ETHICS MODULE

MALPRACTICE ON CAESARIAN OPERATION

By: Group 8A

Debrina Michelle Hanan 011411131051

Tsana Nadhira Susanto 011411131063
Eka Anggun Fitriyah 011411131067
Inna Maya Sufiyah 011411131069
Perthdyatama Shifaq Budiono 011411131070
Indra Rakhmadi N 011411131072
Arya Pradipta 011411131073
Debby Siagian 011411131074
Ardhin Martdana 011411131075
Emeralda Brilian Agnia 011411131076
Auliai Khoirunnisa 011411131077
Nadiya Auliya Nabila 011411131078

Airlangga University

2016

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 CONTENTS
CONTENTS ................................................................................................................. 2
PART I BRAINSTORMING AND COGNITIVE STRATEGY ................................. 4
1.1 Main Problem ...................................................................................................... 4
1.2 Keywords ............................................................................................................ 4
1.3 Early Hypothesis ................................................................................................. 4
1.4 Additional Question or Information .................................................................... 5
1.5 Learning Issues ................................................................................................... 6
1.6 Early Concept Mapping ...................................................................................... 7
PART II PROBLEM ANALYSIS ................................................................................ 8
2.1 Cognitive Strategy............................................................................................... 9
2.2 Answers of Learning Issues ................................................................................ 9
2.2.1 What are the sign of partus ? ....................................................................... 9
2.2.2 What is meconial aspiration syndrome ?.....10
2.2.3 What is the medical ethical issues in Indonesia which is related on the case
based on KODEKI, UU no. 29 tahun 2004 dan UU Kesehatan no. 36 tahun
2009?...........................................................................................................11
2.2.4 What are the Standard Operating Procedure of giving birh in
Puskesmas?.................................................................................................12
2.2.5 What are the criteria or procedure of refrence from local health provider
(Puskesmas) to Hospital?........................................................................ ...15
2.2.6 What are the content of informed consent?................................................19
2.2.7 In what condition do the doctor needs informed consent from the
patient?........................................................................................................20
2.2.8 What are medical malpractice, negligence, and error ?...............................21
2.2.9 What are the criteria of normal & caesar childbirth facility?......................23
2.2.10 What are the Caesarea Section Surgery Procedure?..................................29
2.2.11 What are the indications of caesarean section?.........................................31
2.2.12 Which KUHP is indicating the scenario? .................................................33
2.2.13 How the informed consent in an emergency situation?.............................34

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 2.3 Summary of Literature Review ......................................................................... 35
PART III PROBLEM SOLVING ............................................................................... 38
3.1 Final Concept Mapping ..................................................................................... 38
3.2 Final Hypothesis ............................................................................................... 39
3.3 Group Discussion and Opinion ......................................................................... 39
3.4 Conclusion ........................................................................................................ 39
REFERENCES ........................................................................................................... 41
CRITICAL APPRAISAL ........................................................................................... 44

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 PART I
BRAINSTORMING AND COGNITIVE STRATEGY

1.1 Scenario
Mrs. Ita was referred from the primary health care to the hospital with the
diagnosis of dilation phase 2 of delivery. After 8 hours into delivery process,
there wasnt any improvement, there was even meconium detected. The doctor
decided to perform a caesarean operation, the baby was born but Mrs. Ita died 20
minutes after the operation. Mrs. Itas family sued the doctor for malpractice.

1.1 Main Problem

A doctor is suspected of malpractice after performing a caesarian
operationon Mrs. Ita and Mrs. Itadied 20 minutes after surgery.

1.2 Keywords
From the problem above, we found some keywords as below:
1. Malpractice
2. Caesarian operation
3. Meconium
4. Patients death after operation
5. The second delivery opening but eight hours there has no progress

1.3 Early Hypothesis

1. Lack of explanation by the doctor to Mrs. Ita and her family before
performs a caesarian operation on Mrs. Ita

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1.4 Additional Question or Information
In order to obtain more information about Mrs. Itas delivery and the cause
of her death, we asked some additional questions as will be mentioned below:
1. How old is Mrs. Ita?
She is 26 years old.
2. Is this Mrs.Itas first pregnancy?
No, this is her second pregnancy.
3. Did Mrs. Ita has a history of abortion ?
No, she didnt
4. What is the habits of Mrs. Ita ?
She is a housewife so every day she just managing the household
5. How was the childbirth of Mrs.Itas firstborn?
There was no problem on her first childbirth. The child was delivered
normally at the local clinic.
6. How long was the time gap between Mrs. Itas first childbirth and her
second pregnancy?
The time gap between her first childbirth and her second pregnancy was 2
years.
7. How old was Mrs. Itas pregnancy at the time of delivery ?
Her pregnancy was 38 weeks old
8. How was Mrs. Itas condition and habits during her pregnancy?
Since the beginning of her pregnancy until before delivery, she regularly
came for controls. There was no problem on her second pregnancy.
9. How was Mrs. Itas condition at the local clinic?
She was scheduled for normal delivery. She was diagnosed that her
progress of delivery is already at phase dilution 2 but there wasnt any
improvement.
10. Was there informed consent before the caesarian operation performance on
Mrs.Ita?

