CHAPTER I

INTRODUCTION

1.1 Background
Growth and geriatrics Block is Block XXI in Semester VII of the
Competency Based Curriculum (KBK) system of Medical Education, Faculty
of Medicine, Muhammadiyah University, Palembang. One of the learning
strategies of the Competency Based Curriculum (CBC) system is Problem
Based Learning (PBL). Tutorial is an implementation of the Problem Based
Learning (PBL) method. In the tutorial students are divided into small groups
and each group is guided by a tutor / lecturer as a facilitator to solve existing
cases.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah Palembang University.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II
DISCUSSION

2.1 Tutorial’s Data

Tutor : dr. Indriyani, M. Biomed
Moderator : Achmad Ridhoullah Pratama
Secretary : Assyifa Salsabila
Notulis : Dita Azzahra Maso
Date and Time :
1. Tuesday, September 17th 2019
Time : 08.00 to 10.30 a.m
2. Thursday, September 19th 2019
Time : 08.00 to 10.30 a.m
Rules :
1. Everyone in the group should express their opinion
2. Gadget should be nonactive or in silent mode.
3. Ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 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 spontaneosly on RSMP
from 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 the 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: 3000g, HC: 35cm
Vital Sign: HR:158x/M, RR: 78x/M, Temp: 36,6oC
Spesific Examination:

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 Head: Nose: nasal flaring breathing (+), cyanosis (-)
Thorax: chest retraction (+), epigastrium, supresternal
Pulmo: vesiculer (+/+), ronchi (-/-)
Cor: Hearth sounds I-II normal, murmur (-)
Anus: meconium (+)
Laboratory Examination: Blood Chemistry: hemoglobin 15,0 mg/dl,
trombocyte 208.000/mm3, leukocyte 28.000/mm3, LED: 6mm/jam
Rontgen Thoraks:

2.3 Terms Clarification

Table 2.1 Terms Clarification
No Terms Clarifications
Ward for babies who were born early or have a
1. Perinatology wards
condition at birth (Dorland, 2012)
(Activity, Pulse, Grimmace, Appearance,
2. APGAR score Respiration) is a test given to newborn soon after
birth (Miller, 2014)
The protective liquid contained by the amniotic
3. Amniotic fluid
salc of a gravid amniote (Ahanya, 2015)
The first subtance discharge from the GI tract in
4. Meconium
the perinatal period (Ahanya, 2015)
Condition of deficiency supply oxygen to the
5. Asphyxia body that arise from abnormal breathing (Miller,
2014)
A bluish purple discoloration of skin and
6. Cyanosis
mucous membrane usually resulting from a

3
 deficiency of oxygen in the blood (Dorland,
2012)
7. Whimpering Frightened sound (Dorland, 2012)

2.4 Identification of Problems

1. A baby boy was brought to the perinatology wards with a chief complain
of shortness of breath.
2. The 3000 gram baby was born spontaneosly on RSMP from 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
the tenth minute. The water was broke 24 hours before the delivery, and
the amniotic fluid were mucoid green and smelly.
3. Physical examination
General appearance: hipoactive, whimpering, weak suction reflexes, BL:
50cm, BBW: 3000g, HC: 35cm
Vital Sign: HR: 158x/M, RR: 78x/M, Temp: 36,6oC
Spesific Examination:
Head: Nose: nasal flaring breathing (+), cyanosis (-)
Thorax: chest retraction (+), epigastrium, supresternal
Pulmo: vesiculer (+/+), ronchi (-/-)
Cor: Hearth sounds I-II normal, murmur (-)
Anus: meconium (+)
4. Laboratory Examination: Blood Chemistry: hemoglobin 15,0 mg/dl,
trombocyte 208.000/mm3, leukocyte 28.000/mm3, LED: 6mm/jam
Rontgen Thoraks:

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2.5 Analysis dan Synthesis of Problem
1. A baby boy was brought to the perinatology wards with a chief complain of
shortness of breath.
a. What is the anatomy of this case?
Surface Anatomy and Landmarks (Lung)
 Enclosed in the rib cage in the chest, there are two sides of the lung,
one that take in the air particles and the other side which expels the
air waste. The lung is like a balloon that uses atmospheric pressure
to let the flow of air into the nose. The diaphragm muscles put
pressure on the lung to expel the outgoing air particles. There is a
cavity on the right side for the heart and only two smaller chambers
on the right side than the two chambers on the left side.
 It is important that this tissue is flexible while at the same time it
does not leak air into the surrounding tissue. Elastic fibers in the lung
are stretched during inspiration and then recoils when a person takes
a breath.
 Lungs regulate the breathing of oxygen and the exhalation of carbon
dioxide. Perfusion is the blood flow which can include the
capillaries regulating the efficient transfer of gas between the
alveolus and pulmonary capillary. The ventilation and the perfusion
of the pulmonary unit must be matched.
(Wahlstedt R, 2019)

b. What is the physiology of this case?

