SKENARIO A BLOK 21

KELOMPOK
 Anita Febrianti 702016086
 Muhammad Fikri 702015035
 Alifah Dimar Ramadhina 702016078
 Mutiara Resya 702016067
 Zadi Oktariansyah 702016028
 Tasya Dwi Vayari 702016047
 Nyimas Salsabila. K 702016029
 Mahdi Arif Prasetya 702016016
 Fildzah Sharfina 702016068
 Putri Oktaria 702016041
 CASE SCENARIO
Silence of the baby

A baby boy was brought to the perinatology wards with a chief complain of shortness of
breath. The 3000 gram baby was born spontaneously on RSMP from a 43 weeks G4P2A1
mother. After the delivery, the baby wasn’t crying. The Apgar score on the first minute was
three, five on the fifth minute, and eight on tenth minute. The water was broke 24 hours
before the delivery, and the amniotic fluid were mucoid green and smelly.
Physical Examination
General Appearance : hipoactive, whimpering, weak suction reflexes, BL : 50 cm, BBW : 30
00 g, HC : 35 cm.
Vital Sign : HR : 158x/M, RR : 78x/M, Temp : 36,6°C.
Spesific examination
Head : Nose : nasal flaring breathing (+) , Cyanosis (-)
Thorax : Chest retraction (+) epigastrium, suprasternal
Pulmo : vesiculer (+/+), ronchi (-/-)
Cor : Heart sounds I-II normal, murmur (-)
Anus : Meconium (+)
Laboratory Examination : Blood Chemistry : Hemoglobin 15,0 mg/dl, trombocyte 208.000
/mm3, LED : 6 mm/jam
Rontgen Thoraks
  Term Clarification

1. Shortness of breath : is often describe as an intens tightening in the che

st air hunger, difficulty broathing breathlessness suffocation.
2. Amniotic fluid: is a clear slightly yellowish liquid that surround
3. the unborn baby or fetus during pregnancy.
4. Cyanosis : is a change of skin and mucosa membrane colour into blu
eish due to excrasive reduction of hemoglobin concentration in the blood
5. Mekonium: is the dark green subtances forming the first feses of the ne
wborn Infant.
6. APGAR Score : (Appearance, pulse, greemish, activity, Resporation) is
a test that given to a new born, soon after birth. This test checks baby H
R, muscle tone, and other sign to see if extra care of emergency care is n
eeded.
7. Ronchi: are continues rettling lung sound that often resemble snoring.
8. Hipoactive: less than normally active.
Problem Analysis
1. A baby boy was brought to the perinatology wards with
a chief complain of shortness of breath. The 3000 gram b
aby was born spontaneously on RSMP from a 43 weeks G
4P2A1 mother

a) What is the meaning of baby boy was brought to the

perinatology wards with a chief complain of shortness of
breath?

 Shortness of breath or breathlessness also known as dyspnoea,

is a sensation of uncomfortable breathing. Dyspnoea is
primarily of respiratory or cardiac origin.

(Coccia et al, 2016)

b) What are the possible causes of shortness of breath in
neonatus?
Central Nervous Intraventricular Bleeding, Medication, Seizures, Hypoxic Injury
System
Respiratory Pneumonia, obstructive airway lesions, atelectasis, premature,
laryngeal reflexes, phrenic nerve paralysis, Respiratory Distress
Syndrome, Pneumothorax
Infeksi Sepsis, necrotizing enterocolitis, meningitis
Gastrointestinal Oral feeding, bowel movements, gastroesophageal reflux, esophagitis,
intestinal perforation
Metabolik Low glucose, low calcium, low pressure 02, low or high sodium, high
ammonia, high organic acid, high temperature, hypothermia

Kardiovaskular Hypotension, hypertension, heart failure, anemia, hypovolemia,

changes in vagal tone
Idiopatik Central breath immaturity, sleep state, collapse of the upper airway

(Marcdante, dkk., 2013)

c) What is the relation of the baby born from 43 weeks with a
chief complain?

