TUTORIAL REPORT

SCENARIO A BLOCK 21

Group 5
Tutor: dr. RA. Tanzila, M.Kes
Member's name :
1. Tania Evita Salsabila 702017068
2. Fandika Dimas Prayogi 702018002
3. Mellyana Cahyadi 702018010
4. Fransiska Delvia 702018020
5. Liani Khoirunnisa 702018034
6. Melenia Rhoma Dona YS 702018041
7. Novita Sari 702018047
8. Putra Pratama Adi Candra 702018054
9. Syabrina Afni Mahmuda 702018083
10. Mona Regita Utami 702018095
11. Shafa Almira 702018097

FACULTY OF MEDICINE
UNIVERSITY OF MUHAMMADIYAH PALEMBANG
2020
 FOREWORD

Praise to Allah SWT for all His mercy and grace. We were able to complete
the tutorial report entitled "Tutorial Scenario A Block 21 " as a group competency
assignment. Shalawat along with greetings are always poured out to our lord, the
great prophet Muhammad SAW and his family, friends and followers until the end
of time
We recognize that this tutorial report is far from perfect. Therefore, we expect
constructive criticism and suggestions for improvement in the future. In completing
this tutorial report, the author received a lot of help, guidance and advice. On this
occasion, the author would like to respect and thank:
1. Allah SWT, who has given life with the coolness of faith.
2. Both parents who always provide material and spiritual support.
3. dr. RA. Tanzila, M.Kes as the tutor for group 5.
4. Colleagues.
5. All those who help us.

May Allah SWT reward all the charities given to all those who have
supported the author and I hope this tutorial report is useful for us and the
development of science. May we always be protected by Allah SWT.

Palembang, September
2021

Writer
 TABLE OF CONTENTS

FOREWORD .......................................................................................................... i
TABLE OF CONTENTS...................................................................................... ii
BAB I ...................................................................................................................... 3
PRELIMINARY.................................................................................................... 3
1.1 Background .............................................................................................. 3
1.2 Purpose and Objectives ............................................................................ 3
BAB II .................................................................................................................... 4
DISCUSSION ........................................................................................................ 4
2.1 Tutorial Data ............................................................................................. 4
2.2 Scenario .................................................................................................... 2
2.3 Clarification of Terms .............................................................................. 3
2.4 Identification of Problem .......................................................................... 4
2.5 Problem Analysis ..................................................................................... 5
2.6 Conclusion .............................................................................................. 38
2.7 Conceptual of Framework ...................................................................... 38
REFERENCES .................................................................................................... 40
 BAB I
PRELIMINARY

1.1 Background
Block for Growth and Development and Geriatrics is block XXI in semester
VII of the Medical Education Competency-Based Curriculum, Faculty of Medicine,
Muhammadiyah University of Palembang.
On this occasion a scenario A case study tutorial was carried out, Ababy girl
was delivered spontaneously at PONEK RSMP Emergency Department, the baby
wasn’t crying, from a 43 weeks G1P0A0 mother,and birth weight 2800 gram.The
Apgar score on the first minute was three, five on the fifth minute, and eight on the
tenth minute. There wasfever history in mother when giving birth with leukocytes
18.000/mm3. The baby moved to perinatology care, when being treated, the baby
looks short of breath and starts to turn blue.Theamniotic fluid weregreen.

1.2 Purpose and Objectives

The aims and objectives of this case study tutorial report are :
1. As a tutorial group assignment report which is part of the CBC learning
system at the Faculty of Medicine, Muhammadiyah University of
Palembang.
2. Can solve the cases given in the scenario with the method of analysis and
group discussion learning.
3. The achievement of the objectives of the tutorial learning method.
4. Is a knowledge provision in diagnosing patients in the field after becoming
a doctor.
 BAB II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. RA. Tanzila, M.Kes
Moderator : Putra Pratama Adi Candra
Secretary Desk : Fransiska Delvia
Day / Date and Time : 1. Tuesday, 28 September 2021
Time : 13.00 – 15.30 WIB
2. Thursday, 30 September 2021
Time : 13.00 – 15.30 WIB
Tutorial Rules :
1. Tutorial members must have an opinion.
2. Prior permission if you want to give an
opinion.
3. Speak politely and full of manners.

Scenario A Blok 21
“Silence of the Baby”
A baby girl was delivered spontaneously at PONEK RSMP Emergency
Department, the baby wasn’t crying, from a 43 weeks G1P0A0 mother,and birth
weight 2800 gram.The Apgar score on the first minute was three, five on the fifth
minute, and eight on the tenth minute. There wasfever history in mother when
giving birth with leukocytes 18.000/mm3. The baby moved to perinatology care,
when being treated, the baby looks short of breath and starts to turn
blue.Theamniotic fluid weregreen.
Physical Examination
General Appearance: hipoactive, whimpering, weak suction reflexes, BL: 49cm,
BBW: 2800 g, HC: 34 cm, Oxygen saturation 90%
Vital Sign: HR: 132x/M, RR: 70 x/M, Temp.: 36,6oC.
Specific Examination:
Head: Caput succesaneum (+) Nose: nasal flaring breathing (+), Cyanosis (+)
Thorax: Chest retraction (+) epigastrium, suprasternal, down score: 6
Pulmo: vesiculer (+/+), ronchi (+/+)
Cor: Hearth sounds I – II normal, Murmur (-)
Anus: meconium (+)
Laboratory Examination: Blood Chemistry: hemoglobin 16,0 mg/dl, trombocyte
208.000/mm3,leukocyte 34.000/mm3, LED: 15 mm/jam, CRP: 20mg/L
Rontgen thoraks:

I. Clarification of terms
1. Fever : An abnormaly highly temperature.
2. APGAR score:A method who checked the condition of new born.
3. Leukocyte : White cell; white blood cell; colorless blood cells that can
move amoeboidally, whose main function is to protect the body against
microorganism that cause disease.
4. Meconium : Dark green slimy material or liquid in the intestines of term
infants.
5. Ronchi : Continuous sound, such as snoring in the throat or bronchial
tubes, due to partial obstruction (Dorland, 2015).
6. Cyanosis :A bluish discoloration of the skin and mucous membranes
due to excessive concentrations of reduced hemoglobin in the blood.
7. Chest retraction:A contraction that occurs in the chest muscle and rib that
drawn in when we inhale.
8. Down score : Clinical diagnostic means for assessing hypoxemia in
clinical respiratory distressed neonates (Dorland, 2015).
9. Amniotic fluid:The protective liquid contained by the amniotic salc of a
gravid amniote (Dorland, 2015).
10. Hypoactive : An inhibition of behavioral or locomotor activity.

