8, urine output 100cc.
11 You re-examine the patient again,uterine fundal still cannot 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 600ug vaginally and do abdominal aorta ✓ ★
compression but uterine contraction wont get better. You insert uterine
tamponade using Saeba condom method and plan to refer her to RSMH,
hospital nearby.
12 The laboratory result;
Hb: 4,2g/dl, WBC: 3,200/mm3, Platelet: 115 000/mm3, INR: 1,3, APTT:
39’
✓ ★
You finally refer this patient after 1 hour treatment in you public health
service to RSMH.
 Analisis Masalah
Mrs. Sukinem, 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 gave birth a male baby, weighed
4000grams.
• Bagaimana hubungan usia ibu,usia kehamilan,
jumlah partus, bb bayi?
• Apa dampak pada ibu dan janin apabila
persalinan dibantu oleh dukun beranak?
She lived her husband who is a farmer and her mother in law
who is a birth attendant.
• Apakah pada kasus ini ada pengaruh dari status
sosioekonomi?

The placenta was delivered by birth attendant, she claimed it

was delivered completely.S uddenly after placenta was
delivered, massive blood came out from the vagina.
• Bagaimana teknik melahirkan plasenta?
• Bagaimana managemen aktif kala 3 ?
• Apa saja tanda2 plasenta telah lahir dengansempurna?
• Mengapa terjadi perdarahan massive pada kasus?
The birth attendant called midwife and according to
midwife, uterine contraction was poor and uterine fundal
could not be palpated at that time.
• Apa yg menyebabkan fundus uteri tidak dapat dipalpasi?
• Apa penyebab kontraksi uterinya buruk?

She gave the mother intramuscular oxytocin injection 10 IU

and referred her to primary health service (Puskesmas)
which already got PONED certification.
• Apadampak dari pemberian injeksi oksitosin?
• Apa indikasi dan kontraindikasi pemberian injeksi
oksitosin?
• Prosedur injeksi oksitosin?
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 9g/dl)
• Apa dampak dari ANC tidak teratur?
• Bagaimana nutrisi yg baik dgn anemia ringan?
• Apa hubungan anemia ringan dgn kasus?

On arrival, as general practitioner public health service, you

find the patient is consciousness but drowsy and pale. You
also find approximately 1000ml of blood clots in her pants.
• Bagaimana mekanisme terjadi mengantuk dan pucat?
• Mengapa darah yang ditemukan dalam bentuk bekuan?
In the examination findings:
Height 155cm, weight 50kg, Blood pressure 60/40mmHg, heart rate 140x/min,
respiratory rate 36x/min, temperature 35 C. 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.
• Apa interpretasi dari pemfis?
• Bagaimana mekanisme abnormalitas?

You do resuscitation on her, made her to become in Trendelenburg position, gave

her oxygen 6-8L/min , insert 2 venous line and foley catheter, do blood examination
including routine blood analysis, hemostatic analysis and serum blood analysis. You
gave 2000ml crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500 ml
crystalloid fluid.
• Bagaimana managemen awal pada kasus ?
• Bagaimana interpretasi managemen awal pd kasus (resusitasi, oksigenasi, injeksi
oksitosin, injeksi kristaloid)?
• Bagaimana managemen koagulopati?
After 30 min, she became consciousness and not drowsy anymore.Blood pressure
become 100/70mmHg, pulse 92x/min,respiratory rate 22x/min, temperature 35,8,
urine output 100cc.
• Bagaimana interpretasi keadaan vital dan urin output?