 The longer gestational age, the ability of the placenta to supply

oxygen and nutrients had been reduced. Severe lack of oxygen,
makes the baby release meconium in the uterus. Amniotic fluid
mixed with meconium can damage the baby lungs which
interprete the chief complain. Meconium passage is rare before
34 weeks of gestational age. Meconium passage is occurs in up
to 20% of full term gestations and can occur in more than 35%
of pregnancies continuing beyond 42 weeks gestation.
Meconium passage most commonly occurs in postmature
infants.

(Celeste et. al, 2009)

2. After the delivery, the baby wasn’t crying. The Apgar scor
e on the first minute was three, five on the fifth minute, and e
ight on tenth minute

a) What is the meaning the baby wasn’t crying after the

delivery?

 The condition of the baby at birth does not immediately cry

indicates that the baby has Asphyxia Neonatorum. Asphyxia in
newborns (BBL) according to IDAI (Indonesian Pediatrician
Association) is spontaneous and regular breath failure at birth
or shortly after birth.

(Prambudi, 2013)
b) What is the possible cause the baby wasn’t crying after the
delivery?

 Babies do not cry right away can be caused by lungs that have
not developed properly, asphyxia. Causes of babies not crying
right away:

1. Maternal factors
2. Umbilical Cord Factor
3. The baby factor

(Depkes RI, 2009)

c) What is the meaning of the APGAR score on the first minute
was three, five on the fifth minute, and eight on tenth minute?

 The baby's condition has occurred asphyxia neonatorum.

Neonatal asphyxia is a failure to breathe spontaneously and
regularly at birth or at birth. The first minute has a score of
three, meaning severe asphyxia occurs. The fifth minute has a
score of five means that asphyxia is moderate, and a score of
eight in the tenth minute means the baby is normal. Crying at
birth is a pure reflex that occurs when air enters the vocal cords
(vocal cords) which cause the vocal cords to vibrate. Where the
purpose of the baby is crying is pumping the lungs to allow
breathing and provide oxygen into the blood.

(Prawirohardjo, S. 2013)
d) What is the classification of Asphyxia?

 Normal with Apgar score 7-10.

 Mild-Moderate asphyxia with Apgar Score 4-6 and
Physical examination was HR <100/minute cyanosis and
muscle tone good.
 Severe Asphyxia Apgar Score 0-3 and Phisical
Examination HR >1000/minute, severe cyanosis and
weak muscle tone.
 Severe Asphyxia with cardiac arrest.

 (Dahlan, 2008)
e) How to assess the apgar score?

 The APGAR score is a rapid scoring system based on physiological

responses to the birth process, which is a good method for determining
the need for resuscitation in infants. The Apgar score or Apgar score is a
simple method for quickly assessing the health condition of a newborn
shortly after birth. Apgar scores are calculated by assessing the condition
of newborns using five simple criteria on a scale of values ​zero, one, and
two.
 The five criterion values ​are then summed to produce zeros to 10. The
word "Apgar" was later made as a donkey bridge as a summary of
Appearance, Pulse, Grimace, Activity, Respiration (skin color, heart rate,
reflex response, muscle tone /activity, and breathing) , to make it easier
to memorize.
(Dahlan, 2008).
f) What is the patophysiology of the complain above?

 At the end of the normal transition period, the baby breathes

air and uses his lungs to get oxygen. The first cry and deep
breath will push the fluid from the airway. Oxygen and lung
development are the main stimuli for pulmonary blood vessel
relaxation. When oxygen is adequate in the blood vessels, the
baby's skin color will change from gray / blue to reddish.

 The clinical meaning is that the baby has asphyxia caused by

the fluid in the alveoli not entering into the interstitial tissue
that should be replaced with air, so the baby can breathe air
and use his lungs to get oxygen.