II. Identification of problem

1. A baby girl was delivered spontaneously at PONEK RSMP Emergency
Department, the baby wasn’t crying, from a 43 weeks G1P0A0 mother, and
birth weight 2800 gram.The Apgar score on the first minute was three, five
on the fifth minute, and eight on the tenth minute.
2. There was fever history in mother when giving birth with leukocytes
18.000/mm3. The baby moved to perinatology care, when being treated, the
baby looks short of breath and starts to turn blue. Theamniotic fluid
weregreen.
 3. Physical examination
General Appearance: hipoactive, whimpering, weak suction reflexes, BL:
49cm, BBW: 2800 g, HC: 34 cm, Oxygen saturation 90%
Vital Sign: HR: 132x/M, RR: 70 x/M, Temp.: 36,6oC.
Specific Examination:
Head: Caput succesaneum (+) Nose: nasal flaring breathing (+), Cyanosis
(+)
Thorax: Chest retraction (+) epigastrium, suprasternal, down score: 6
Pulmo: vesiculer (+/+), ronchi (+/+)
Cor: Hearth sounds I – II normal, Murmur (-)
Anus: meconium (+)
4. Laboratory Examination: Blood Chemistry: hemoglobin 16,0 mg/dl,
trombocyte 208.000/mm3,leukocyte 34.000/mm3, LED: 15 mm/jam, CRP:
20mg/L
5. Rontgen thorax

III. Priority of problem

Identification no. 1 → the main complain that we have to cure it first so it wont
cause death

IV. Analysis of problem

1. A baby girl was delivered spontaneously at PONEK RSMP Emergency
Department, the baby wasn’t crying, from a 43 weeks G1P0A0 mother,
and birth weight 2800 gram.The Apgar score on the first minute was three,
five on the fifth minute, and eight on the tenth minute.
a. What is anatomy and physiology in this case?(liani,melenia,
Answer:
The lungs are located in the upper chest cavity, bordered on the sides by
muscles and ribs and on the bottom by a strong muscular diaphragm. The
lungs have two parts, namely the right lung (pulmo dexter) which consists
of 3 lobes and the left lung (pulmo sinister) which consists of 2 lobes. The
lungs are covered by two thin membranes, called the pleura. The inner
membrane that directly covers the lungs is called the inner pleura (visceral
pleura) and the membrane that covers the chest cavity adjacent to the ribs
is called the outer pleura (parietal pleura). The lungs are composed of
bronchioles, alveoli, elastic tissue, and blood vessels. Bronchioles do not
have cartilage, but the bronchial cavity is still ciliated and at the ends has
ciliated cuboidal epithelium (Patwa, A. and Shah, A. 2015).

Physiology :
The process of breathing takes place through several stages, namely:
1. Pulmonary ventilation, which means the exchange of air between the
atmosphere and the alveoli of the lungs (Guyton, 2014).
2. Diffusion of oxygen and carbon dioxide between the alveoli and the
blood (Guyton, 2014).
3. Transport of oxygen and carbon dioxide in the blood and body fluids
to and from body tissue cells (Guyton, 2014).
Air moves in and out of the lungs because of the pressure difference
between the atmosphere and the alveoli due to the mechanical work of the
muscles. Among them are changes in intrapulmonary pressure,
intrapleural pressure, and changes in lung volume (Guyton, 2014).
In and out of respiratory air occurs through 2 mechanical processes,
namely:
1. Inspiration: an active process with the contraction of the inspiratory
muscles to increase the intrathoracic volume, the lungs are pulled in a
more expanded position, the pressure in the respiratory tract becomes
negative and air flows into the lungs (Sherwood, 2014).
2. Expiration: a passive process in which the elasticity of the lungs
(elastic recoil) pulls the chest back to the expiratory position, the
recoil pressures of the lungs and chest wall are balanced, the pressure
in the respiratory tract becomes slightly positive so that air flows out
of the lungs, in this case the muscles. breathing plays a role
(Sherwood, 2014).
b. What is the meaning of the baby wasn’t crying, from a 43 weeks
G1P0A0 mother, and birth weight 2800 gram?
Answer :
• The meaning of the baby not crying is the possibility that
neonatorum aphixia has occurred, which is neonatorum aphixia,
namely spontaneous and regular respiratory failure immediately
after birth. Because crying at birth is a purely reflex action that
occurs when air enters the vocal cords (vocal cords) which causes
the vocal cords to vibrate. The purpose of the baby crying is to
pump the lungs to allow breathing and provide oxygen to the blood.
(Kosim, 2010)
• The meaning of the mother G1P0A0 43 weeks is Gravida 1, Partus
0, Abortion 0, 43 weeks: the baby is born in a post term state (born
directly at a gestational age of more than 42 weeks calculated from
the first day of the last menstruation).
• The meaning of a birth weight of 2800 grams is a normal baby
weight which is normally from 2500gr-4000gr.
• This means that the baby may have meconium aspiration syndrome
(SAM) where in most cases, SAM generally affects term infants
(37 to 42 weeks of gestation) with adequate birth weight (2500 to
4000 grams), not too much difference between the number of baby
girl and boy.
• Based on the pathophysiology, it is true that meconium comes out
intrauterine due to certain stress on the fetus. Generally the fetus is
full term and time to be born but due to some reason it is still in the
intrauterine which causes meconium to come out with marked fetal
distress10. The longer the fetus is exposed to meconium-
contaminated amnion, the greater the risk of aspiration of
meconium-containing amnion.
c. How are the correlation between43 weeks G1P0A0 in this case?
Answer:
MSAF is more common in post-term newborns. Its incidence varies
with gestational age. One study reported MSAF in 5.1%, 16.5%, and
27.1% of preterm, term, and post-term newborns, respectively (Sayad
et al, 2021).

d. What is the etiology of the baby wasn’t crying?