Newborn Reflexes
One of the neonate’s greatest strengts is a full set of useful reflexes. A
reflex is an involuntary and automatic response to a stimulus.

Table 2.2 Major reflexes present in full term neonates

Development
Name Response Significance
and course
Survival reflex

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 Provides oxygen
Breathing Repetitive inhalation
Permanent and expel carbon
reflex and expiration
dioxide
Protect the eyes
Eye-blink Closing or blinking
Permanent from bright lights,
reflex the eyes
adapt visual
Pupilary Constriction of pupils
Protect against
reflex to bright; dilatation to Permanent
bright lights
dark
Rooting Disappears over
reflex Turning the head in the first few
the direction of a weeks of life and Orients baby to the
tactile (touch) is replaced by breast
stimulus to the cheek voluntary head
turning.
Sucking Sucking on object
Allows baby to take
reflex placed (or taken ) into Permanent
in nutrients
the mouth
Swallowing Allows baby to take
Swallowing Permanent
reflex in nutrients

Primitive reflexes
Its presence at birth
Usually
Fanning and then and disappearance
disappears
Babinsky curling the toes when in the first year are
within the first 8
reflex the bottom of the foot an indication of
months to 1 year
is stroked normal neurogical
of life
development
Its presence at birth
Disappears in and later
Curling of the fingers
Palmar first 3-4 months disappearance in
around object (such a
grasping and is then the first year are an
finger) that touch the
reflex replaced by a indication of
baby’s palm
voluntary grasp normal neurogical
development
The arm
movements and
A loud noise or arching of the
sudden change in the back disappear
position of the baby’s over the first 4-6
Its presence at birth
head will cause the months;
and later
baby to throw his or however, the
disappearance are
Moro reflex her arms outward, child continues
an indication of
arch the back, and to react to
normal
then bring the arms unexpected
neurological
toward each other as noises or a loss
development
if to hold onto of bodily support
something. by showing a
startle reflex
(which does not
disappear).

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 An infant immersed
in water will display,
active movements of
Its presence at birth
the arms and legs and
and later
involuntarily hold his Disappears in
Swimming disappearance are
or her breath (thus the first 4-6
reflex an indication of
giving the body months.
normal
buoyancy); this
neurological
swimming reflex will
development
keep an infant afloat
for some time,
allowing easy rescue.
Disappears in Its presence at birth
Infants held upright the first 8 weeks and later
Stepping so that their feet unless the infant disappearance are
reflex touch a flat surface has regular an indication of
will step as if to walk. opportunities normal
practice this neurological
response. development.
Source: Shaffer and Kipp, 2010

Figure 1. Fetal Circulation

The transition from intrauterine to extrauterine environment and

from fetal to postnatal life begins with the clamping of the umbilical
cord and the infant’s first breath.

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 In utero, fetal circulation depends on the placenta and three fetal
ducts: the ductus venosus, the foramen ovale, and the ductus arteriosus.
The placenta allows for the exchange of gases, nutrients, and metabolic
waste products. It is a low-resistance circuit that maintains a low fetal
systemic vascular resistance, while the pulmonary fetal circuit maintains
a high pulmonary vascular resistance. Subsequently, the increased
pulmonary vascular resistance and low systemic vascular resistance
promote right-to-left shunting through the fetal ducts. The ductus
venosus allows part of the oxygenated blood carried by the umbilical
vein to bypass the liver. Oxygenated blood entering the heart flows
through the foramen ovale into the left atrium, then perfuses the brain
and the heart via the carotid, subclavian, and coronary arteries. The
ductus arteriosus directs blood from the main pulmonary artery to the
descending aorta. Fetal admixture at the foramen ovale and ductus
arteriosus lowers fetal arterial oxygen tension to ~ 25–35 mm Hg. The
low fetal oxygen tension helps to maintain pulmonary artery
vasoconstriction, allowing blood to bypass the lung and flow instead
through the foramen ovale and ductus arteriosus.
In summary, fetal blood flows from the placenta via the umbilical
vein, bypasses the liver via the ductus venosus, and enters the inferior
vena cava. From the inferior vena cava, blood enters the right atrium,
where the majority of it is shunted through the foramen ovale into the
left atrium. Blood continues into the left ventricle, where it mixes with
blood returning from the pulmonary veins, and is then injected into the
ascending aorta. From the ascending aorta, it supplies the carotid.
subclavian, and coronary arteries before mixing with blood shunted
across the ductus arteriosus. The remainder of the blood entering the
right atrium mixes with blood from the superior vena cava and continues
into the right ventricle and pulmonary arteries. Most of this blood shunts
across the ductus arteriosus into the descending aorta.
Once the infant is delivered and the transition to extrauterine life
begins, respiratory and cardiovascular changes occur independently but

