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Skenario A Blok 24

Mrs Anita, 40 years old women in her fifth pregnancy delivered her son spontaneously 3
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 ‘becak’ driver 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 claimed it was delivered completely. 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. She gave the mother intramuscular oxytocin injection 10 IU and
reffered her to primary public health service (Puskemas) 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 9 g/dl)
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 155cm, weight 50kg. Blood pressure 60/40 mmHg, heart rate 140x/minute,
respiratory rate 36x/minute, temperature 350C. 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 indentified.
You do resuscitation on her, made her to become in Trendelenburg position, gave her oxygen
6-8L/ minute, insert 2 venous line and folley catheher, do 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 drowsy anymore. Blood pressure
became 100/70 mmHg, pulse 92x/minute, respiratory rate 22x/minute, temperature 35,80C,
urine output 100 cc. You re-examine 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 600µg vaginally and
do abdominal compression, but uterine contraction won’t get better. You insert uterine
tamponade using Sayeba condom method, and plan to refer her to RSMH, hospital nearby.
The laboratory result come out:
Hemoglobin
White cell count
Platelet
INR
APTT

:6,2 g/dl
:3.200/mm3
:115.000/mm3
:1,3
:39’

Laserasi portio 6. anemia ringan 3. PONED 4. About 1 week later. Dalam waktu singkat. cairan cristalloid 10. cristalloid sebagian besar akan keluar dari intravaskular sehingga volume yang diberikan harus lebih banyak 3:1 dengan volume darah yang hilang Sel darah merah yang plasmanya telah dibuang Adalah sebuah tabung plastik flexible yang dimasukkkan ke dalam kandung kemih untuk menyediakan drainase kemih terus menerus. PRC 11. Misoprostol Pelayanan obstetrik neonatal emergency dasar. jantung dan alat vital lainnya Adalah larutan air dengan elektrolit dan atau dextrosa yang tidak mengandung molekul besar. Merupakan pelayanan untuk mengnangulangi kasus-kasus kegawatdarutan obstetrik neonatal Robekan pada vagina atau kulit dan otot di sekitar vagina. Laserasi vagina/perineal 5. Intramuskular oxytosin 2. Klarifikasi Istilah 1. Folley katater 12. Trendelenburg position 8. Kontraksi uterus 7. resusitasi 9. Kateter ini memiliki balon di ujung kandung kemih Suata analog sintetik prostalglandin E1 yang . you got referral reply from RSMH which is describe the patient got laparotomy subtotal hysterectomy. pemberian oksigen dan curah jantung cukup untuk menyalurkan oksigen kepada otak.You finally refer this patient after 1 hour treatment in your public health service to RSMH. robekan paling sering terjadi pada perineum(perineum adalah area di antara anus dan vagina) Serangkaian kontraksi rahim yang teratur karena otot-otot polos rahim bekerja dengan baik dan sempurna yang akan mendorong janin melalui serviks dan vagina sehingga janin dapat keluar dari rahim ibu Pasien berbaring supinasi dimana kepala dimiringkan ke bawah sekitar 30-40o dan bagian lutut ditekuk Usaha dalam memberikan ventilasi yang adekuat.

Sayeba condom method 15. 40 years old women in her fifth pregnancy delivered her son spontaneously 3 hours ago. Dimasulkkan ke dalam cavum uteri sebagai alternative penanganan HPP Suatu alat yang digunakan untuk mengembangkan tekanan intrauterine yang gunanya untuk menghentikan perdarahan Suatu tindakan emergenci yang digunakan untuk mengurangi perdarahan postpartum dengan cara menekan di atas umblilikus agar bisa terjadi resusitasi Insisi melalui dinding perut International Normalised Ratio. Abdominal aorta compression 17. Mrs Anita. INR 19. she claimed it was delivered Konsen V . She was helped by birth attendant in her village. Adalah uji laboratorium untuk menilai aktivitas factor koagulasi jalur intrinsik. APTT 20. about 1. Rasio nilai prothrombin pasien terhadap nilai PT normal yang dipangkatkan dengan nilai ISI (International Sensitivity Index) yang digunakan untuk system analisis. Nilai normal 20-35 detik Suatu tindakan pengangkatan rahim dengan cara pembedahan tanpa diikuti pengangkatan serviks dan tuba fallopi Identifikasi Masalah Masalah 1. Tamponade uterine 16. The placenta was delivered by birth attendant. Activated Partial Thromboplastin Time. She gave birth a male baby.5 hours away from referral hospital. She lived with her husband who is a ‘becak’ driver and her mother in law who is a birth attendant. Bimanual interna compression 14.13. weighed 4000grams. Laparotomy 18. subtotal hysterectomy dapat digunakan untuk melembutkan dan mematangkan serviks dan menginduksi kontraksi uterus Suatu tindakan tatalaksana yang biasanya digunakan apabila terdapat perdarahan postpartum dengan cara menekan fundus secara interna maupun externa Pemasangan tampon condom secara aseptic yang telah diikatkan pada kateter.