Answer:
The etiology are:
Babies do not cry immediately can be caused by lungs that have not
developed completely and can indicate the possibility of asphyxia.
Perinatal asphyxia can occur due to maternal events (hemorrhage,
amniotic fluid embolism; hemodynamic collapse), placental events
(acute abruption), uterine events (rupture), cord events (tight nuchal
cord, cord prolapse/avulsion) and intrapartum infection (maternal
fever) (Gillam, 2021).
1. Asphyxia in pregnancy:
a. Acute infectious disease
b. Chronic infectious disease
c. Poisoning by drugs
d. Uremia and toxemia gravidarum
e. Severe anemia
f. Congenital defects
g. Trauma
2. Asphyxia in labor:
a) Lack of O2
1) Long labor (rigid cervix and atony / uterine insertion)
2) Severe uterine rupture, continuous uterine contractions
disrupt blood circulation to the placenta
3) Pressure is too strong from the child's head on the placenta
 4) Pheniculi prolapse of the umbilical cord will be pressed
between the head and pelvis
5) Administration of drugs is too much and not on time
6) Bleeding profusely (placenta previa and abruption of the
placenta)
7) If the placenta is old: post maturity (serotonin, uterine
dysfunction)
b) Paralysis of the respiratory center
1) External trauma such as forceps action
2) Internal trauma such as from anesthetic
(Maryuni, et al. 2013).

e. What is the meaning of the Apgar score on the first minute was three,
five on the fifth minute, and eight on the tenth minute?
Answer:
The meaning are:
1) First minute was three→ severe asphyxia
2) Five on the fifth minute→ mild asphyxia
3) Eight on the tenth minute→ normal
Showed that the baby initially had severe asphyxia in the first minute
so that urgent resuscitation was needed. The resuscitation resulted in an
improvement in asphyxia which was characterized by an increase in the
score. Resuscitation is a procedure applied to neonates who fail to
breathe spontaneously (Saifuddin et al, 2014).

f. What is assessed in the APGAR score?

Answer:
The Apgar score is used as a part of early assessment of a newborn. A
score of 0, 1, or 2 is assigned to each of the 5 physical signs at 1 and 5
minutes after birth. The maximum score that can be assigned is 10.
Scores ranging from 7-10 are considered normal. If the 5-minute Apgar
 score is abnormal (< 7), appropriate measures should be taken. Apgar
scores should be assigned every 5 minutes until the infant is stabilized.
1. Heart rate :
2 points = ≥100 beats/min
1 point = < 100 beats/min
0 points = Absent
2. Respirations
2 points = Regular breathing/strong cry
1 point = Irregular/weak/slow breathing/gasping
0 points = Absent
3. Muscle tone and movement
2 points = Good flexion/action motion
1 point = Some flexion
0 points = None/limp
4. Skin color / oxygenation
2 points = Body and extremities pink
1 point = Blue at extremities; pink body
0 points = Completely blue
5. Reflex irritability to tactile stimulation
2 points = Cry/cough/sneeze
1 point = Grimace/feeble cry when stimulated
0 points = Silence; no resp

g. What is the definition and function of PONEK?

Answer:
PONEK is a comprehensive essential/emergency neonatal obstetric
service. The main goal is to be able to save mothers and newborns
 through a planned referral program in one district, municipality or
province (Andarini. 2015).

h. What are the general criteria of PONEK?

Answe:
The general criteria of PONEK according to Kemenkes RI are :
• Thereare doctors on duty who are trained in the ER to handle both
general emergency cases and obstetric - neonatal emergencies.
• Doctors, midwives and nurses have attended the PONEK team
training in the hospital covering neonatal resuscitation, obstetric
emergencies and neonates.
• Have a Standard Operating Procedure for admission and handling
of obstetric and neonatal emergencies.
• No down payment policy for patients with obstetric and neonatal
emergencies.
• Has a certain delegation procedure of authority.
• Have a standard response time in the emergency room for 10
minutes, in the delivery room less than 30 minutes, blood service
less than 1 hour.
• There is an operating room that is ready (24 hours standby) to
perform the operation, if there is an obstetric or general emergency
case.
• There are delivery rooms that can set up surgery in less than 30
minutes.
• Have a crew / crew who are ready to carry out operations or carry
out tasks at any time, even though they are on call.
• There is support from all parties in the PONEK service team,
including midwifery doctors, pediatricians, doctors / anesthetists,
internal medicine doctors, other specialists as well as general
practitioners, midwives and nurses.
 • Available 24-hour blood service.
• There are other supporting services that play a role in PONEK,
such as 24-hour Laboratory and Radiology, 24-hour recovery
room, medicines and supporting tools that are always available.
• Equipment
- All equipment must be clean (free of dust, dirt, spots, liquids,
etc.)
- Metal surfaces must be free of rust or spots
- All fixtures must be sturdy (no loose or unstable parts)
- The painted surface must be intact and free from major scratches
- Gika gear wheels (available) must be complete and functioning
properly
- Instruments that are ready to use must be sterilized
- All electrical equipment must be functioning properly (switches,
cables and plugsare firmly attached)
• Material
- All materials must be of high quality and sufficient in quantity
to meet theneeds ofthis unit (Kemenkes RI, 2014).

i. What is the pathophysiology of the baby wasn’t crying?

