KATA PENGANTAR

Puji syukur kami sampaikan kepada Allah SWT. atas segala rahmat dan karunia-Nya
sehingga kami dapat menyelesaikan laporan tutorial yang berjudul sebagai tugas
kompetensi kelompok. Shalawat beriring salam selalu tercurah kepada junjungan kita, nabi
besar Muhammad SAW beserta para keluarga, sahabat, dan pengikut-pengikutnya sampai
akhir zaman.
Kami menyadari bahwa laporan tutorial ini jauh dari sempurna. Oleh karena itu, kami
mengharapkan kritik dan saran yang bersifat membangun guna perbaikan di masa mendatang.
Dalam penyelesaian laporan tutorial ini, kami banyak mendapat bantuan, bimbingan,
dan saran. Pada kesempatan ini, kami ingin menyampaikan rasa hormat dan terima kasih
kepada:
1. Allah SWT, yang telah memberi kehidupan dengan sejuknya keimanan,
2. dr. Fatimah Usman, Sp. OG, selaku tutor kelompok 3,
3. teman-teman sejawat Fakultas Kedokteran Unsri,
4. semua pihak yang telah membantu kami.
Semoga Allah SWT memberikan balasan pahala atas segala amal yang diberikan
kepada semua orang yang telah mendukung kami dan semoga laporan tutorial ini bermanfaat
bagi kita dan perkembangan ilmu pengetahuan. Semoga kita selalu dalam lindungan Allah
SWT. Amin.
Palembang, 3 Februari 2017

Kelompok 3

Laporan Tutorial Skenario C Blok 24 Kelompok A3

Halaman 1

DAFTAR ISI
Kata pengantar.......................................................................................................
Daftar isi.................................................................................................................
Skenario.................................................................................................................
Klarifikasi istilah....................................................................................................
Identifikasi masalah...............................................................................................
Analisis masalah....................................................................................................
Hipotesis.................................................................................................................
Learning issue........................................................................................................
Kerangka konsep....................................................................................................
Kesimpulan............................................................................................................
Daftar pustaka........................................................................................................

1
2
4

KEGIATAN TUTORIAL
Tutor

: dr. Fatimah Usman, Sp. OG

Laporan Tutorial Skenario C Blok 24 Kelompok A3

Halaman 2

Moderator

: M. Maruf Agung

Sekretaris Meja 1

: Husnul Khotimah

Sekretaris Meja 2

: Kamila Rahmah

Hari/Tanggal Pelaksanaan

: Senin dan Rabu, 30 Januari dan 1 Februari 2017

Waktu Pelaksanaan

: 10.00-12.30 WIB

Peraturan selama tutorial

Diperbolehkan untuk minum

Alat komunikasi mode silent

Pada saat ingin berbicara terlebih dahulu mengacungkan

tangan, lalu setelah diberi izin moderator baru bicara

Saling menghargai dan tidak saling menggurui

SKENARIO

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Mrs. Sukinem, 38 years old woman 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 from referral hospital. He 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 coming 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
referred 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 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
conscious but drowsy and pale. You also find approximately 1000 ml of blood clot in her
pants.
In the examination findings:
Height 155 cm, weight 50 kg, blood pressure 60/40 mmHg, heart rate 140x/minute,
respiratory rate 36x/minute, temperature 35oC. The peripheral extremities are cold. The
abdomen is otherwise soft and non-tender. The uterus fundal cannot be palpated, no uterine
contraction. On vaginal inspection, there is blood clot in vagina and no portio lacerations or
vaginal/perineal lacerations are identified.
You do resuscitation on her, made her to become in Tredelenburg position, gave her
oxygen 6-8 L/minute, insert 2 venous lines and folley catheter, do blood examination
including routine 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 becomes conscious and not drowsy anymore. Blood pressure
become 100/70 mmHg, pulse 92x/minute, respiratory rate 22x/minute, temperature 35,8oC,
urine output 100 cc. You examine the patient again, uterine fundal still cannot be palpated,
uterine contraction is poor, and vaginal bleeding is still coming out. You do bimanual internal
compression, but still no uterine contraction. You gave her misoprostol 60g 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.