urine output 100 cc. She gave the mother intramuscular oxytocin injection 10 IU and reffered her to primary public health service (Puskemas) which already got PONED certification. made her to become in Trendelenburg position. On arrival.completely. You also find approximately 1000 ml of blood clot in her pants. uterine fundal still can not be palpated. do blood analysis. no uterine contraction. weight 50kg. On vaginal inspection there is blood clot in vagina and no portio laceration or vaginal/perineal laceration are indentified. You do resuscitation on her. heart rate 140x/minute. pulse 92x/minute. you find the patient is consciousness but drowsy and pale. also oxytocin 20 IU in 500 ml crystalloid fluid. and serum blood analysis. temperature 35. uterine contraction was poor and uterine fundal could not be palpated at that time. You gave 2000 ml crystalloid fluid and 300 cc pack red cells. hemostatic analysis. uterine contraction is poor. respiratory rate 22x/minute. massive blood was came out from vagina. You do bimanual interna compression but still no uterine contraction. The uterus fundal can not be palpated. insert 2 venous line and folley catheher.80C. she become consciousness and not drowsy anymore. temperature 350C. You re-examine the patient again. as general practitioner public health service. After 30 minutes. and vaginal bleeding is still coming out. 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) 2. Suddenly after placenta was delivered. respiratory rate 36x/minute. Blood pressure became 100/70 mmHg. gave her oxygen 6-8L/ minute. 4. 3. You VV VVV VVV . The peripheral extremities are cold. Blood pressure 60/40 mmHg. In the examination findings: Height 155cm. The abdomen is otherwise soft and non tender. The birth attendant called midwife and according to midwife.

massive blood was came out from vagina.200/mm3 Platelet :115. respiratory rate 36x/minute. temperature 350C. you got referral reply from RSMH which is describe the patient got laparotomy subtotal hysterectomy. In the examination findings: Height 155cm. riwayat kehamilan. as general practitioner public health service. The laboratory result come out: Hemoglobin :6. On arrival. She was helped by birth attendant in her village. 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. heart rate 140x/minute. Bagaimana peneyebab dan mekanisme dari kontraksi uterus yang lemah dan fundus uterine yang tidak bisa dipalpasi setelah persalinan? (rian. The birth attendant called midwife and according to midwife. but uterine contraction won’t get better.2 g/dl White cell count :3. uterine contraction was poor and uterine fundal could not be palpated at that time.gave her misoprostol 600µg vaginally and do abdominal compression.5 hours away from referral hospital. she claimed it was delivered completely. You finally refer this patient after 1 hour treatment in your public health service to RSMH. weight 50kg.000/mm3 INR :1. Mrs Anita. hospital nearby. You insert uterine tamponade using Sayeba condom method.3 APTT :39’ 5. Bagaimana hubungan usia. weighed 4000 grams. you find the patient is consciousness but drowsy and pale. Blood pressure 60/40 mmHg. Suddenly after placenta was delivered. riwayat persalinan dengan keluhan pada kasus? (Rian. About 1 week later. She lived with her husband who is a ‘becak’ driver and her mother in law who is a birth attendant.esty) 2. The peripheral . Aprilia) b. and plan to refer her to RSMH. 40 years old women in her fifth pregnancy delivered her son spontaneously 3 hours ago. She gave birth a male baby. about 1. You also find approximately 1000 ml of blood clot in her pants. The placenta was delivered by birth attendant. VVV Analisis Masalah 1. She gave the mother intramuscular oxytocin injection 10 IU and reffered her to primary public health service (Puskemas) which already got PONED certification.