Answer:
j. What is the classification of babies based on birth weight and
gestational age?
Answer:
Classification according to birth weight is Low Birth Weight Babies
(LBW), namely birth weight <2500 grams, normal birth weight babies
with birth weight 2500-4000 grams and babies with more birth weight
weighing > 4000 grams (Sylviati, 2008).
Based on gestational age or gestation period:
1. Premature babies, namely babies born at the age ofpregnancy does
not reach 37 weeks.
2. Full-term baby (mature/term), namely babies whoborn at the age
of 37-40 weeks
 3. Postterm infant or more months (postmature), namely babies born
at 42 weeks of gestation or more.
(Surasmi, 2013).

2. There was fever history in mother when giving birth with leukocytes
18.000/mm3. The baby moved to perinatology care, when being treated,
the baby looks short of breath and starts to turn blue. Thea mniotic fluid
were green.
a. What is the meaning of therewas fever history in mother when giving
birth with leukocytes 18.000/mm3?
Answer:
This means that the mother may have clinical chorioamnionitis, which
is an acute condition diagnosed when the typical clinical signs are
present: maternal fever (>38ᵒC) plus 2 additional findings of maternal
and/or fetal tachycardia (in the mother, >100 beats per minute. In fetus,
>160 beats per minute), maternal leukocytosis (>15,000-18,000
cells/mm3), uterine tenderness, and foul or pus-smelling amniotic
fluid.
Fever history in mother when giving birth with leukocytes 18.000/mm3
indicates the possibility of infection in the mother. Inflammation is part
of the innate defense mechanism of the body against infectious or non-
infectious etiologies. This mechanism is non-specific and
immediate. There are five fundamental signs of inflammation that
include: heat (calor), redness (rubor), swelling (tumor), pain (dolor),
and loss of function (functiolaesa).Acute inflammation starts after a
specific injury that will cause soluble mediators like cytokines, acute
phase proteins, and chemokines to promote the migration of
neutrophils and macrophages to the area of inflammation that cause
leukocytosis (Hannoodee et al, 2020). Infection is suspected as
chorioamnionitis. Chorioamnionitis presents as a febrile illness
associated with an elevated white blood cell (WBC) count, uterine
 tenderness, abdominal pain, foul-smelling vaginal discharge, and fetal
and maternal tachycardia. Diagnosing clinical chorioamnionitis
includes fever of at least 39 C (102.2 F) or between 38 C (100.4 F) and
39 C (102.2 F) within 30 minutes and one of the clinical symptoms.
The majority of women presenting with chorioamnionitis are in labor
or have ruptured membranes (Fowler et al, 2020).

b. What is the meaning of the baby moved to perinatology care, when

being treated, the baby looks short of breath and starts to turn blue?
Answer:
The meaning are:
1) The baby moved to perinatology care→ indicates that the infant is
receiving post-resuscitation care
2) When being treated, the baby looks short of breath and starts to turn
blue → indicates that the baby has dyspnea and cyanosis.
Complaints that appear blue and have difficulty breathing indicate
that there may have been a respiratory disorder causing shortness
of breath, making it difficult to breathe. Shortness of breath is the
body's effort (compensation from the body) to meet oxygen needs
by increasing the respiration process (Sherwood, 2014). Shortness
of breath occurs due to disruption of gas exchange O2 and CO2. If
the gas exchange of O2 and CO2 is continuously disturbed, it will
cause tissue hypoxia which is characterized by cyanosis (Price &
Wilson, 2015).

c. What is the etiology baby looks short of breath and starts to turn blue?
Answer:
Shortness of breath and cyanosis can occur for various reasons,
including the following (Dicky et al, 2017).
1. The presence of mechanical disturbances to the ventilation process
(airflow obstruction, impaired lung expansion, and chest
wall/diaphragm).
2. Weakness of the breath pump.
3. Increased respiratory drive (hypoxemia and metabolic acidosis).
4. Inadequate ventilation (capillary destruction/emphysema and large
vessel obstruction/pulmonary embolism), and psychological
dysfunction (somatization, anxiety, and depression).
Various kinds of possible etiology of shortness of breath can be
concluded due to interference from one or several organs. However,
each of these organs has some differences regarding the state of
shortness of breath (Dicky et al, 2017).
1) The heart can cause shortness of breath in sufferers which can be
followed by cyanotic or acyanotic conditions, and usually
shortness of breath because the heart will feel heavier because of
the increasingly heavy activity being a risk factor. Shortness of
breath caused by the heart can be followed by additional heart
sounds (murmurs or gallops).
2) Shortness of breath due to lung caused by various things, including
due to obstruction of the airway and the presence of certain factors
that cause the lungs/alveoli to fail to expand properly (lack of
surfactant or pressure from the abdominal cavity/heart). Shortness
of breath in the lungs does not depend on the severity of a person's
activity and sometimes severe shortness of breath due to the lungs
can cause a person to become cyanotic. Shortness of breath caused
by the lungs can be followed by additional breath sounds, such as
rhonchi (wet/dry) or wheezing.
3) Shortness of breath arising from the liver or kidneys, shortness of
breath arising from these two organs is a complication that arises
due to metabolic disorders (metabolic acidosis) which results in the
lungs causing shortness of breath.
d. What is the classification of amniotic fluid based on the color?
Answer:
The normal color of amniotic fluid that are clear but can combine with
yellowish. The color of the amniotic fluid indicates greenish or
brownish color that the neonate has excreted meconium (excrement
formed before birth, under circumstances normal discharge after birth
during bowel movements the first time). This can be a sign of that
neonates under stress. Hypoxic state causes intestinal peristalsis and
relaxation of the sphincter muscles ani, then the meconium can pass
through the anus. Colorless liquid pink indicates new bleeding occurs,
while the amniotic fluid is wine-colored indicates a history of bleeding.
Sign the color of the amniotic fluid may be nontrivial but can be help
determine possible causes(Kosim, 2016).

e. What is the meaning of the amniotic fluid were green?