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The laboratory results are hemoglobin: 4,2 g/dL, white cell count: 3.200/mm3,
platelet: 115.000/mm3, INR: 1,3, APTT: 39.
You finally refer this patient after 1 hour treatment in your public health service to
RSMH.
A. KLARIFIKASI ISTILAH
1. placenta
Organ yang menghubungkan ibu dan bayinya, mengadakan sekresi endokrin dan
pertukaran selektif substansi yang dapat larut serta terbawa darah melalui lapisan
rahim dan bagian trofoblas yang mengandung pembuluh darah.
2. massive blood
Kehilangan 500 ml atau lebih darah setelah persalinan pervaginam atau 1000 ml atau
lebih setelah seksio sesaria.
3. oxytocin
Hormon hipotalamus yang tersimpan di hipofisis posterior, memiliki aktivitas untuk
mengontraksikan uterus dan mengeluarkan air susu.
4. PONED certification
Pelayanan Obstetri Neonatus Esensial Dasar; merupakan puskesmas yang siap 24
jam sebagai rujukan antara kasus-kasus dari polindes dan puskesmas.
5. laceration
Luka robek.
6. Tredelenburg position
Posisi berbaring di tempat yang datar di mana kepala berada lebih rendah dari
pelvis; ini adalah posisi standar untuk pembedahan abdominal dan ginekologi.
7. two venous lines
8. Folley catheter
Kateter indwelling yang dipertahankan dalam kandung kemih oleh suatu balon yang
dikembangkan dengan udara atau cairan.
9. hemostatic analysis
10. packed red cell
Sel darah merah yang sudah dipisahkan dan disimpan digunakan untuk transfusi
darah.
11. crystalloid fluid
12. drowsy
Mengantuk; adalah perasaan hendak tidur.
13. bimanual internal compression

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Teknik kompresi bimanual di mana uterus dikompresi antara satu tangan

dimasukkan ke dalam vagina dan tangan yang lain menyokong uterus dari luar untuk
membuat kontriksi pembuluh darah uterus dan menghentikan pendarahan.
14. misoprostol
Obat yang biasanya digunakan bersamaan dengan mifepristone untuk mengkahiri
kehamilan.
15. Sayeba condom method
Metode pemasangan kondom sebagai tampon untuk PPH dengan penyebab atonia
uteri.
16. INR (International Normalize Ratio)
Penghitungan hasil PT yang digunakan untuk memonitor individu yang sedang
diterapi menggunakan antikoagulan warfarin.
17. APTT (Activated Prothrombin Time)
Pemeriksaan untuk mengetahui adanya defisiensi faktor pembekuan atau adanya
inhibitor dalam jalur intrinsik.
B. IDENTIFIKASI MASALAH
No
.
1.

Masalah
Mrs. Sukinem, 38 years old woman in her fifth pregnancy delivered her son
spontaneously 4 hours ago. She was helped by birth attendant in her village,

2.

about 1,5 hours away from referral hospital. Her son weighed 4000 grams.
He lived with her husband who is a farmer and her mother in law who is a birth

3.

attendant.
The placenta was delivered by birth attendant; she claimed it was delivered
completely. Suddenly after placenta was delivered, massive blood was coming
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.

4.

(VVV)
She gave the mother intramuscular oxytocin injection 10 IU and referred her to
primary public health service (Puskesmas) which already got PONED

5.

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

6.

Hb count was 9 g/dL).

On arrival, she is conscious but drowsy and pale, and approximately 1000 ml of

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Halaman 6

7.

blood clot was found in her pants.

In the examination findings:
Height 155 cm, weight 50 kg, blood pressure 60/40 mmHg, heart rate
140x/minute, respiratory rate 36x/minute, temperature 35oC. The peripheral
extremities are cold. The abdomen is otherwise soft and non-tender. The uterus
fundal cannot be palpated, no uterine contraction. On vaginal inspection, there is
blood clot in vagina and no portio lacerations or vaginal/perineal lacerations are

8.

identified.
You do resuscitation on her, made her to become in Tredelenburg position, gave
her oxygen 6-8 L/minute, insert 2 venous lines and folley catheter, do blood
examination including routine blood analysis, hemostatic analysis, and serum
blood analysis. You gave 2000 ml crystalloid fluid and 300 cc pack red cells,

9.

also oxytocin 20 IU in 500 ml crystalloid fluid.