8
 simultaneously. Fetal lung fluid is replaced by air, so the liquid-liquid
interface of alveoli becomes an air-liquid interface and surface tension
forces begin. Surfactant decreases the surface tension with the first
breath and arterial oxygen tension rises, resulting in reversal of
hypoxemia-induced pulmonary vasoconstriction. The pulmonary
vascular resistance begins to decline as a result of increasing oxygen
saturations and decreasing carbon dioxide levels, resulting in an increase
in pulmonary blood flow. Removal of the placental circuit by the
clamping of the umbilical cord results in increasing systemic vascular
resistance. Simultaneous cardiovascular changes include the closing of
fetal shunts. The ductus venosus functionally closes as the umbilical
cord is clamped. Functional closure of the foramen ovale occurs at birth
from the changing atrial pressures and increasing systemic vascular
resistance. The left atrial pressure is now greater than the right atrial
pressure. With increasing arterial oxygen tension and decreasing levels
of prostaglandin E, the ductus arteriosus closes functionally at 15–24
hours of age but does not close anatomically for 3–4 weeks (Gardner &
Armstrong, 2010)

c. What is the meaning of shortness of breath (respiratory distress)?

Dyspnoea, often known as shortness of breath or breathlessness is
defined as ‘a subjective experience of breathing discomfort that consists
of qualitatively distinct sensations that vary in intensity’, and may either
be acute or chronic.The distinct sensations often reported by patients
include effort/work of breathing, chest tightness, and air hunger (a
feeling of not enough air on inspiration). Dyspnoea should be assessed
by the intensity of these sensations, the degree of distress involved, and
its burden or impact on instrumental activities of daily living. Dyspnoea
is a normal symptom of heavy exertion but may be pathological if it
occurs in unexpected situations It derives from interactions among
multiple physiological, psychological, social, and environmental
factors, and may induce secondary physiological and behavioural

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 responses. Its management typically depends on the underlying cause
(Parshall, 2012).
Newborns with respiratory distress commonly exhibit tachypnea
with a respiratory rate of more than 60 respirations per minute. They
may present with grunting, retractions, nasal flaring, and cyanosis
(Christian & Anand, 2015).
Nasal flaring is a compensatory symptom that increases upper
airway diameter and reduces resistance and work of breathing.
Retractions, evident by the use of accessory muscles in the neck, rib
cage, sternum, or abdomen, occur when lung compliance is poor or
airway resistance is high. Grunting is an expiratory sound caused by
sudden closure of the glottis during expiration in an attempt to maintain
FRC and prevent alveolar atelectasis (Warren, 2010).

d. What are the etiology of shortness of breath?

Some causes of birth shortness of breath include:
• Too little oxygen in the mother’s blood before or during birth
• Problems with the placenta separating from the womb too soon
• Very long or difficult delivery
• Problems with the umbilical cord during delivery
• A serious infection in the mother or baby
• High or low blood pressure in the mother
• Baby’s airway is not formed properly
• Baby’s airway is blocked
• Baby’s blood cells cannot carry enough oxygen (anemia)
(Seattle Children, 2019)

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e. How to do neonatal resuscitation?

Source: American Heart Association, 2018

f. What kinds of the possible disease that can cause shortness of breath?
The most common causes of respiratory distress in newborns are
transient tachypnea of the newborn (TTN), respiratory distress
syndrome (RDS), meconium aspiration syndrome, pneumonia, sepsis,
pneumothorax, and delayed transition. Rare causes include choanal
atresia; diaphragmatic hernia; tracheoesophageal fistula; congenital
heart disease; and neurologic, metabolic, and hematologic disorders
(Hermansen, 2007).

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 g. How is the patophysiology in this case?
Post-term and multigravida are the risk factors to increase the
rupture of the amniotic membrane which will cause an intrauterine
homeostatic imbalance, the imbalance condition will cause a decrease
in intrauterine blood flow to the fetus, resulting in hypoxia and make
the distress condition of fetus. Meconium is normally retained in the
fetal gut until postnatal life, but passage of meconium occurs in response
to fetal distress (hypoxic bowel stimulation). The rectal sphincter tone
or muscle may relax after vagal reflex stimulation and release meconium
into the amniotic fluid (amnion fluid become green and smelly). The
fetus begins gasping in response to asphyxia and may inhale meconium
into the airway. With the infant’s first breath, meconium can be
aspirated into the lungs. This aspirated thick meconium can result in air
way obstruction and cause inflammatory response of the
tracheobronchial epithelium. The rupture of the amniotic membrane
will cause an extra uterine and intra uterine contact which will cause
vaginal bacteria to rise and cause inflammation of the amniotic fluid so
it will cause infection of infant (Gardner & Armstrong, 2010; Kosim,
2009)

2. The 3000 gram baby was born spontaneosly on RSMP from 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 the
tenth minute.
a. What is the meaning of the 3000 gram baby was born spontaneosly on
RSMP from 43 weeks G4P2A1 mother?
The meaning of 3000 gram baby was born spontaneosly is the baby have
normal weight and deliver normally. Was born in 43 weeks gestation
and G4P2A1 mother mean multigravida with gestation age classified to
postterm or partus serotinus. Postterm and multigravida are risk factor
that can cause the complaint in this case.