Answer:
Meaning Greenish or brownish color of the amniotic fluid indicates
that the neonate has passed meconium (faeces formed before birth,
which normally pass after birth during the first bowel movement). This
can be a sign that the neonate is under stress. The hypoxic state causes
intestinal peristalsis and relaxation of the anal sphincter muscle, so
meconium can come out through the anus (Ahanya SN, 2005).
The meaning of a baby with SAM is when the amniotic fluid is mixed
with meconium so that it is green and the baby can experience severe
respiratory distress with the discovery of meconium in the trachea during
neonatal resuscitation and no other causes of respiratory distress other
than meconium aspiration are found.

f. What are the divition of the perinatology care room?

Answer:
 Operational Limitations of Neonatal Services provided in the
Perinatology Room of Regional General Hospitals are based on 3
(three) levels, namely:
1. Neonatal Nursing Service level I
Namely Healthy Neonate Care:
Basic Neonatal Services and low-risk infants that require minimal
basic nursing care, where the care of the baby is mainly carried out
by the mother.
2. Neonatal Nursing Service level II
Namely special neonatal care/care for moderately ill infants who are
expected to recover quickly which requires observation and
treatment with normal nursing care.
3. Level III Neonatal Nursing Services
Namely neonatal intensive care that requires continuous supervision
from nurses, doctors and the support of high-tech facilities.

g. What is the criteria for a baby to transfered to perinatology care?(

Answer:
1. Criteria for a normal healthy newborn level 1:
a. Normal delivery / procedure without complications
b. Apgar score 5 min > 7
c. Birth weight 2500 grams – 4000 grams
d. 37 weeks – 41 weeks gestatio
e. No congenital abnormalities
f. No risk of disease
g. Take care of joining/care with her mother until she comes home.
2. Criteria level 2:
a. LBW < 1000 grams without complications
b. BBL > 4000 grams/macrosomia
c. Mild to moderate respiratory distress
d. Local infection/mild moderate infection
 e. Mild to moderate congenital abnormalities that are not serious
f. Other complicated diseases without requiring intensive care
g. Treatment in Perinatology room SCN (special care unit)
3. Criteria level 3
a. Very very low birth weight (< 1000 grams)
b. Apgar score 5/10 min < 3
c. Severe breathing problems
d. Severe infection
e. Meningitis
f. Neonatal seizures
g. Mild congenital abnormalities with emergency
department\Newborns with complications requiring mechanical
ventilation

h. How are the pathophysiology of the baby looks short of breath and
starts to turn blue?
Answer:
i. What is the correlation between risk factor with main complain?
Answer:
Fever history in mother when giving birth with leukocytes 18.000/mm3
indicates the possibility of infection in the mother suspected
chorioamnionitis. Chorioamnionitis is an infection that can occur
before labor, during labor, or after delivery. Most commonly,
chorioamnionitis is associated with preterm labor, prolonged rupture
of membranes, prolonged labor, tobacco use, nulliparous pregnancy,
meconium-stained fluid, multiple vaginal exams post rupture of
membranes, and in women with known bacterial or viral infections.
Studies show a strong correlation between histologic chorioamnionitis
and the key clinical symptoms of fever, uterine tenderness, meconium
 aspiration syndrome, and foul-smelling vaginal discharge.
Chorioamnionitis presents as a febrile illness associated with an
elevated white blood cell (WBC) count. Neonatal complications of
chorioamnionitis include premature birth, cerebral palsy, retinopathy
of prematurity, neurologic abnormalities, respiratory distress
syndrome, bronchopulmonary dysplasia in premature infants, neonatal
sepsis, and neonatal death (Fowler et al, 2020).
Perinatal asphyxia can occur due to intrapartum infection (maternal
fever in labor) (Gillam-Krakauer et al, 2020).MAS is due to the
aspiration of meconium-stained amniotic fluid. Unlike infant stool,
meconium is darker and thicker. It is formed through the accumulation
of fetal cellular debris (skin, gastrointestinal, hair) and secretions.
Aspiration of these materials causes airway obstruction, triggers
inflammatory changes, and inactivates surfactant. Through these
mechanisms, the neonate develops respiratory distress (Sayad et al,
2021). Neonatal respiratory distress syndrome (RDS) occurs from a
deficiency of surfactant, due to either inadequate surfactant
production, or surfactant inactivation in the context of immature lungs
(Yadav et al, 2021). Respiratory distress in the newborn is recognized
as one or more signs of increased work of breathing, such as tachypnea,
nasal flaring, chest retractions, or grunting (Reuter et al, 2014).

4. Physical examination
General Appearance: hipoactive, whimpering, weak suction reflexes,
BL: 49cm, BBW: 2800 g, HC: 34 cm, Oxygen saturation 90%
Vital Sign: HR: 132x/M, RR: 70 x/M, Temp.: 36,6oC.
Specific Examination:
Head: Caput succesaneum (+) Nose: nasal flaring breathing (+), Cyanosis
(+)
Thorax: Chest retraction (+) epigastrium, suprasternal, down score: 6
Pulmo: vesiculer (+/+), ronchi (+/+)
Cor: Hearth sounds I – II normal, Murmur (-)
Anus: meconium (+)
a. What is the interpretation of physical examination?
Answer:

Interpretati
Examination In thecase Normal
on

Hipoactive,
Active, crying,
whimpering,
strongsuctionre Asphyxia
weaksuctionre
flexes
General flexes
Appearance

BL: 49cm, BBW: 2800 g, HC:

Normal
34 cm
Oxygensaturat
95-100% Hypoxia
ion 90%

HR: 132x/M 120-160x/m Normal

Vital sign
RR: 70 x/M 35-50x/m Tachypnea
Temp.: 36,6oC 36,5-37 oC Normal

Head:
SpecificExami
Caputsuccesa - Abnormal
nation
neum (+)
 Nose: nasal Nasal
flaringbreathi flaringbreathin Dyspnea
ng (+) g (-)
Cyanosis (+) Cyanosis (-) Hypoxia
Thorax :
Chestretractio
Chestretraction
n (+) Dyspnea
(-)
epigastrium,
suprasternal
Respiratorydi
Downscore: 6 Downscore: 0
stress
Pulmo : Vesiculer(+/+) Normal
Pulmo:
Ronchi (-) Abnormal
Ronchi (+/+)
Cor:Hearthsounds I – II normal,
Normal
Murmur (-)
Anus : Meconium (+) Post term

b. What is abnormal mechanism of physical examination?