You insert uterine tamponade using Sayeba condom method. You re-examine the patient again. she become consciousness and not drowsy anymore. but uterine contraction won’t get better. Blood pressure became 100/70 mmHg. The uterus fundal can not be palpated. and plan to refer her to RSMH. Trendelenburg position (rian) 4. no uterine contraction. You gave 2000 ml crystalloid fluid and 300 cc pack red cells. and vaginal bleeding is still coming out. The laboratory result come out : Hemoglobin White cell count Platelet INR APTT :6. Pada umumnya dapat dilakukan secara simultan (bila pasien syok) halhal sebagai berikut:  Sikap Tredelenburg. Bagaimana penyebab dan mekanisme: i. Tindakan pertama yang harus dilakukan bergantung pada keadaan kliniknya. memasang venous line. urine output 100 cc. respiratory rate 22x/minute. You gave her misoprostol 600µg vaginally and do abdominal compression. atau sampai syokberat hipovolemik. sedikit anemis. also oxytocin 20 IU in 500 ml crystalloid fluid. hospital nearby. The abdomen is otherwise soft and non tender.80C. Apa indikasi dan tujuan : i.3 :39’ a. a.extremities are cold. uterine fundal still can not be palpated. do blood analysis. You do bimanual interna compression but still no uterine contraction. Tekanan darah 60/40 mmHg (rian) 3. After 30 minutes.2 g/dl :3. You do resuscitation on her. uterine contraction is poor. made her to become in Trendelenburg position. and serum blood analysis. . temperature 35.200/mm3 :115. On vaginal inspection there is blood clot in vagina and no portio laceration or vaginal/perineal laceration are indentified. insert 2 venous line and folley catheher. Pasien bias masih dalam keadaan sadar. pulse 92x/minute. Bagaimana penanganan perdarahan post partum pada kasus? (anusha. dan memberikan oksigen.rian) Banyaknya darah yang hilang akan memengaruhi keadaan umum pasien.  Sekaligus merang sang kontraksi uterus dengan cara:  Masase fundus uteri dan merangsang putting susu. gave her oxygen 6-8L/ minute. a.000/mm3 :1. hemostatic analysis.

atau s. hipertensi.  Kompresi aorta abdominalis.pemberian misoprostol 8001000 µg per-rektal. kondom dalam kavum uteri disambung dengan kateter. Bila semua tindakan itu gagal. maka dipersiapkan untuk dilakukan tindakan operatif laparotomi dengan pilihan bedah konservatif (mempertahankan uterus) atau melakukan histerektomi. difiksasi dengan karet gelang dan diisicairan infuse 200 ml yang akan mengurangi perdarahan dan menghindari tindakan operatif. anak besar. hidramnion)  Partus lama.v. Alternatifnya berupa:  Ligasi arteri uterina atau arteri ovarika  Operasi ransel B Lynch  Histerektomi supravaginal  Histerektomi total abdominal b. Apa saja diagnosis banding pada kasus? (rian. i. Bagaimana intrepretasi dan mekanisme abnormal dari pemeriksaan lab? (rian..m..  Pemberian oksitosin dan turunan ergot melalui suntikan secara i.  Kempresi bimanual eksternal dan/atau internal.c. mual muntah. Apa etiologi dari diagnosis pada kasus? (safit. partus kasep  Partus presipitus/partus terlalu cepat  Persalinan karena induksi oksitosin  Multiparitas  Korioamnionitis  Pernah atonia sebelumnya  Sisa plasenta  Kotiledon atau selaput ketuban tersisa .  Pemasangan “tampon kondom”.  Memberikan derivate prostaglandin F2α(carboprost tromethamine) yang terkadang memberikan efek samping berupa diare.aprilia) Hipotesis Mrs Anita 40 tahun mengalami perdarahan pasca persalinan ec atonia uteri a. febris.rian)  Perdarahan dari tempat implantasi plasenta  Hipotoni sampai atoni uteri  Akibat anestesi  Distensi berlebihan (gemeli.  Catatan: tindakan memasang tampon kasa utero-vaginal tidak dianjurkan dan hanya bersifat temporer sebelom tindakan bedah ke rumas sakit rujukan. dan takikardi.esty) b.

rian) Learnin Issue a. APRILIA. c. solusio plasenta. PPP ( RIAN. inkreta.FADIL) . kematian janin dalam kandungan. sindroma HELLP. preeklamsia. prekreta  Perdarahan karena robekan  Episiotomi yang melebar  Robekan pada perineum. Bagaimana prognosis dari diagnosis pada kasus? (afkur. vagina. dan emboli air ketuban. misalnya pada kasus trombofilia. Plasenta susenturiata  Plasenta akreta. dan seriks  Rupture uteri  Gangguan koagulasi  Jarang terjadi tetapi bias memperburuk keadaan di atas.