(Reuter et al, 2014)

3. The water was broke 24 hours before the delivery, and t
he amniotic fluid were mucoid green and smelly.

a) What is the meaning of the water was broke 24 hours

before the delivery, and the amniotic fluid were mucoid
green and smelly?

 The meaning early amniotic fluid broke is rupture of

membranes 24 hours is premature rupture of membranes.
Premature rupture of membranes is the rupture of the
membranes before labor. Under normal circumstances, the
membranes rupture during labor.
 The meaning of amniotic fluid were mucoid green and
smelly means it mixed with meconium, which contributes
to the color change. This can be an indication of a baby in a
distress.
b) What is the patophysiology of the complain above?

 Risk factor (infection, malpersentation of the fetus, cervical

incompetence, trauma to the abdomen) > cervix is either
closed or dilated > leakage of amniotic fluid from the
amiotic sac. (Gahwagi et al, 2015)

 Transient parasympathetic neural stimulation because of

head or cord compression, increasing cholinergic
innervation with advancing gestational age accounts, in
utero stress with resultant fetal hypoxia and acidosis > vagal
respond > increase peristaltis and relaxed anal sphincter >
meconium passage amniotic fluid were mucoid green
and smelly. (Goel and Nangia, 2017) (Raju et al, 2011)
c) What is the impact the water was broke 24 hours before the delivery?

 The effects of premature rupture of membranes are:

1. Premature Labor
2. Infection
3. Hypoxia and Asphyxia
4. Fetal Deformity Syndrome

d) What is the normal characteristic of the amnion fluid?

 The characteristics of amniotic fluids are:

 Amniotic fluid is usually clear to pale yellow in color.

 It should be odorless, or slightly sweet in odor—although some say it has a bleach-
like smell.
 The amount of fluid increases throughout pregnancy until about 34 weeks, when it
begins to decrease slightly.
 The fluid is made up of water, electrolytes, proteins, carbohydrates, lipids,
phospholipids, and urea, as well as fetal cells.

(Czukas, 2019).
4. Physical Examination
a) What is the interpretation of the physical examination?

 Activity: hypoactive, normal: active movements.

 Suction reflex: weak.
 HR: 158x / minute : tachycardia (normal : 100-160 x / minute).
 RR: 78x / minute : tachypnea (normal : 40-60 x / min).
 Temperature: 36,60C normal temperature.
 PB / BL: 50 cm normal: birth 50 cm, plus 0 - 3 months (3.5 cm /
month).
 BBL: 3000 g, Normal Baby Weight (500-4000 grams).
 HC: 35 cm : normal.
 Specific checks:
 Head Nose: dilated nasal breathing (+)> Asphyxia, Cyanosis (-).
 Thoracic: Epigastric (+) chest retraction, supraternal> Abnormal.
 Pulmo: vesiculer (+ / +), ronchi (- / -).
 Cast: Hearth sounds normal I-II, murmurs (-).
 Anus: meconium (+).
b) What is the abnormal mechanism of the physical examination?

 Premature rupture of membranes → liquid inhalation by the

fetus → infeksi intraunterine alveoli fail to expand → alveoli
collapse → disruption of air ventilation → hypoxia →
respiratory distress → increasing late expiration → closing of
glottis → whimpering.

 Premature rupture of membranes → liquid inhalation by the

fetus → infeksi intraunterine alveoli fail to expand → alveoli
collapse → disruption of air ventilation → hypoxia →
respiratory distress → hipoactive, weak suction reflexes.
C. What is the classification og birth weight ?

Birth Low Baby Birth Birth weight <2500

weight Weight gram

Normal Baby Birth Birth weight 2500-

Weight 4000 gram
High Baby Birth Birth weight >4000
Weight gram

(Damanik SM, 2010)

5. Laboratory Examination
a.What is the interpretation of the laboratory examination?

Findings References Result

Hemoglobin 15,0 mg/dl 14-20 mg/dl Normal

Trombocyte 150.000-400.000 Normal

208.000/mm3 0-20 mm/jam Normal
LED : 6 mm/jam <30.000 Normal
Leukocyte: 28.000
6. Radiology Examination

a. What is the interpretation of the radiology examination?