 Answer:

c. What is the indication of down score?

Answer:
Downes score can be used as a clinical diagnoastic means for assessing
hypoxemia in neonates with respiratory distress, with 88% sensitivity
adn 81% specificity (Rusmawati et al., 2008).

d. How to assessed the down score?

 Answer:

5. Laboratory Examination: Blood Chemistry: hemoglobin 16,0 mg/dl,

trombocyte 208.000/mm3,leukocyte 34.000/mm3, LED: 15 mm/jam, CRP:
20mg/L
a. What is the interpretation of laboratory examination?
Answer:
BloodChemistr Interpretatio
In thecase Normal
y n
13,5-24
Hemoglobin 16,0 mg/dl Normal
mg/dl
150.000-
208.000/mm
Trombocyte 450.000/mm Normal
3
3

9000-
Leukocyte 34.000/mm3 Leukocytosis
30.000/mm3
0-20
LED 15 mm/jam Abnormal ↑
mm/jam
CRP 20mg/L <10 mg/L Abnormal ↑

b. What is abnormal mechanism of laboratory examination?

Answer:
 Risk factors: postterm, suspect chorioamnionitis → Fetus ingests
inflammatory mediator microor-ganisms from mother → increased
intestinal peristalsis → meconium discharge→ meconium aspiration→
Immune system activation → an inflammatory resp-onse occurs
(mediated by matrix metalloproteinase 8, interleukin 6, interleukin 8,
interferon gamma, TNF-α) → leukocytosis, LED ↑, CRP ↑
(Monfredini et al, 2021; Sayad et al, 2021)

6. Rontgen thorax

a. What is the interpretation of rotgen thorax?

Answer:
The interpretation of rontgen thorax are:

Interpretation: Infiltrates in the right and left lung fields

b. What is abnormal mechanism of rotgen thorax?

Answer:
Risk factors: postterm, suspect chorioamnionitis → Fetus ingests
inflammatory mediator microor-ganisms from mother → increased
 intestinal peristalsis → meconium discharge → meconium aspiration
→ Immune system activation → an inflammatory resp-onse occurs
(mediated by matrix metalloproteinase 8, interleukin 6, interleukin 8,
interferon gamma, TNF-α) →accumulation of exudate between the
capillaries and the alveoli → pressure the capillaries so that the
alveolar capillaries leak→ infiltrate picture(Monfredini et al, 2021;
Sayad et al, 2021)

7. How to diagnose in this case?

Answer:
To diagnose in thiscase are:
A baby girl was delivered spontan eously at
PONEK RSMP Emergency Department, the
Patient’s data
baby wasn’ tcrying, from a 43 weeks
G1P0A0 mother, and birth weight 2800 gram
The Apgar score on the first minute was
Examination three, five on the fifth minute, and eight on
the tenth minute.
There was fever history in mother when
Mother’s and birth
giving birth with leukocytes 18.000/mm3.
history
The amniotic fluid were green.
The baby moved to perinatology care, when
Follow-upcheck being treated, the baby looks short of breath
and starts to turn blue.
General appearance: Hipoactive, whim
pering, weak suction reflexes, oxygen
saturation 90%
Physica lexamination
Vital sign: RR: 70 x/M
Specific examination: Head: Caput succes
aneum (+), nasal flaring breathing (+),
 cyanosis (+), chest retraction (+), downs core
6, ronchi (+/+), anus: Meconium (+)
Laboratory Leukocyte↑, LED ↑, CRP ↑
examination
Rontgen thorax

8. What are differential diagnose in this case?

Answer:
The differential diagnose in this case are (Gallacher et al, 2016):
Persistent
Transient
Meconium pulmonary
Congenital tachypneu
aspiration hypertension
pneumonia in newborn
syndrome of the
(TTN)
newborn
Pneumonia, like
Risk factors for neonatal sepsis,
Risk factors
meconium is described as
for TTN
aspiration syndrome being either Characterised
include
(MAS) are any early or late by the failure
maternal
factor increasing onset. Early of the
diabetes,
the risk or onset, or pulmonary
maternal
indicating the congenital, vasculature to
asthma,
presence of fetal pneumonia is adapt to the
male sex,
distress; post-term associated with ex-utero
low birth
gestational age, trans-placental environment
weight and
reduced Apgar infection and following
macrosomia
score, presents within birth.
, caesarean
oligohydramnios 48 h of age.
sections
and male sex Chorioamnioniti
s is a major
 contributory
factor for sepsis,
with infected
uterine fluid
being inhaled by
the fetus,
potentially
resulting in
pneumonia
Fetal distress, Risk factor: Mal-
usually during Invasive group development
labour, can cause B streptococcal and under-
the fetus to pass infection in a development
meconium into the previous baby, are
amniotic fluid Maternal group commonly
before delivery. A B streptococcal associated
physiological colonisation, with
response to bacteriuria or congenital
worsening fetal infection in the defects which
distress is for the current affect either
fetus to attempt pregnancy, the lung
gasping respiratory Prelabour parenchyma
effort. During such rupture of or pulmonary
gasps the fetus may membranes, blood vessels
inhale meconium Preterm birth or both, as
stained liquor into following associated
the lungs. The spontaneous with
inhaled meconium labour (before congenital
adversely affects 37 weeks’ diaphragmati
the lung in several gestation), c hernia.
ways (Mechanical Suspected or Infants with
 obstruction of the confirmed maladaptatio
airways leading to rupture of n have
ventilation/perfusio membranes for normal
n mismatch, more than 18 h anatomy but
Chemical in a preterm fail to adapt
pneumonitis, birth, to extra-
infection) Intrapartum uterine life.
fever higher than Most
38°C or maladaptatio
confirmed or n is as a
suspected consequence
chorioamnionitis of lung
, Parenteral parenchymal
antibiotic disease,
treatment given infection or
to the woman for perinatal
confirmed or asphyxia.
suspected Maladaptatio
invasive n associated
bacterial with primary
infection (such PPHN has
as septicaemia) also been
at any time linked with
during labour, or chromosomal
in the 24-h or genetic
periods before disorders,
and after the including
birth, Suspected trisomy 21
or confirmed
infection in
another baby in
 the case of a
multiple
pregnancy

