Skenario C blok 22 tahun 2019

Mrs. A is a 40-year-old G7P6A0 woman has brought to a midwife by a traditional birth

attendant due to failure to deliver the baby after pushing for 2 hours. She was put on oxytocin
drip and delivered a 4100-gram infant by spontaneous delivery 3 hours ago with the
assistance of the midwife. The placenta was delivered spontaneously and intact. She received
episiotomy and had it repaired. After delivered, she complained of massive vaginal bleeding
and was brought to a hospital. Due to the absence of the OBGYN, she was reffered to Moh.
Hoesin Hospital. The estimated blood loss at the time of delivery was 500 cc. At the hospital,
the patient looked pale, weak, and drowsy. Her prenatal course was uncomplicated and had
no significant medical history. She had no history of previous contraception.

In the examination findings :

Height = 163 cm ; weight = 75 kg ;

Sense : Somnolen
BP : 70/40 mmHg. HR : 121 x / min, RR : 24 x m. T : 36.4 C

Obstetric examination

Outer examination : abdomen flat, soft, uterine fundus palpable at the level of umbilicus,
uterine conraction was poor, active bleeding (+)
Inspeculo : portio livide, external uterine ostium was opened, fluor (-) fluxus (+) active
bleeding, erosion (+), laceration (+) repaired, polyp (-)
Lab : HB 4,7 g/d/l ; PLT : 225.000/mm3 WBC : 20.600/mm3, BT/CT : 3 minutes/ 12 minutes
Ureum : 48,5 mg/dL; creatinine : 1.10 mg/dL

Klarifikasi istilah

1. Traditional birth attendant : bidan tradisional ( dukun beranak ) yang memberikan

perawatan kesehatan dasar, dukungan dan saran selama dan setelah kehamilan dan
melahirkan, terutama berdasarkan pengalaman dan pengetahuan yang diperoleh
secara informal melalui tradisi dan praktik masyarakat dimana mereka berasal.
2. Oxytocin drip : hormon yang dibuat untuk menginduksi persalinan aktif
meningkatkan kekuatan kontraksi pada persalinan, mengontraksikan otot uterus
 setelah kelahiran plasenta, mengontrol perdarahan pasca kelahiran dan merangsang
ejeksi susu yang diberikan dengan dicampurkan cairan infus dengan kecepatan
tertentu
3. Intact : utuh
4. Episiotomy : insisi bedah ke dalam perineum dan vagina dengan indikasi obstetrik
5. Massive vaginal bleeding : hilangnya 50% jumlah darah dalam waktu < 3 jam
melalui vagina
6. Contraception : usaha untuk mencegah terjadinya kehamilan yang bersifat sementara
atau permanen
7. Somnolen : kesadaran menurun, respon psikomotor yang lambat, mudah tertidur,
namun kesadran dapat pulih bila dirangsang atau mudah dibangunkan tapi jatuh
tertidur lagi, mampu menjawab verbal
8. Active bleeding : perdarahan lebih dari 500-1000 cc dalam waktu kurang dari 24 jam
yang mengganggu hemodinamik
9. Laserasi : luka terbuka atau luka berupa robekan
10. CT : lamanya waktu yang diperlukan darah untuk membeku / ukuran aktivitas faktor-
faktor pembekuan darah terutama faktor-faktor yang membentuk tromboplastin dan
yang berasal dari trombosit
11. BT : uji lab untuk mengukur hemostasis dan koagulasi menentukan lamanya tubuh
menghentikan perdarahan akibat trauma yang dibuat secara laboratoris
12. Polyp : tumor jinak yang tumbuh menonjol dan bertangkai berasal dari selaput lendir
atau kelenjar di membran mukosa

Identifikasi masalah

1. Mrs. A is a 40-year-old G7P6A0 woman has brought to a midwife by a traditional

birth attendant due to failure to deliver the baby after pushing for 2 hours.
2. She was put on oxytocin drip and delivered a 4100-gram infant by spontaneous
delivery 3 hours ago with the assistance of the midwife. The placenta was delivered
spontaneously and intact.
3. She received episiotomy and had it repaired.
4. After delivered, she complained of massive vaginal bleeding and was brought to a
hospital. Due to the absence of the OBGYN, she was reffered to Moh. Hoesin
Hospital. The estimated blood loss at the time of delivery was 500 cc.
5. At the hospital, the patient looked pale, weak, and drowsy. Her prenatal course was
uncomplicated and had no significant medical history. She had no history of previous
contraception
6. In the examination findings :
Height = 163 cm ; weight = 75 kg ;
Sense : Somnolen
BP : 70/40 mmHg. HR : 121 x / min, RR : 24 x m. T : 36.4 C
7. Obstetric examination

Outer examination : abdomen flat, soft, uterine fundus palpable at the level of
umbilicus, uterine conraction was poor, active bleeding (+)
Inspeculo : portio livide, external uterine ostium was opened, fluor (-) fluxus (+)
active bleeding, erosion (+), laceration (+) repaired, polyp (-)

8. Lab : HB 4,7 g/d/l ; PLT : 225.000/mm3 WBC : 20.600/mm3, BT/CT : 3 minutes/ 12

minutes
Ureum : 48,5 mg/dL; creatinine : 1.10 mg/dL

Analisis masalah

1. Mrs. A is a 40-year-old G7P6A0 woman has brought to a midwife by a traditional

birth attendant due to failure to deliver the baby after pushing for 2 hours. Clar,
vezi aul
a. Apa hubungan usia, riwayat obstetrik dengan lama waktu mengedan pada
kasus? (pada kala II )
b. Apa saja fase saat persalinan? (kala I, kala II, kala III, kala IV dengan waktu
normal)
c. Apa saja faktor yang menyebabkan kala II lama pada kasus?
d. Apa komplikasi dari kala II lama pada kasus?

