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 600g vaginally and
do abdominal 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:
Hemoglobin
White cell count
Platelet
INR
APTT

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

You finally refer this patient after 1 hour treatment in your public health service to RSMH.
About 1 week later, you got referral reply from RSMH which is describe the patient got
laparotomy subtotal hysterectomy.

Klarifikasi Istilah
1. Intramuskular oxytosin
2. anemia ringan
3. PONED

4. Laserasi vagina/perineal

5. Laserasi portio
6. Kontraksi uterus

7. Trendelenburg position

8. resusitasi

9. cairan cristalloid

10. PRC
11. Folley katater

12. Misoprostol

Pelayanan obstetrik neonatal emergency

dasar. Merupakan pelayanan untuk
mengnangulangi kasus-kasus kegawatdarutan
obstetrik neonatal
Robekan pada vagina atau kulit dan otot di
sekitar vagina, 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, pemberian oksigen dan curah
jantung cukup untuk menyalurkan oksigen
kepada otak, jantung dan alat vital lainnya
Adalah larutan air dengan elektrolit dan atau
dextrosa yang tidak mengandung molekul
besar. Dalam waktu singkat, 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.
Kateter ini memiliki balon di ujung kandung
kemih
Suata analog sintetik prostalglandin E1 yang

13. Bimanual interna compression

14. Sayeba condom method

15. Tamponade uterine

16. Abdominal aorta compression

17. Laparotomy
18. INR

19. APTT

20. 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.
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. Rasio nilai
prothrombin pasien terhadap nilai PT normal
yang dipangkatkan dengan nilai ISI
(International Sensitivity Index) yang
digunakan untuk system analisis.
Activated Partial Thromboplastin Time.
Adalah uji laboratorium untuk menilai
aktivitas factor koagulasi jalur intrinsik. Nilai
normal 20-35 detik
Suatu tindakan pengangkatan rahim dengan
cara pembedahan tanpa diikuti pengangkatan
serviks dan tuba fallopi

Identifikasi Masalah
Masalah
1. 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 4000grams. The placenta was delivered
by birth attendant, she claimed it was delivered

Konsen
V

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)
2. 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.
3. 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.
4. 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

VV

VVV

VVV

gave her misoprostol 600g vaginally and do

abdominal 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:
Hemoglobin
:6,2 g/dl
White cell count
:3.200/mm3
Platelet
:115.000/mm3
INR
:1,3
APTT
:39
5. You finally refer this patient after 1 hour
treatment in your public health service to RSMH.
About 1 week later, you got referral reply from
RSMH which is describe the patient got
laparotomy subtotal hysterectomy.

VVV

Analisis Masalah
1. 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)
a. Bagaimana hubungan usia, riwayat kehamilan, riwayat persalinan dengan keluhan
pada kasus? (Rian, Aprilia)
b. Bagaimana peneyebab dan mekanisme dari kontraksi uterus yang lemah dan
fundus uterine yang tidak bisa dipalpasi setelah persalinan? (rian,esty)
2. 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.
a. Bagaimana penyebab dan mekanisme:
i.
Tekanan darah 60/40 mmHg (rian)

3. 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.
a. Apa indikasi dan tujuan :
i.
Trendelenburg position (rian)

4. 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 600g vaginally and do abdominal
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 :
Hemoglobin
White cell count
Platelet
INR
APTT

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

a. Bagaimana penanganan perdarahan post partum pada kasus? (anusha,rian)

Banyaknya darah yang hilang akan memengaruhi keadaan umum pasien. Pasien
bias masih dalam keadaan sadar, sedikit anemis, atau sampai syokberat
hipovolemik. Tindakan pertama yang harus dilakukan bergantung pada keadaan
kliniknya. Pada umumnya dapat dilakukan secara simultan (bila pasien syok) halhal sebagai berikut:
Sikap Tredelenburg, memasang venous line, dan memberikan oksigen.
Sekaligus merang sang kontraksi uterus dengan cara:
Masase fundus uteri dan merangsang putting susu.

Pemberian oksitosin dan turunan ergot melalui suntikan secara

i.m., i.v., atau s.c.
Memberikan derivate prostaglandin F2(carboprost tromethamine)
yang terkadang memberikan efek samping berupa diare, hipertensi,
mual muntah, febris, dan takikardi.pemberian misoprostol 8001000 g per-rektal.
Kempresi bimanual eksternal dan/atau internal.
Kompresi aorta abdominalis.
Pemasangan tampon kondom, kondom dalam kavum uteri
disambung dengan kateter, difiksasi dengan karet gelang dan
diisicairan infuse 200 ml yang akan mengurangi perdarahan dan
menghindari tindakan operatif.
Catatan: tindakan memasang tampon kasa utero-vaginal tidak
dianjurkan dan hanya bersifat temporer sebelom tindakan bedah
ke rumas sakit rujukan.
Bila semua tindakan itu gagal, maka dipersiapkan untuk dilakukan
tindakan operatif laparotomi dengan pilihan bedah konservatif
(mempertahankan uterus) atau melakukan histerektomi. Alternatifnya
berupa:
Ligasi arteri uterina atau arteri ovarika
Operasi ransel B Lynch
Histerektomi supravaginal
Histerektomi total abdominal

b. Bagaimana intrepretasi dan mekanisme abnormal dari pemeriksaan lab?

(rian,aprilia)
Hipotesis
Mrs Anita 40 tahun mengalami perdarahan pasca persalinan ec atonia uteri
a. Apa saja diagnosis banding pada kasus? (rian,esty)
b. Apa etiologi dari diagnosis pada kasus? (safit,rian)
Perdarahan dari tempat implantasi plasenta
Hipotoni sampai atoni uteri
Akibat anestesi
Distensi berlebihan (gemeli, anak besar, hidramnion)
Partus lama, partus kasep
Partus presipitus/partus terlalu cepat
Persalinan karena induksi oksitosin
Multiparitas
Korioamnionitis
Pernah atonia sebelumnya
Sisa plasenta
Kotiledon atau selaput ketuban tersisa

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