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 43 week (posterm) pregnancy cause a decrease in the amount of
amniotic fluid. At 40 weeks gestation the amniotic fluid volume is
reduce to approximately 800 ml and at 40 weeks gestation the amniotic
fluid volume 250-300 ml. this reduce amniotic fluid will increase the
umbilical cord compressiom so that fetal circulation and oxygenation
are disrupted and eventually asphyxia will occur when the baby is born
to intrauterine fetal hypoxia.
Classification from birth weight:
- Macrosomia: >4000g
- Normal: 2500-4000 g
- Low birth weight (LBW) <2500 g (<5 lb 8 oz)
- Very low birth weight (VLBW) <1500 g (<3 lb 5 oz)
- Extremely low birth weight (ELBW ) <1000 g (<2 lb 3 oz)
Classification from gestational age:
- Pre term labor < 37 weeks, divided into 3 parts: abortus (< 22
weeks), partus immaturus (22-28 weeks) and partus prematur (28-
37 weeks)
- Aterm labor 37-42 weeks
- Post term labor (partus serotinus) > 42 weeks
(Muslihatun, 2011)

b. What is the relation between the 3000 gram baby was born spontaneosly
on RSMP from 43 weeks G4P2A1 mother with the complain shortness
of breath?
The relation is because of his mom pregnant in 43 weeks (post term)
will cause the complain shortness of breath. Post-term is one of risk
factor that can cause meconium aspiration syndrome that can make
respiratory distress to the newborn baby .

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c. What is the impact of postterm pregnancy?
Fetal risks
Fetal morbidity is increased in postterm pregnancies and pregnancies
that progress beyond 41 weeks gestation. This includes passage of
meconium, meconium aspiration syndrome, macrosomia and
dysmaturity. Post term pregnancy also is an independent risk factor for
low umbilical cord pH levels (neonatal acidaemia), low 5-minute Apgar
scores, neonatal encephalopathy, and infant death in the first year of life
(Badawi et al., 1998).
Maternal risks
Postterm pregnancy is associated with significant risks to the mother.
There is an increased risk of: 1) labour dystocia (9-12% versus 2-7% at
term); 2) severe perineal lacerations (3rd & 4th degree tears), related to
macrosomia (3.3% versus 2.6% at term); 3) operative vaginal delivery;
and 4) doubling in caesarean section (CS) rates (14% versus 7% at term).
Caesarean delivery is associated with higher incidence of endometritis,
haemorrhage, and thromboembolic disease (Galal, et al. 2012).

d. How is the physiology of the newborn baby?

The initial examination of a newborn infant should be performed as soon
as possible after delivery. Temperature, pulse, respiratory rate, color,
signs of respiratory distress, tone, activity, and level of consciousness of
infants should be monitored frequently until stabilization.
1) Lungs
Normal variations in rate and rhythm are characteristic and fluctuate
according to the infant's physical activity, the state of wakefulness,
or the presence of crying. Because fluctuations are rapid, the
respiratory rate should be counted for a full minute with the infant
in the resting state, preferably asleep. Under these circumstances,
the usual rate for normal term infants is 30-60 breaths/min; in
premature infants the rate is higher and fluctuates more widely. A
rate consistently >60 breaths/min during periods of regular

14
 breathing that persists for >1 hr after birth is an indication to rule out
pulmonary, cardiac, or metabolic disease (acidosis) etiologies.
Normally, the breath sounds are bronchovesicular. Suspicion of
pulmonary pathology because of diminished breath sounds, rhonchi,
retractions, or cyanosis should always be verified with a chest
radiograph.
2) Heart
The pulse is usually 110-140 beats/min at rest but may vary
normally from 90 beats/min in relaxed sleep to 180 beats/min during
activity. The still higher rate of supraventricular tachycardia (>220
beats/min) may be determined better with a cardiac monitor or
electrocardiogram (ECG) than by auscultation. Preterm infants
usually have a higher resting heart rate, up to about 160 beats/min,
but may have a sudden onset of sinus bradycardia secondary to
apnea.
3) Abdomen
The liver is usually palpable, sometimes as much as 2 cm below the
rib margin. Less often, the tip of the spleen may be felt. The
approximate size and location of each kidney can usually be
determined on deep palpation. At no other period of life does the
amount of air in the gastrointestinal tract vary so much, nor is it
usually so great under normal circumstances. The intestinal tract is
gasless at birth. Gas is swallowed soon after birth, and gas should
normally be present in the rectum on radiograph by 24 hr of age
4) Genitals
Erection of the penis is common and has no significance. Urine is
usually passed during or immediately after birth; a period without
voiding may normally follow. Most neonates void by 12 hr, and
approximately 95% of preterm and term infants void within 24 hr.
5) Anus