2. She was put on oxytocin drip and delivered a 4100-gram infant by spontaneous
delivery 3 hours ago with the assistance of the midwife. The placenta was
delivered spontaneously and intact. Sisi jason rere miranti
a. Apa indikasi dan kontraindikasi pemberian oksitosin drip?
b. Bagaimana cara pemberian oksitosin drip?
c. Bagaimana manajemen aktif kala III? (pemberian oksitosin, dsb)
d. Berapa berat badan normal pada bayi baru lahir?
e. Apa komplikasi yang ditimbulkan pada ibu dan bayi makrosomia?
f. Apa penyebab bayi makrosomia?

3. She received episiotomy and had it repaired. Dyah, nendy iqbal ulfi
a. Apa indikasi dan kontraindikasi episiotomi?
b. Apa komplikasi yang bisa ditimbulkan dari episiotomi?
c. Episiotomi grade berapa yang dapat menyebabkan perdarahan?

4. After delivered, she complained of massive vaginal bleeding and was brought to
 hospital. Due to the absence of the OBGYN, she was reffered to Moh. Hoesin
Hospital. The estimated blood loss at the time of delivery was 500 cc.
a. Apa penyebab perdarahan massive?
b. Bagaimana mekanisme perdarahan massiv?
c. Apa hubungan usia, riwayat obstetri lama waktu persalinan dengan massive
vaginal bleeding?
d. Bagaimana tatalaksana awal dari massive vaginal bleeding?
e. Kapan indikasi dilakukan transfusi darah? Berapa target Hb yang diinginkan?
berapa maksimal jumlah darah yang diberikan dalam sehari?
f. Bagaimana sistem merujuk Ny A yang mengalami perdarahan
g. Bagaimana cara menghitung persentasi darah yang hilang saat perdarahan
masif?
h. Bagaimana mekanisme pucat, lemah dan mengantuk ?
i. Bagaimana komplikasi dari massive vaginal bleeding?

5. At the hospital, the patient looked pale, weak, and drowsy. Her prenatal care was
uncomplicated and had no significant medical history. She had no history of
previous contraception
a. Apa makna klinis kalimat di atas?
b. Apa hubungan tidak menggunakan kontrasepsi sebelumnya dengan vaginal
bleeding?

6. In the examination findings :

Height = 163 cm ; weight = 75 kg ;
Sense : Somnolen
BP : 70/40 mmHg. HR : 121 x / min, RR : 24 x m. T : 36.4 C
a. Apa interpretasi dan mekanisme abnormalitas pemeriksaan fisik di atas

7. Obstetric examination

Outer examination : abdomen flat, soft, uterine fundus palpable at the level of
umbilicus, uterine conraction was poor, active bleeding (+)
Inspeculo : portio livide, external uterine ostium was opened, fluor (-) fluxus (+)
active bleeding, erosion (+), laceration (+) repaired, polyp (-)

a. Apa interpretasi dan mekanisme abnormalitas pemeriksaan obstetrik

b. Bagaimana mekanisme terjadinya involusi dan berapa lama waktu yang
diperlukan agar tidak terjadi perdarahan?
c. Bagaimana gambaran hasil pemeriksaan obstetrik di atas?
 8. Lab : HB 4,7 g/d/l ; PLT : 225.000/mm3 WBC : 20.600/mm3, BT/CT : 3 minutes/
12 minutes
Ureum : 48,5 mg/dL; creatinine : 1.10 mg/dL

a. Apa interpretasi dan mekanisme abnormalitas

Hipotesis : Ny A 40 tahun grandemultipara mengalami perdarahan pasca persalinan diduga

karena kontraksi uterus inadekuat

a. Bagaimana diagnosis banding? Aul clar vezi

b. Algoritma penegakkan diagnosis?
c. Diagnosis kerja
d. Definisi
e. Etiologi
f. Epidemiologi
g. Faktor risiko sisi rere jason miranti
h. Patogenesis
i. Patofisiologi
j. Klasifikasi
k. Manifestasi klinis
l. Pemeriksaan penunjang ulfi dyah nendy iqbal
m. Tatalaksana farmakologi dan non farmakologi
n. Komplikasi
o. Prognosis
p. Edukasi dan pencegahan
q. SKDI

LI

1. HPP semua
2. Fase Persalinan (kala I, kala II, kala III, kala IV) aul vezi clar
3. APN sisi rere jason miranti
4. Episiotomi ulfi dyah nendy iqbal
5. Anatomi dan fisiologi ( yang kemarin aja ya  )

Warna biru : clar aul vezi

Warna hijau : sisi rere jason miranti
Warna hitam ulfi dyah nendy dan iqbal
Sumber : Harris pregnancy