SKENARIO C

Mrs. Sukinem, 38 years old women in her fitth pregnancy delivered her son
spontaneously 4 hour ago. She was helped by birth attendant in her village, about 1,5 hours away
from referral hospital. he lived with her husband who is a farmer and her mother in law who is
a bbirth attendant. She gave birth a male baby, weighted 4000 grams. The placenta was delivered
by birth attendant, she claimed it was delivered completely. Suddenly after plasenta was
delivered, massive blood was came out from vagina. The birth attendant called midwife and
according to midwife, uterin contraction was poor and uterine fundal could not be palpated at
that time. She gave the mother intramuscular oxytocin injection 10 IU and reffered her to
primary public health service (Puskesmas) which already got PONED certification. Her atenatal
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 9gdl).

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 clot in her
pants.

In the examination findings :

Height 155 cm, weight 50 kg. BP 60/40mmHg, HR 140x/menit, RR 36x/menit, Temperatur

35oC. 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/menit, insert 2 venous line and folley catheher, 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.

After 30 minutes, she become consciousness and not drownsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, RR 22x/minute, Temperature 35,8oC, 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 600mikrogram 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 come out:

HB : 4,2 g/dl

WBC: 3200/mm3

Platelet: 115.000mm3
INR: 1,3

APTT :39

You finally refer this patient after 1 hours treatment in your public health service to RSMH.

KLARIFIKASI ISTILAH

No Istilah Arti
1. Plasenta Organ yang dibentuk dari jaringan pembuluh darah, dan
menghubungkan janin yang sedang berkembang dengan
dinding Rahim sehingga janin dapat menerima nutrisi,
pertukaran gas dari asupan darah ibu, pertahanan melawan
infeksi, dan memproduksi hormone yang dapat menyokong
kehamilan
2. Oksitosin Berfungsi untuk menginduksi persalinan atau memperkuat
kontraksi persalinan ketika melahirkan, dan untuk
mengendalikan perdarahan setelah melahirkan
3. PONED Pelayanan obstetri neonatus esensial dasar
4. Laserasi Luka yang disebabkan oleh robekan, bukan bentuk yang
teratur, seperti sayatan bedah
5. Tr Posisi tidur pasien, dalam posisi bagian kepala lebih rendah
dari bagian kaki
6. Folley catheher Selang yang digunakan untuk mengeluarkan urine dari
pasien yg kemudian ditampung di dalam urine bag
7. Cairan kristaloid Substansi yang lebih kecil dari koloid, dalam bentuk larutan
dan dapat melewati membrane semipermeabel
8. Bimanual Interna Tindakan yang dilakukan dengan tangan kanan masuk ke
Compression forniks anterior vagina dan tangan kiri yang satunya
menekan fundus uterus
9. Misoprostol Obat yang digunakan untuk memulai persalinan, dapat
menyebabkan aborsi, mencegah dan mengobati tukak
lambung, dan menangani perdarahan post partum akibat
atoni uteri
10. Abdominal aorta Manuver kegawatdaruratan yang bertujuan untuk
compression mengurangi perdarahan post partum, memberi waktu untuk
resusitasi dan mengontrol peradarahan
11. Uterine tamponade Upaya mengontrol perdarahan post partum karena atoni
uteri. Prinsip kerjainya menekan cavum uteri dari sisi dalam
kea rah luar dengan kuat sehingga, terjadi penekanan pada
arteri sistemik serta memberikan tekanan hidrostatik pada
arteri uterina
12. Sayeba condom Metode tampanode uteri yang diindikasikan untuk PPH
dengan penyebab atonia uteri dengan memasang kondom
sebagai tampon.
13. INR International Normalised Ratio, digunakan untuk
 pemantauan pemakaian antikoagulan seperti warfarin
14. APTT Activated parsial tromboplastin time, periode yang
dibutuhkan untuk pembentukan bekuan pada plasma darah
yang terkalsifikasi setelah kontak dan ditambahkan
pengganti plaetelet. Untuk mengukur jalur intrinsic dan jalur
umum di kaskade koagulasi

IDENTIFIKASI MASALAH

1. Mrs. Sukinem, 38 years old women in her fitth pregnancy delivered her son
spontaneously 4 hour ago. She was helped by birth attendant in her village, about 1,5
hours away from referral hospital. he lived with her husband who is a farmer and her
mother in law who is a bbirth attendant.

2. She gave birth a male baby, weighted 4000 grams. The placenta was delivered by birth
attendant, she claimed it was delivered completely. Suddenly after plasenta was
delivered, massive blood was came out from vagina.

3. The birth attendant called midwife and according to midwife, uterin contraction was poor
and uterine fundal could not be palpated at that time. 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 atenatal 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
9gdl).

5. 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 clot in
her pants.
In the examination findings :
Height 155 cm, weight 50 kg. BP 60/40mmHg, HR 140x/menit, RR 36x/menit,
Temperatur 35oC. 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.

6. You do resuscitation on her, made her to become in Trendelenburg position, gave her
oxygen 6-8L/menit, insert 2 venous line and folley catheher, 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 consciousness and not drownsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, RR 22x/minute, Temperature 35,8oC, 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
600mikrogram 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.

