SKENARIO C BLOK 24

Mrs. Sukinem,38 years old women in her fifth pregnancy delivered her son
spontaneously 4 hours ago. She was helped by birth attendant in her village about 1,5 hours away
rom referral hospital. She lived with her husband who is a farmer 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 vagna. The birth attendant called midwife and according to
midwife, uterine contraction was poor and uterine fundal could not b palpated at that time. She
gave th mother intramuscular oxytocin injection 10 IU and reffered her to primary public health
service (Puskesmas) which already got PONED certification. Her antenatal care history was 2
times with midwife in this public health and already diagnosed with mild anema due to Fe serum
deficiency (her last month Hb count was 9 g/dl).
On arrival, as general practitioner public health service, ou find the patient is
consciousness but drowsy and pale. You also find approximately 1000ml of blood blot in her
pants. In the examination findings:
Height 155cm, weight 50kg. blood pressure 60/40 mmHg, heart rate 140xminute,
respiratory rate 36x/minute, temperature 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/minute, insert 2 venous line and folley catheter, do blood examination including
routine blood analysis, hemostatic analysis, and serum blood analysis. You gave 2000ml
crystalloid fluid and 300 cc pack red cells, also oxytocin 20 IU in 500ml crystalloid fluid.
After 30 minutes, she become consciousness and not drowsy anymore. Blood pressure
become 100/70mmHg, pulse 92x/minute, respiratory rate 22x/minute, temperature 35,8oC, urine
output 100cc. 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:
Hemoglobin

: 4,2 g/dl

White cell count

Platelet
INR
APTT
You finally refer this patient

: 3.200/mm3
: 115.000/mm3
: 1,3
: 39
after 1 hours treatment in your public health service to

RSMH.
Analisis Masalah
1. Ny. Sukinem, 38 tahun, istri dari seorang petani, telah melahirkan anak kelima berjenis
kelamin laki-laki dengan berat 4000 g 4 jam yang lalu secara spontan dibantu oleh dukun.
Setelah plasenta dilahirkan, terjadi perdarahan masif melalui vagina. Berdasarkan keterangan
dari bidan, kontraksi uterus lemah dan fundus uteri tidak teraba.
a. Apa hubungan usia, status kehamilan, berat badan bayi dan cara persalinan serta status
ekonomi terhadap perdarahan masif pasca persalinan? 1,2,3
b.Apa makna klinis dari fundus uteri tidak teraba? 1, 7, 3
2. Bidan memberikan oksitosin intramuscular 10 IU dan merujuk ke Puskesmas yang
tersertifikasi PONED.
a. Bagaimana farmakodinamik dari oksitosin intramuscular? 3, 9, 5
3. Riwayat ANC : dilakukan dua kali oleh bidan dan didiagnosis dengan anemia ringan akibat
defisiensi besi (Hb bulan lalu 9 g/dl).
a. Bagaimana prosedur persalinan yang tepat pada ibu hamil dengan anemia defisiensi besi?
10, 3, 6
4. In the examination findings:
Height 155cm, weight 50kg. blood pressure 60/40 mmHg, heart rate 140xminute,

respiratory rate 36x/minute, temperature 35oC.

The peripheral extremities are cold. The abdomen is otherwise soft and non tender. The

uterus fundal can not be palpated, no uterine contraction.

a. Bagaimana interpretasi dan mekanisme abnormal dari hasil pemeriksaan fisik? 9, 3, 7
5. Ny. Sukinem ditatalaksana dengan resusitasi, diposisikan pada posisi Trendelenburg, diberikan
oksigen 6-8L/menit, diberikan infus 2 jalur dan kateter Folley, dilakukan pemeriksaan darah
rutin, analisis hemostasis dan analisis serum darah. Selanjutnya diberikan 2000ml cairan
kristaloid dan 300cc PRC serta oksitosin 20 IU dalam 500ml cairan kristaloid. Setelah 30 menit

Kesadaran membaik

Blood pressure become 100/70mmHg, pulse 92x/minute, respiratory rate 22x/minute,

temperature 35,8oC, urine output 100cc.

Uterine fundal still can not be palpated, uterine contraction is poor, and vaginal bleeding is
still coming out.
a. Bagaimana algoritma tatalaksana perdarahan pasca persalinan yang sesuai standar prosedur?
(bandingkan dengan tatalaksana yang diberikan pada kasus) 3, 1, 4
b. Bagaimana cara pemberian oksitosin pada kasus? 4, 2, 3
c. Bagaimana cara pemberian resusitasi cairan pada kasus? 5, 3, 2

6. Selajutnya dilakukan bimanual interna compression tetapi kontraksi uterin tetap tidak ada. Ny.
Sukinem diberikan misoprostol 600mikrogram pervaginam dan dilakukan kompresi aorta
abdominal, tetapi kontraksi uterus tidak membaik. Kemudian, dimasukkan tampon uterus
menggunakan metode Sayeba condom, dan direncanakan untuk dirujuk ke RSMH.
a. Bagaimana cara kerja misoprostol? 9,7,3
b. Bagaimana cara pemasangan tampon dengan metode Sayeba condom dan apa fungsinya?
3,9,5
7. Setelah satu jam ditatalaksana di Puskesmas, Ny. Sukinem dirujuk ke RSMH.
a. Bagaimana prosedur merujuk pasien perdarahan pasca persalinan? 3,4,5
8. Manajemen aspek klinis
a. Diagnosis Banding 9,1,3
b. Pemeriksaan Penunjang 1, 3,5
c. Etiologi 3,5,7
d. Tatalaksana, follow-up 7,9,1,5
e. Komplikasi 9,1,3
f. SKDI SEMUA
LEARNING ISSUE
1. Perdarahan Post-Partum SEMUA
2. Manajemen Resusitasi 3,6,9