15
 Some passage of meconium usually occurs within the 1st 12 hr after
birth; 99% of term infants and 95% of premature infants pass
meconium within 48 hr of birth.
(Kliegman, 2019).

e. What is the meaning of after the delivery, the baby wasn’t crying?
The meaning is he suffer asphyxia because of obstruction in his
respiratory system.

f. What is the relation between the baby wasn’t crying with the complain
shortness of breath?
The baby wasn’t crying, it means that baby was asphyxia, causes of
decreases to get oxygen supplies (hypoxia). So, it is one of etiology in
shortness of breath case (Kosim, et al., 2014)

g. What is the classification of asphyxia?

According to Dahlan (2008), asphyxia are classified into:
 Vigorous baby 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>100/minute, severe cyanosis and weak muscle tone
 Severe Asphyxia with cardiac arrest.

h. What is the risk factor of asphyxia?

Asphyxia is a condition that occur when there is an impairment of
blood gas exchange, resulting in hypoxemia (lack of oxygen) and
hypercapnia (accumulation of carbon dioxide). The combination of
decreased oxygen supply (hypoxia) and blood supply (ischemia) results
in a cascade of biochemical change inside body, whose events lead to
neuronal cell death and brain damage. Continuous asphyxia will also
lead to multiple organ system dysfunction.

16
 The risk factor of birth asphyxia is defided into antepartum,
intrapartum and fetal. The risk factor of antepartum are age of mother,
pre-eclampsia, intake of diuretic and adrenergic drugs. From the
intrapartum, the risk factor like breech presentation, prolapse of
umbilical cord and cephalopelvic disproportion. The significant fetal
risk factor were oligohydroamnion, mechonium stained amniotic fluid,
pre-mature delivery, and low birth weight (Aslam et all, 2014).
In this case the risk factor of asphyxia is because of the mechonium
stained amniotic fluid.

i. How to assess APGAR score?

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.
Heart rate
• 2 points = ≥100 beats/min
• 1 point = < 100 beats/min
• 0 points = Absent
Respirations
• 2 points = Regular breathing/strong cry
• 1 point = Irregular/weak/slow breathing/gasping
• 0 points = Absent
Muscle tone and movement
• 2 points = Good flexion/action motion
• 1 point = Some flexion
• 0 points = None/limp
Skin color / oxygenation
• 2 points = Body and extremities pink
• 1 point = Blue at extremities; pink body

17
 • 0 points = Completely blue
Reflex irritability to tactile stimulation
• 2 points = Cry/cough/sneeze
• 1 point = Grimace/feeble cry when stimulated
• 0 points = Silence; no response to stimulation
(Miller JL, 2014)

j. What is the interpretation of the APGAR score in this case?

An APGAR score of 0-3 represents severe distress, 4-7 indicates
moderate distress, and 7-10 indicates an absence of difficuly in adjusting
to extrauterine life (Queensland Government, 2016).
In this case, the interpretation of first minute was three represents
severe distress, five on the fifth minute represents moderate distress, and
eight on the tenth minute represents an absence of difficulty in adjusting
to extrauterine life (not distress). So, there was increase score of
APGAR status in this baby boy.

k. What is the meaning of the water was broke 24 hours before the delivery
and the amniotic fluid were mucoid green and smelly?
Premature rupture of membranes (KPD) is defined as spontaneous
leakage of fluid from the amniotic sac before any signs of labor. KPD
events can occur before or after the 40 week gestation period. Based on
the time, premature rupture of membranes can occur in preterm
pregnancies or preterm pregnancies before the 37th week of gestational
age, whereas in term pregnancies or term pregnancy occurs after the
37th week of gestational age.
In the KPD preterm pregnancy and KPD at term later pregnancy
divided into the initial KPD which is less than twelve hours after rupture
of membranes and prolonged KPD that occurs twelve hours or more
after rupture of membranes (Laras, 2017).

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l. What is the normal characteristic of amniotic fluid?
Amniotic fluid is vital to well-being of the fetus. It cushions the fetus
from injury, helps prevent comprehension of the umbilical cord, and
allows room for it to move and grow. Amniotic fluid is usually clear to
pale yellow in color. It should be odorless, or slightly sweet in odor –
although some say ithas a bleach like smell. The amount of fluid
increases thoughout pregnancy until about 40 weeks, when it
begins to decrease slightly.
1) 10 weeks gestation: 10-20 ml
2) 16 weeks gestation: up to 250 ml
3) 33 weeks gestation: more than 800 ml
4) 38-39 weeks: plateaus at more than 1000 ml
5) Finally decreases at 40 weeks to 800 ml.
The fluid is made up of water, electrolytes, proteins, carbohydrates,
lipids, phospholipids and urea, as well as fetal cells.