After 30 minutes, she becomes conscious and not drowsy anymore. Blood
pressure become 100/70 mmHg, pulse 92x/minute, respiratory rate 22x/minute,

10.

temperature 35,8oC, urine output 100 cc.

You examine the patient again, uterine fundal still cannot be palpated, uterine
contraction is poor, and vaginal bleeding is still coming out. You do bimanual
internal compression, but still no uterine contraction. You gave her misoprostol
60g vaginally and do abdominal aorta compression, but uterine contraction
wont get better. You insert uterine tamponade using Sayeba condom method,

11.

and refer her to RSMH hospital nearby 1 hour after treatment.

The laboratory results are hemoglobin: 4,2 g/dL, white cell count: 3.200/mm3,
platelet: 115.000/mm3, INR: 1,3, APTT: 39.

C. ANALISIS MASALAH
1. Mrs. Sukinem, 38 years old woman 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 from referral hospital. Her son weighed 4000 grams.
a. Apa hubungan usia ibu dan riwayat kehamilan dengan keluhan pada kasus? 1 4
b. Apa hubungan berat badan bayi dengan keluhan pada kasus dan berapa berat
badan normal bayi baru lahir? 2 5
c. Apa dampak melahirkan dengan bantuan dukun beranak dengan keluhan pada
kasus? 3 6
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d. Apa dampak lamanya perdarahan PPP terhadap kondisi Ibu ini? 4 7

2. He lived with her husband who is a farmer and her mother in law who is a birth
attendant.
a. Apa hubungan pekerjaan suami dengan kasus? 5 8
b. Apa hubungan pekerjaan ibu mertua dengan kasus? 6 9

3. The placenta was delivered by birth attendant; she claimed it was delivered
completely. Suddenly after placenta was delivered, massive blood was coming 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.
a. Bagaimana persalinan normal dari plasenta? (+gambar) 7 10
b. Bagaimana hubungan lemahnya kontraksi uterus dengan persalinan plasenta? 8
1
c. Bagaimana dampak persalinan plasenta tidak lengkap? 9 2
d. Bagaimana penyebab dan mekanisme perdarahan masif setelah lahirnya
plasenta? 10 3
e. Bagaimana interpretasi dari fundus uteri tidak bisa diraba? 1 4

4. She gave the mother intramuscular oxytocin injection 10 IU and referred her to
primary public health service (Puskesmas) which already got PONED certification.
a. Apa indikasi pemberian injeksi IM oksitosin 10 IU? 2 5
b. Bagaimana indikasi, kontraindikasi, dan cara kerja oksitosin pada kasus? 3 6
c. Apa makna ibu dibawa ke puskesmas bersertifikat PONED? 4 7
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5. 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 jadwal antenatal care yang baik dan benar? 5 8
b. Bagaimana dampak dan hubungan anemia defisiensi besi dengan PPP? 6 9
6. On arrival, she is conscious but drowsy and pale, and approximately 1000 ml of
blood clot was found in her pants.
a. Bagaimana mekanisme mengantuk dan pucat pada kasus? 7 10