9. What is additional examination in this case?

Answer:
1. Blood culture with indication of bacteremia, is not very helpful because
the new results are obtained> 48 hours.
2. Blood gas analysis to assess blood acidity or acid-base status.
3. Blood glucose level with suspected hypoglycemia indication.
4. Complete blood count including type with indication of leucocytosis,
bacteremia, anemia, polycythemia, thrombocytopenia.
5. Lumbar puncture with suspected meningitis indication.
6. Pulse oxymeter with indications for hypoxemia, oxygen therapy.

10. What is working diagnose in this case?

Answer:
Respiratory distress syndrome and neonatal asphyxia et causa meconium
aspiration syndrome

11. What are the treatment in this case?

Answer:
1. Non-pharmacological
Clean residual meconium with a meconium aspirator treat incubator
monitor general condition TTV, CRT, down score consider giving
CPAP (Feriyanto, 2013)
2. Pharmacology
a. Resuscitation infusion fluids D10 % 60-70 ml/ KgBW/Day
(Feriyanto, 2013).
b. Antibiotics: the use of broad-spectrum antibiotics is indicated only
in cases with infiltrates on chest X-ray. Ampicillin 100 mg/kg/day at
 12-hour intervals Gantamicin 5 mg/kg/day at 48-hour intervals
(Feriyanto, 2013).
c. Surfactant : Meconium inhibits endogenous surfactant activity.
Surfactant therapy can improve oxygenation, reduce pulmonary
complications (Feriyanto, 2013).

12. What are the complication in this case?

Answer:
• Short-term (acute) complications can occur:
Rupture of alveoli, Infections, Intracranial hemorrhage and
periventricular leukomalacia, PDA with increased left-to-right
shunting
• Common long-term complications:
Bronchopulmonary dysplasia (BPD), Premature retinopathy
(Soegijanto, S. 2016).

13. What is the prognose in this case?

Answer:
• Quo ad vitam : Dubia ad bonam
• Quo ad fungsionam : Dubia ad bonam
• Quo ad sanationam : Dubia ad bonam

14. How SKDU in this case?

Answer:
Proficiency Level 3: diagnosing, initiating initial management, and
referring (3B Emergency)
General practitioners are able to make clinical diagnoses and provide
preliminary therapy in an emergency to save lives or prevent patient
severity and/or disability. General practitioners can determine the most
appropriate referral for further patient management. General practitioners
can also do follow-up after returning from a referral.
15. What is islamic point of view in this case?\
Answer:
Al-kahfi 46
Wealth and children are adornments of the life of this world, but
continuous good deeds are better in reward with your Lord and better for
hope
Asy-syuara 49-50
He (Pharaoh) said, "Why did you believe in Moses before I gave you
permission? Verily he is your leader who teaches you magic. Later you
will surely know (the result of your actions). I will surely cut off your
hands and feet and be sure to crucify all of you."
They said, “We have nothing to fear, for we will return to our Lord.
At- takwir 8-9
and when the baby girls who were buried alive are asked,
for what sin was he killed?
An-nahl 58-59
In fact, when one of them is informed of the birth of a daughter, his face
becomes black (red), and he is very angry.
He hid from the crowd, because of the bad news that was brought to him.
Will he nurture him with (bear) disgrace or will he bury him in the ground
(alive)? Remember how bad (decision) they made it.
Qs. Al-An'am : 151
‫قُ ۡلتَعَالَ ۡوااَ ۡتلُ َما َح َّر َم َربُّكُمۡ عَلَ ۡيكُمۡ اَ ََّّلت ُ ۡش ِركُ ۡوابِ ٖه ش َۡيــــا َّوبِ ۡال َوا ِلد َۡينِاِحۡ َسانًا ۚ َو ََّلت َۡقتُلُ ۡۤۡوا اَ ۡو ََّلدَكُمۡ م ِۡن اِمۡ ََلق‬
ُ ٰ ‫س الَّت ِۡى َح َّر َم‬
‫ّللا‬ َ ‫طنَ ۚ َو ََّل ت َۡقتُلُوا النَّ ۡف‬َ َ‫ظ َه َر مِ ۡن َها َو َما ب‬ َ ِ‫نَحۡ نُ ن َۡر ُزقُكُمۡ َواِيَّاهُمۡ ۚ َو ََّل ت َۡق َربُوا ۡالف ََواح‬
َ ‫ش َما‬
َ‫صٮكُمۡ بِ ٖه لَعَلَّكُمۡ تَعۡ ِقلُ ۡون‬ ٰ ‫ق ٰذ ِلكُمۡ َو‬ ِ ‫ا ََِّّل بِ ۡال َحـ‬
Means:
Say, "Let me read what the Lord has forbidden you. Do not associate him
with anything, do good to your mother, do not kill your children for being
poor.
Qs. Al-Luqman : 13
 ‫اّٰلل ؕاِنَّالش ِۡر َكلَـظُ ۡل ٌمعَظِ ۡي ٌم‬
ِ ٰ ِ‫َوا ِۡذقَالَلُ ۡقمٰ ن َُِل ۡبن ِٖه َوه َُويَ ِعظُهٗ ٰيبُنَٮ َََّلت ُ ۡش ِر ۡكب‬
Means:
And (remember) when Lukman said to his son, when he taught him, "O
my son! Do not associate with Allah, but to associate (Allah) is a great
deal."
Albaqarah 233
And mothers should breastfeed their children for two whole years, for
those who want to breastfeed completely. And it is the duty of the father
to provide for their maintenance and clothing in a proper manner. A person
is not burdened more than he can bear. A mother should not suffer because
of her child and neither should a father suffer because of his child. The
heirs are (obligated) like that too. If both want to wean by agreement and
deliberation between them, then there is no sin on either of them. And if
you want to nurse your child to someone else, then there is no sin for you
to pay it in a proper way. Fear Allah and know that Allah is All-Seeing of
what you do.