m. What is the possible causes of amniotic fluid were mucoid green and
smelly?
The color of greenish or brownish amniotic water shows that the
neonate has excreted meconium (feces that form before birth, in the
normal state come out after birth at the first bowel movement). This can
be a sign that the neonate is in a state of stress. Hypoxia causes intestinal
peristalsis and relaxation of the anal sphincter muscles, so the meconium
can pass through the anus (Ahanya, 2005).
Origin Amniotic water is sterile but because meconium is the best
medium for bacteria to flourish, although it is still under debate but
many experts believe that meconium can cause irritation of the airways.
The combination of perinatal asphyxia, passage of meconium, and fetal
gasping may lead to meconium aspiration syndrome (MAS), a
potentially life threatening pulmonary disease caused by the
combination of mechanical obstruction, inflammatory response,
disruption of surfactant function, and often pulmonary hypertension.

19
 n. How is the patophysiology of the water was broke 24 hours before the
delivery and the amniotic fluid were mucoid green and smelly?
Post-term and multigravida are the risk factors to increase the
rupture of the amniotic membrane which will cause an intrauterine
homeostatic imbalance, the imbalance condition will cause a decrease
in intrauterine blood flow to the fetus, resulting in hypoxia and make
the distress condition of fetus. Meconium is normally retained in the
fetal gut until postnatal life, but passage of meconium occurs in response
to fetal distress (hypoxic bowel stimulation). The rectal sphincter tone
or muscle may relax after vagal reflex stimulation and release meconium
into the amniotic fluid (amnion fluid become green and smelly)
(Gardner & Armstrong, 2010).
Meconium-stained amniotic fluid (MSF) → infection → cytokine
release → increased amount of prostaglandin → disturb synthesis of
collagen in the amniotic membrane → ↑MMP 1 and MMP 3 (matriks
metalloproteinase) activity → weakened amniotic membrane tension →
water broke 24 hours before the delivery

3. Physical examination
General appearance: hipoactive, whimpering, weak suction reflexes, BL:
50cm, BBW: 3000g, HC: 35cm
Vital Sign: HR: 158x/M, RR: 78x/M, Temp: 36,6oC
Spesific Examination:
Head: Nose: nasal flaring breathing (+), cyanosis (-)
Thorax: chest retraction (+), epigastrium, supresternal
Pulmo: vesiculer (+/+), ronchi (-/-)
Cor: Hearth sounds I-II normal, murmur (-)
Anus: meconium (+)

a. How is the normal value of vital sign examination of the newborn baby?

20
 Figure 2. Normal Value Vital Sign Examination
Source: Leduc D, Wood S. 2015

b. What are the interpretation of the physical & spesific examination?

Table 2.3 Physical Examination
Findings References Result
Activity hypoactive Active Abnormal
Weak suction reflexes Strong Abnormal
Whimpering Strong Abnormal
Heart rate 158x/minutes 100-160x/minutes Normal
Respiratory rate 40-60x/minutes Tachypnea
78x/minutes
Temperature 36,6 ºC 36,3-37,2 ºC Normal
Body length 50 cm 46-55 cm Normal
Birth weight 3000 gram 2500-4000 gram Normal
Head circumference 35 32-38 cm Normal
cm

21
 Table 2.4 Specific Examination
Findings References Result
Head
Nose: Nasal flaring breathing (-) Abnormal (indicate
(+) respiratory distress)
Cyanosis (-) (-) Normal
Thorax:
Chest retraction (+) (-) Abnormal (indicate
respiratory distress)
Lungs: Normal vesicular, Normal, ronchi Normal
no ronchi (-)
Cor
Heart sounds I-II normal, Normal Normal
Murmur (-)
Anus
Meconium (+) (+) Normal

c. How is the abnormal mechanism from the physical & spesific

examination?
Risk factor (Pregnancy >42 weeks) → Stimulation of gastrointestinal
nerve maturity → Myelination of fibers, ↑ tone parasymphatetic, ↑
motilin (a peptide that stimulate intestinal muscle contraction) → A
peristaltic wave & relaxation of anal sphincter → Meconium comes out
from the anus → Meconium-stained amniotic fluid (MSF) → Aspiration
occur in utero/immediately after birth → Meconium reaches the small
airways and make partial obstruction → Air trapping & hyperaeration
→ Respiratory distress → takipneu, whimpering, acivity
hipoactive,weak suction reflex, nasal faring breathing (+), chest
retraction(+)

4. Laboratory Examination: Blood Chemistry: hemoglobin 15,0 mg/dl,

trombocyte 208.000/mm3, leukocyte 28.000/mm3, LED: 6mm/jam
Rontgen Thoraks:

22
a. What are the interpretation of the laboratorium examination and rontgen
thorax?
Table 2.5 Laboratorium Examination
Lab Normal value in Case Interpretation
examination neonatus
Hemoglobin 14,9-23,7mg/dl 15,0mg/dl Normal
Trombocyte (150-450)10 /mm 208.000/mm3
3 3
Normal
Leukocyte (10-26)103/mm3 28.000/mm3 Leukositosis,
because of
infection
LED 0-2mm/hours 6mm/hours Abnormal,
because of
inflamation
(Source: Fischbach & Dunning III, 2009)

Rontgen Thorax: bilateral fluffy densities with hiperinflation that

indicate meconium aspiration syndrome.

b. How is the abnormal mechanism from the laboratorium examination?