b. Bagaimana cara menghitung jumlah PPP pada kasus? 8 1

c. Bagaimana mekanisme terbentuknya dan dampak dari terbentuknya gumpalan
darah sekitar 1 L pada kasus? 9 2
7. In the examination findings:
Height 155 cm, weight 50 kg, blood pressure 60/40 mmHg, heart rate 140x/minute,
respiratory rate 36x/minute, temperature 35oC. The peripheral extremities are cold.
The abdomen is otherwise soft and non-tender. The uterus fundal cannot be palpated,
no uterine contraction. On vaginal inspection, there is blood clot in vagina and no
portio lacerations or vaginal/perineal lacerations are identified.
a. Bagaimana interpretasi dan mekanisme abnormalitas dari:
- IMT 10 3
- TD 1 4
- HR 2 5
- RR 3 6
- T47
- Ekstremitas dingin 5 8
- Abdomen 6 9
- Fundus uteri tidak teraba 7 10
- Tidak ada kontraksi uterus 8 1
b. Apa makna tidak ada laserasi pada porsio atau pada vagina/perineum? 9 2
8. You do resuscitation on her, made her to become in Tredelenburg position, gave her
oxygen 6-8 L/minute, insert 2 venous lines and folley catheter, do blood examination
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including routine 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 becomes conscious and not drowsy
anymore. Blood pressure become 100/70 mmHg, pulse 92x/minute, respiratory rate
22x/minute, temperature 35,8oC, urine output 100 cc.
a. Apa tujuan dilakukan posisi Tredelenburg pada kasus? 10 3
b. Bagaimana indikasi dan tujuan diberikan hal-hal berikut pada kasus:
- Oksigen 1 4
- 2 venous lines 2 5
- Kateter Folley 3 6
- Pemeriksaan darah rutin 4 7
- Analisis hemostasis 5 8
- Analisis serum darah 6 9
- Cairan kristaloid 7 10
- Packed red cell 8 1
- Oksitosin 9 2
c. Apa makna hasil pemeriksaan fisik setelah dilakukan resusitasi? 10 3
9. You examine the patient again, uterine fundal still cannot be palpated, uterine
contraction is poor, and vaginal bleeding is still coming out. You do bimanual
internal compression, but still no uterine contraction. You gave her misoprostol 60g
vaginally and do abdominal aorta compression, but uterine contraction wont get
better. You insert uterine tamponade using Sayeba condom method, and refer her to
RSMH hospital nearby 1 hour after treatment.
a. Bagaimana cara melakukan kompresi bimanual internal? 1 4
b. Bagaimana indikasi, kontraindikasi, dan cara kerja misoprostol? 2 5
c. Bagaimana cara melakukan kompresi abdominal aorta? 3 6
d. Mengapa kontraksi uterus tidak membaik setelah dilakukan injeksi oksitosin,
kompresi bimanual, pemberian misoprostol, dan kompresi abdominal aorta? 4 7
e. Mengapa kontraksi uterus tidak membaik setelah dilakukan resusitasi dengan
posisi Tredelenburg? 5 8
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f. Bagaimana indikasi dan cara melakukan pemasangan tampon dengan metode

Sayeba? 6 9
g. Bagaimana indikasi pasien dirujuk ke RSMH? 7 10
10. The laboratory results are hemoglobin: 4,2 g/dL, white cell count: 3.200/mm3,
platelet: 115.000/mm3, INR: 1,3, APTT: 39.
a. Bagaimana interpretasi dan mekanisme abnormalitas dari:
- Hb 8 1
- WBC 9 2
- Trombosit 10 3
- INR 1 4
- APTT 2 5
D. Hipotesis: Ny. Sukinem usia 38 tahun mengalami PPP diduga akibat masalah tonus
dan thrombin.
1. Bagaimana cara mendiagnosis dan pemeriksaan penunjang yang diperlukan untuk
mendiagnosis penyakit pada kasus? 3 6
2. Apa saja diagnosis banding dari penyakit pada kasus dan apa diagnosis pada kasus?
47
3. Bagaimana epidemiologi dari penyakit pada kasus? 5 8
4. Bagaimana etiologi dari penyakit pada kasus? 6 9
5. Bagaimana faktor risiko dari penyakit pada kasus? 7 10
6. Bagaimana patogenesis dan patofisiologi dari penyakit pada kasus? 8 1 7 10
7. Bagaimana gejala klinis dari penyakit pada kasus? 9 2
8. Bagaimana tatalaksana dari penyakit pada kasus? 10 3 8 9
9. Bagaimana pencegahan dan edukasi dari penyakit pada kasus? 1 4
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10. Bagaimana komplikasi dari penyakit pada kasus? 2 5

11. Bagaimana prognosis dari penyakit pada kasus? 3 6
12. Bagaimana SKDI dari penyakit pada kasus?
E. LEARNING ISSUE
1. PPP (1, 3, 5, 7, 9)
2. Tatalaksana PPP (2, 4, 6, 8, 10)
F. KERANGKA KONSEP

G. KESIMPULAN

DAFTAR PUSTAKA

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