V. Conclusion
The baby girl had dyspnea and cyanosis because of she experienced respiratory
distress syndrome and neonatal asphyxia et causa meconium aspiration
syndrome.
VI. Conseptual framework

Fr Post term+suspect
korioamnionitis

the fetus ingests microorganisms and

inflammatory mediators (leukocytosis from
the mother)

increased intestinal peristalsis

Passage of meconium mixed with amniotic

fluid

neonatal aspiration aphyxia aspiration

decreased ventilation

impaired percussion of O2 and CO2

(respiratory distress)

Cyanosis, dypnea
 DAFTAR PUSTAKA

Andarini, dkk. 2015. Application Database of Comprehensive Emergency Neonatal

and Obstetric Service in Sampang Hospital. Surabaya
:DepartemenEpidemiologi FKM UA JurnalBerkalaEpidemiologi, Vol. 3, No.
3.
Behera MK, Kulkarni SD, Gupta RK. Meconium aspiration syndrome: a clinical study.
Med J Armed Forces India. 2017;54:19-20.
Dicky, K. N. A., Anggraeni, J. W. 2017. Tatalaksana Terkini Bronkopneumonia
pada Anak di Rumah Sakit Abdul Moeloek. J. Medula Unila. Vol. 7. No. 2.
[Jurnal].
Fowler, J. R., Leslie, V. S. 2020. Chorioamnionitis. Available in:
https://www.ncbi.nlm.nih.gov/ books/NBK532251/. Accessed on: 29th of
September 2021.
Gallacher, D. J., Kylie, H., Sailesh, K. 2016. Common Respiratory Conditions of
The Newborn. Reath. Vol. 12. No. 1. Available in: https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC4818233/. Accessed on: 29th of September
2021.
Gillam-Krakauer, M., Clearence, W. G. 2020. Birth Asphyxia. Available in:
https://www.ncbi.nlm.nih.gov/books/NBK430782/. Accessed on: 29th of
September 2021.
Hannoodee, S., Dian, N. N. 2020. Acute Inflammatory Response. Available in:
https://www.ncbi. nlm.nih.gov/books/NBK556083/. Accessed on: 29th of
September 2021.
Kemenkes RI, 2014. Rencana Aksi Dirjen Bina Upaya Kesehatan 2015-2019.
Jakarta: DirjenYankes
Kosim, MS. 2016. PemeriksaanKekeruhan Air Ketuban.Semarang:Sari Pediatri
Lee JH, Romero R, Lee KA, Kim EN, Korzeniewski SJ, Chaemsaithong P, et al.
Meconium aspiration syndrome: a role for fetal systemic inflammation. Am J
Obstet Gynecol. 2016;214:3661-9.
Maryuni, et al. 2013.Asuhan Kegawatdaruratan Maternal danNeoantal.Jakarta:
Trans Info Media.
Patwa, A. and Shah, A. (2015). Anatomy and physiology of the respiratory system
relevant to anaesthesia. Indian Journal of Anaesthesia, 59(9), p.533.
Price, S. A., Wilson, L. M. 2015. Patofisiologi: Konsep Klinis Proses-Proses
Penyakit. Jakarta: Penerbit Buku Kedokteran EGC.
Putra, TR, & Mutiara, H. (2017). Meconium Aspiration Syndrome Meconium
Aspiration Syndrome. Meconium Aspiration Syndrome J Medulla
Unila|Volume, 1, 74.
Reuter, S., Chuanpit, M., Michelle, B. 2014. Respiratory Distress in The Newborn.
Pediatrics in Review. Vol. 35. No. 10. Available in:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4533247/. Accessed on:
29th of September 2021.
Rusmawati, A., Haksari, E.L., Naning, R. 2008. In Neonates With Respiratory
Distress. Yogyakarta:PaediatricaIndonesiana.
Saifuddin, A. S., Trijatmo, R., Gulardi, H. W. 2014. IlmuKebidanan. Edisi 4.
Jakarta: PT Bina PustakaSarwonoPrawirohardjo.
Sayad, E., Manuel, S. 2021. Meconium Aspiration. Available in:
https://www.ncbi.nlm.nih.gov/books/NBK557425/. Accessed on: 29th of
September 2021.
Sherwood, L. 2014. Fisiologimanusia: dariselkesistem. Edisi 8. Jakarta: Penerbit
Buku Kedokteran EGC.
Soegijanto, S. 2016. PenyakitTropisdanInfeksi di Indonesia. Surabaya: Airlangga
University Press.
Sylviati M, 2008. Klasifikasi Bayi Menurut Berat Lahir dan MasaGestasi. In:
Sholeh Kosim, dkk. Buku Ajar Neonatologi. Jakarta: Badan Penerbit IDAI
Yadav, S., Brian, L., Ranjith, K. 2021. Neonatal Respiratory Distress Syndrome.
Available in: https://www.ncbi.nlm.nih.gov/books/NBK560779/. Accessed
on: 29th of September 2021.