 The interpretation is the chest x-ray showing hyperinflation with variable

areas of atelectasis, patchy infiltrates, pneumothorax and there is not
flattening of the diaphragm.

7. How to diagnose?

 Anamnesis : Shortness of breath, After the delivery, the baby wasn’t

crying. The Apgar score on the first minute was three, five on the fifth
minute, and eight on tenth minute. The water was broke 24 hours before the
delivery, and the amniotic fluid were mucoid green and smelly.
 Physical Examination : Hypoactive,whimpering,tachycardia,tachypnea, nasal
flaring breathing, Chest retraction, Meconium (+).
 Radiology Examination : showing hyperinflation with variable areas of
atelectasis, patchy infiltrates, pneumothorax and there is not flattening of the
diaphragm.
8. How to different diagnosis?

 Respiratory Distress et causa infection with asphyxia.

 Respiratory Distress et causa meconium aspirasi with
asphyxia.
 Respiratory Distress et causa TTN with asphyxia.

9. How to additional examination?

 Blood glucose, blood culture, AGD to determine the
presence of acute respiratory failure marked by PaCO2>
50 mmHg, PaO2 <60 mmHg or arterial oxygen
saturation <90%.

10. How to working diagnosis?

 Respiratory distress e.c meconium aspiration with
asphyxia
11. How to treatment?

 Supportive management, generally the same in all respiratory

distress:

a. Liquid administration
 The first day of dextrose 7.5 - 12.5% (GIR 6-8 mg / kgBB / min) +
Ca Gluconas 10%.
 Need for Ca gluconas / day: 5 mL / kgBB.
 Starting on day 2 or having an initial dieresis and adding Na or K 2-
3 meq / kgBB / day or as needed.
 If there are signs of dehydration, treat dehydration.
 If there is acidosis give dextrose and sodium bicarbonate (4: 1). If
you can check for blood gas analysis, acidosis and correct it directly
by administering 4.2% sodium bicarbonate solution slowly.
 If you can not eat orally give amino acids solution 1-3 g / kg / BW /
day. If you can drink orally, give milk or formula milk.
 Education and Prevention
 Efforts to prevent MAS in the prenatal stage are:

• Identification of high risk pregnancies that can cause

uteroplacental insufficiency and fetal hypoxia, namely:
 Mothers with preeclampsia or hypertension.
 Mothers with chronic cardiovascular or respiratory disease.
 Mothers who have fetuses with stunted growth.
 Post-mature pregnancy, heavy smokers.
• Strict fetal monitoring. Signs of fetal distress, ie amniotic
meconium mixed with membrane rupture, fetal tachycardia, or
deceleration must be followed up immediately.
• Amnioinfusion. Normal saline solution is inserted into the
uterus via the cervix in the mother with amniotic fluid mixed
with meconium and decelerating the baby's heart rate.

b. Oxygen therapy (intra nasal, CPAP bubble, ventilator)

12. What is complication?

Air leak syndromes (pneumothorax, pneumomediastinum,

pneumopercardium), which occur in 10-30% of infants with MAS.

13. What is prognose?

Quo ad vitam : Dubia ad bonam.

Quo ad functionam : Dubia ad bonam.
Quo ad sanationam : Dubia ad bonam.

14. What is General Practitioner?

For Respiratory distress and Neonatal Asphyxia: 3B. Emergency

15. What is Islamic Value?

"Every soul will feel dead. We will test you with ugliness and goodness
as trials (in truth). And only to Us you are returned ". (Surat al-
Anbiyaa: 35)
 Conclusion

A baby boy postterm complaining of asphyxia because

of suffering respiratory distress e.c meconium
aspiration syndrome
CONSEPTUAL FRAMEWORK