Risk factor (Pregnancy >42 weeks) → Stimulation of gastrointestinal
nerve maturity → Myelination of fibers, ↑ tone parasymphatetic, ↑
motilin (a peptide that stimulate intestinal muscle contraction) → A
peristaltic wave & relaxation of anal sphincter → Meconium comes out
from the anus → Meconium-stained amniotic fluid (MSF) → infection
→ leukocytosis & prolonged blood sedimentation rate.

c. How is the abnormal mechanism from the rontgen thorax?

Risk factor (Pregnancy >42 weeks) → Stimulation of gastrointestinal
nerve maturity → Myelination of fibers, ↑ tone parasymphatetic, ↑
motilin (a peptide that stimulate intestinal muscle contraction) → A
peristaltic wave & relaxation of anal sphincter → Meconium comes out
from the anus → Meconium-stained amniotic fluid (MSF) → Aspiration
occur in utero/immediately after birth → Meconium reaches the small
airways and make partial obstruction → Air trapping & hyperaeration
→ Chest radiograph: diffuse parenchymal infiltrat.

23
5. How to diagnose based on this case?
- Anamnesis: chief complaint of shortness of breath, 43 weeks gestation,
G4P2A1 mother.
- History: After the delivery, the baby wasn’t crying. The APGAR score
on the first minute was three, five on fifth minute and eight on the tenth
minute.
- Physical examination: hipoactive, whimpering, weak suction reflexes,
takipneu, nasal flaring breathung (+), chest retraction (+).
- Laboratory examination: leukocytosis, prolonged LED
Rontgen thoraks: bilateral fluffy densities with hiperinflation that
indicate meconium aspiration syndrome.

6. What are the different diagnose in this case?

Table 2.6 Differential Diagnose
Differential Gestation Onset Risk Factor Etiology
Diagnosed
Meconium Term or Immediate Meconium-stained Lung irritation
aspiration posterm amniotic fluid and obstruction
syndrome
Respiratory Preterm Immediate Male sex, white race, Surfactant
distress maternal diabetes deficiency,
syndrome hypodeveloped
lungs
Transient Any Immediate Maternal asthma, Persistent lung
tachypnea to within male sex, fluid
of the two hours macrosomia, maternal
newborn of birth diabetes melitus,
cesarean delivery
(Source: Hermansen, 2007)

7. What are additional examination in this case?

Ventilation-perfusion (V/Q) mismatch and perinatal stress are prevalent
in meconium aspiration syndrome (MAS); therefore, assessment of the
infant's acid-base status is crucial.

24
 Metabolic acidosis from perinatal stress is complicated by respiratory
acidosis from parenchymal disease and persistent pulmonary hypertension
of the newborn (PPHN).
Measurement of arterial blood gas (ABG) pH, partial pressure of carbon
dioxide (pCO2), and partial pressure of oxygen (pO2), as well as continuous
monitoring of oxygenation by pulse oximetry are necessary for appropriate
management. The calculation of an oxygenation index (OI) can be helpful
when considering advanced treatment modalities, such as extracorporeal
membrane oxygenation (ECMO).
(Geis, 2017).

8. What is the working diagnose in this case?

Respiratory Distress ec. Meconium Aspiration Syndrome

9. How is the comprehensive management in this case?

- Neonatal resuscitasion (like mention in question number 1e)
- Management guidelines for infants exposed to meconium according to
the American Academy of Pediatrics Neonatal Resuscitation Program
(NRP) Steering Committee is if the baby is not fit (weak muscle tone and
lack of breath effort or no or no breathing) is carried out immediately
after tracheal suction. Suction is done for no more than 5 seconds. If you
don't get meconial fluid, don't repeat intubation and suction. Conversely,
if you get meconial fluid without bradycardia, do reintubation and
suction. If bradycardia, ventilate the positive pressure and plan for
repeated suction after some time.
- Management of respiratory distress in neonates in general is to treat the
incubator to maintain body temperature (axilla 36-37 ° C), oxygenation
to maintain oxygen saturation 95-98% by CPAP method, fasting orally
and administering parenteral fluid with 10% dextrose from 60 ml / kg /
day, and give antibiotics and septic work ups until proven not sepsis
(Hermansen & Kevin, 2007).