You re-examine the patient again,uterine fundal still cannot 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 600ug vaginally and do
abdominal aorta compression but uterine contraction wont get better. You insert
uterine tamponade using Saeba condom method and plan to refer her to RSMH,
hospital nearby.
• Mengapa setelah dilakukan tatalaksana awal kontraksi uterus masih buruk dan
perdarahan vagina masih ada?
• Apa yg harus dilakukan utk mengembalikan kontraksi uterus pada kasus?
• Apa yg harus dilakukan utk menghentikan perdarahan pd kasus?
• Bagaimana cara melakukan bimanual interna compression?
• Bagaiman cara melakukan abdominal aorta compression?
• Bagaimana cara pemasangan uterine tamponade dgn metode sayeba condom?
The laboratory result:
Hb: 4,2g/dl
WBC: 3,200/mm3
Platelet: 115 000/mm3
INR: 1,3
APTT: 39’
You finally refer this patient after 1 hour treatment in your
public health service to RSMH.
• Bagaimana intrepretasi dan mekanisme abnormalitas pem
lab?
Learning Issues
 Perdarahan Post Partum
Perdarahan pasca persalinan atau perdarahan
post partum (PPP) adalah perdarahan masif (>
500 ml) setelah bayi lahir yang berasal dari
tempat implantasi plasenta, robekan pada jalan
lahir dan jaringan sekitarnya .
Epidemiologi
Menurut waktu terjadinya dibagi atas dua
bagian :
• Perdarahan postpartum primer (early
postpartum hemorrhage) yang terjadi dalam
24 jam pertama.
• Perdarahan postpartum sekunder (late
postpartum hemorrhage) yang terjadi setelah
24 jam persalinan.
 Etiologi
4T
4T Penyebab Persentase
Tone Atoni uteri 70

Tissue Sisa plasenta 20

Trauma Laserasi, hematom, 9

inversi, ruptur

Thrombin Koagulopati <1

 Atonia Uteri
Atonia uteri adalah keadaan lemahnya
tonus/kontraksi rahim yang menyebabkan
uterus tidak mampu menutup perdarahan
terbuka dari tempat implantasi plasenta setelah
bayi dan plasenta lahir.
 Faktor Predisposisi
• Regangan rahim berlebihan karena kehamilan
gemeli, polihidramnion, atau anak terlalu besar.
• Kelelahan karena persalinan lama atau persalinan
kasep
• Kehamilan grande-multipara
• Ibu dengan keadaan umum yang jelek, anemis,
atau menderita penyakit menahun
• Mioma uteri yang mengganggu kontraksi Rahim
• Infeksi intrauterine (korioamnionitis)
• Ada riwayat pernah atonia uteri sebelumnya.
 Pencegahan
• Melakukan secara rutin manajemen aktif kala
III pada semua wanita yang bersalin karena hal
ini dapat menurunkan insidens perdarahan
pascapersalinan akibat atonia uteri.
• Pemberian misoprostol peroral 2 – 3 tablet
(400 – 600 µg) segera setelah bayi lahir.
 Manajemen Aktif Kala III
• Injeksi oksitosi 10 IU IM
• Peregangan tali pusat terkendali
• Masase fundus
• Jepit dan potong tali pusat
• IMDini
• Meraba kontraksi di perut ibu
• Regangkan tali pusat dan satu tangan
mendorong tali pusat ke arah dorsokranial
 Manajemen
Masase fundus uteri segera
setelah lahirnya plasenta (maks
15 detik)
Evaluasi rutin. Jika uterus berkontraksi
tapi perdarahan terus berlangsung,
periksa apakah perineum, vagina dan
Uterus berkontraksi
serviks mengalami laserasi. Jahit atau
segera rujuk.

• Evaluasi /bersihkan bekuan

darah dan selaput ketuban
• Lakukan kompresi bimanual
interna selama 5 menit
• Pertahankan KBI selama 1-2 menit
• Keluarkan tangan secara perlahan
• Pengawasan kala IV

Uterus berkontraksi
• Anjurkan keluarga untuk membantu melakukan KBE
• Keluarkan tangan secara perlahan
• Suntikkan metilergometrin 0,2 mg IM
• Ulangi KBI

Pantau ibu dengan seksama selama

Uterus berkontraksi
persalinan kala IV

• Rujuk siapkan laparatomi

• Lanjutkan pemberian infus + 20 IU oksitosin meinimal 500 cc/jam hingga
mencapai tempat rujukan
• Selama perjalanan dapat dilakukan kompresi aorta abdominalis atau kompresi
bimanual eksterna
• Ligasi arteri uterina dan/atau
hipograstika Pertahankan uterus
• B-lynch methode

Histerektomi
 Komplikasi
• Syok hipovolemik
• Anemia
• Syndrome sheehan
SKDI
Kerangka Konsep
 Kesimpulan
Mrs. Sukinem, 38 tahun P5 mengalami
perdarahan postpartum primer et causa atonia
uteri dan rupture uteri