8. The laboratory result come out:

HB : 4,2 g/dl

WBC: 3200/mm3

Platelet: 115.000mm3

INR: 1,3

APTT :39

ANALISIS MASALAH

1. Mrs. Sukinem, 38 years old women in her fitth pregnancy delivered her son
spontaneously 4 hour ago. She was helped by birth attendant in her village, about 1,5
hours away from referral hospital. he lived with her husband who is a farmer and her
mother in law who is a birth attendant.

a. Bagaimana hubungan usia dan jumlah kehamilan terhadap perdarahan pasca

persalinan? 1 2 3

b. Bagaimana hubungan social ekonomi dan penolong persalinan pada kasus? 4 5 6

2. She gave birth a male baby, weighted 4000 grams. The placenta was delivered by birth
attendant, she claimed it was delivered completely. Suddenly after plasenta was
delivered, massive blood was came out from vagina.
 a. Apa hubungan BB bayi 4kg terhadap perdarahan pasca persalinan? 789

b. Bagaimana kriteria perdarahan masif ? 0 1 2

c. Apa penyebab dan bagaimana mekanisme perdarahan pasca persalinan pada

kasus? 345

d. Apa dampak dari perdarahan pasca persalinan terhadap ibu dan janin?678

e. Apa makna klinis plasenta dilahirkan lengkap pada kasus?901

3. The birth attendant called midwife and according to midwife, uterin contraction was poor
and uterine fundal could not be palpated at that time. She gave the mother intramuscular
oxytocin injection 10 IU and reffered her to primary public health service (Puskesmas)
which already got PONED certification.

a. Mengapa fundus tidak dapat dipalpasi ? (makna klinis)234

b. Bagaimana mekanisme kerja oksitosin 10 IU IM pada kasus? (dosis, indikasi dan

kontraindikasi)567

c. Apa penyebab dan bagaimana mekanisme kontraksi uterus yg lemah?890

4. Her atenatal 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
9gdl).

a. Berapa kali minimal pemeriksaan ANC dan apa dampak apabila tidak
mencukupi?123

b. Bagaimana hubungan anemia defisiensi besi dengan perdarahan pasca persalinan?

456

c. Bagaimana kriteria anemia pada ibu hamil?789

5. 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 clot in
her pants.
In the examination findings :
Height 155 cm, weight 50 kg. BP 60/40mmHg, HR 140x/menit, RR 36x/menit,
Temperatur 35oC. 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 pemeriksaan fisik?012
 b. Bagaimana gambaran portio laserasi dan vaginal laserasi terkait kasus?345

6. You do resuscitation on her, made her to become in Trendelenburg position, gave her
oxygen 6-8L/menit, insert 2 venous line and folley catheher, 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. Apa tujuan dilakukan resusitasi pada kasus?678
b. Mengapa pada kasus dilakukan resusitasi dengan posisi Trendelenburg?901
c. Apa tujuan pemberian kristaloid, oksitosin, PRC pada kasus?234
d. Apa tujuan dilakukannya pemeriksaan darah, analisis hemostatic, dan serum
darah?567
e. Prognosis perdarahan postpartum 7T?890

7. After 30 minutes, she become consciousness and not drownsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, RR 22x/minute, Temperature 35,8oC, 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
600mikrogram 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.

a. Bagaimana interpretasi dan mekanisme abnormal dari pemeriksaan diatas?123

b. Bagaimana cara melakukan bimanual interna compression, indikasi dan

kontraindikasinya?456

c. Bagaimana cara melakukan abdominal aorta compression, indikasi dan

kontraindikasinya? 789

d. Bagaimana cara pemasangan Sayeba condom, indikasi dan kontraindikasinya?012

e. Bagaimana cara pemberian misoprostol pervaginam, indikasi dan

kontraindikasinya?345

8. The laboratory result come out:

HB : 4,2 g/dl

WBC: 3200/mm3

Platelet: 115.000mm3
 INR: 1,3

APTT :39

a. Bagaimana interpretasi dan mekanisme abnormal dari hasil pemeriksaan

laboratorium?678

9. Aspek Klinis

a. DD901

b. Algoritma penegakan diagnosis234

c. DK 567

d. Etiologi890

e. Epidemiologi123

f. Faktor risiko456

g. Patofisiologi789

h. Patogenesis012

i. Manifestasi klinis345

j. Pemeriksaan penunjang678

k. Tatalaksana dan follow up901

l. Pencegahan dan edukasi234

m. Komplikasi567

n. Prognosis890

o. SKDI123

HIPOTESIS

Ny. Sukinem 38 tahun, mengalami perdarahan pasca persalinan akibat atonia uterus.

LEARNING ISSUE

1.Anatomi alat reproduksi wanita 1,2,3,4,5

2.Asuhan Persalinan Normal 6,7,8,9,10

3.HPP 1,2,3,4,5

4.Atoni uteri 6,7,8,9,10

Pembagian:

1 ova

2 dsa

3 sarah

4 ceplin

5 cila

6 CR

7 aprita

8 thalia

9 erika

10 dita