25
  Respiratory management is carried out in the form of the use of CPAP
which is a simple and effective tool to maintain positive pressure on
the neonatal airways during spontaneous breathing. CPAP is an
indication of the installation criteria which include breath frequency>
60x per minute, wheezing in moderate to severe degree, breathing
retraction, oxygen saturation <93% (preductal), oxygen demand>
60%, frequent apnea and all infants full term or less month which
shows one of the criteria above, must be considered to use CPAP.
 Aminophylline has the effect of stimulating the breath center by
increasing sensitivity to CO2, increasing breath frequency, causing
muscle relaxation including smooth bronchial muscles, decreasing
hypoxia due to respiratory depression, increasing diaphragm activity.
a loading dose of 6mg / kg while a maintenance dose for infants <7
days is given 2.5mg / kg / 12 hours (Prambudi, 2013).
 Destrose IVFD 10%. Neonatal nutrition is given from fluids
calculated from environmental factors, comorbidities and diseases
glucose in requiment (GIR) / normal glucose needed (Prambudi,
2013).

10. What is the complication in this case?

Meconium aspiration syndrome is associated with multiple life threatening
complications including hypoxic ischemic encephalopathy (HIE) (46%),
hypotensive shock (22%), pneumothorax (11.4%), myocardial dysfunction
(22%) and pulmonary hypertension (PHN) (17%) (Louis D, etc, 2014).

11. What is the prognose in this case?

Dubia ad bonam

12. How is the competence of general practitioner in this case?

3B, being able to make a clinical diagnosis based on physical examination
and additional examinations requested by the doctor such as a lab or x-ray

26
 examination. The doctor can decide and give preliminary therapy, as well
as refer to the relevant specialist (emergency case).

13. How is the Islamic point of view of this case?

1) QS. As-Syura: 49
َ ‫نِ َيشَا ُِءِالذُّك‬
ِ‫ُور‬ ُِ ‫نِ َيشَا ُِءِ ّإنَاثًاِ َو َيه‬
ِْ ‫َبِ ّل َم‬ ِْ ‫َبِ ّل َم‬
ُِ ‫قِ َماِ َيشَا ُِءِِۚ َيه‬ ِ ّ ‫تِ َو ْاْل َ ْر‬
ُِ ُ‫ضِِۚ َي ْخل‬ ِّ ‫اوا‬ َ ‫لِلِّ ُم ْلكُِِال‬
َ ‫س َم‬ َِ ّ
Belonging to Allah is the kingdom of heaven and earth, He creates what
He wants. He gives daughters to whom He wants and gives sons to
whom He wants
2) QS. Al-Baqarah: 153
َِ َِِ‫صب ِّْرِ َوالص َََل ِّةِِۚ ّإن‬
َِ‫ّللاَِ َم َِعِالصَا ّب ّرين‬ ْ ‫يَاِأَيُّهَاِالَ ِّذينَِِآ َمنُواِا‬
َ ‫ستَ ّعينُواِ ّبال‬
“ you who have believed, seek help through patience and prayer.
Indeed, Allah is with the patient”
It means that Allah SWT ask us to be patience and always prayers as
our helper in life. Allah SWT always be with those who are patient.

2.6 Conclusion
A baby boy was brought to the perinatology wards with a chief complain of
shortness of breath because of respiratory distress ec meconium aspiration
syndrome.

27
2.7 Conceptual Framework

Risk factor (43 weeks pregnance, G4P2A1)

Meconium comes out Water broke 24 hours

before delivery

Meconium-stained amniotic fluid

(MSF)

Meconium aspiration syndrome

Airway obstruction in neonatus

respiration tract

Respiratory Distress

Shortness of breath, the baby wasn’t cry

after delivery, whimpering, nasal faring
breathing, chest retraction

28
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30
 Attachment 1
Patophysiology of All Cases

Pregnancy >42 weeks

↓amniotic fluid
Stimulation of gastrointestinal
nerve maturity
Umbilical cord compression
Myelination of fibers, ↑ tone
Fetal circulation & parasymphatetic, ↑ motilin (a
oxygenation are peptide that stimulate intestinal
disrupted muscle contraction)
Fetal hipoxia

A peristaltic wave & relaxation

of anal sphincter

Meconium comes out from the

Amniotic fluid
anus
green & smelly

Meconium-stained amniotic fluid Infection

(MSF)

↑MMP 1 and MMP 3

Aspiration occur in
(matriks metalloproteinase)
utero/immediately after birth
activity

Meconium reaches the small

weakened amniotic
airways and make partial
membrane tension
obstruction
Chest radiograph:
diffuse parenchymal water broke 24 hours
Air trapping & hyperaeration
before the delivery
infiltrat

Respiratory distress

Shortness of breath, the baby wasn’t cry

after delivery, whimpering, nasal faring
breathing, chest retraction

31