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 There was spoken informed consent between the doctor and Mrs. Itas
family
11. How was the competence of the doctor who performed the caesarian
operation on Ms. Ita?
The doctor was competent to perform a caesarian operation.
12. How was Mrs. Itas psychological condition ?
Her condition was good
13. Was the caesarean operation done according to the standard operational
procedure ?
Yes, the caesarean operation was done according to the standard operation
procedure.
14. How was the babys condition before and after the caesarean operation ?
The baby was in good condition both before and after the caesarean
operation
15. How heavy was the baby when it was born ?
The baby weighed 4 kg when it was born

1.5 Learning Issues

From the problems above, we also formulated some learning issues as the
following:
1. What are the sign of partus ?
2. What is meconial aspiration syndrome ?
3. What is the medical ethical issues in Indonesia which is related on the case
based on KODEKI, UU no. 29 tahun 2004 dan UU Kesehatan no. 36 tahun
2009?
4. What are the Standard Operating Procedure of giving birh in Puskesmas?
5. What are the criteria or procedure of refrence from local health provider
(Puskesmas) to Hospital?
6. What are the content of informed consent?

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7. In what condition do the doctor needs informed consent from the patient ?
8. What are medical malpractice, negligence, and error ?
9. What are the criteria of normal & caesarean childbirth facility?
10. What are the Caesarea Section Surgery Procedure?
11. What are the indications of caesarean section?
12. Which KUHP is indicating the scenario?
13. How the informed consent in an emergency situation?

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 PART II
PROBLEM ANALYSIS

2.1 Cognitive Strategy

To reach the objective of this module, we did a series of activities:
1. In the 1st, 2nd, and 3rd tutorial, we discuss the problems with our tutor as
facilitator.
2. Group discussion outside the tutorial, we discuss our ideas without the
supervision of our tutor.
3. In tutorial, the tutor helps us to direct the discussion to solve the problem.
4. Attending the lectures to gain information.
5. Learning by ourselves by reading textbooks, journals, articles, and other
information sources with the principle of Evidence Based Learning.
6. Summing the conclusion of our tutorial progress.
7. Attending the plenary discussion with the source person and presenting the
conclusion of our tutorial if we are chosen to present it.

2.2 Answers of Learning Issues

2.2.1 What are the sign of partus ?
Sign of partus (Werner, 1980)
1. A few days before partus, the baby moves down into the uterus. This
situation causes more frequent urination mother, because of pressure on
vesica urinaria.
2. 2-3 days before partus out of mucus that is usually accompanied by
blood
3. Mother feels the his, thats because the contraction of the uterus all of
sudden. More close to the day of partus, the contraction are more often
and more powerful.
4. Bag of water are come out

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 Based on guide book from Indonesian Health Government(2013), a normal
Partus divide to some phase:
Phase I, divide to two phase
Laten phase: Cervix open about 1-3cm, need time about 8 hour.
Active phase: Cervix open about 4-10cm, need time about 8 hour.
Phase II: Cervix fully open until the baby born, need time about an hour in
primigravida and two hour in multygravida
Phase III: after baby has born until the placenta come out, about 30 minute
Phase IV: after the placenta come out until 2 hour post partum

2.2.2 What is meconial aspiration syndrome ?

Aspiration of meconium typically occurs after fetal hypoxic/ischemic
stress leading to intestinal peristalsis, meconium contamination of the
amniotic fluid, and gasping respirations that draw the noxious meconium-
stained fluid deep into the fetal lung. Meconium contamination of amniotic
fluid occurs in 1015% of all pregnancies, and 510% of these infants
develop meconium aspiration syndrome and respiratory failure. The clinical
presentation of meconium aspiration syndrome can be quite variable. For
example, the chest radiograph may be initially marked by patchy parahilar
consolidation associated with aspiration of particulate meconium, but
subsequent progression of diffuse parenchymal disease may complicate the
clinical course (related to a secondary surfactant deficiency or surfactant
inactivation) A subset of patients with meconium aspiration syndrome has
predominantly airway disease associated with aspiration of particulate
meconium. The viscous meconium material within airways often causes
checkvalve obstruction that allows gas flow during inspiration but obstructs
expiratory flow, leading to focal lung overinflation and air leak.

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2.2.3 What is the medical ethical issues in Indonesia which is related on the
case based on KODEKI, UU no. 29 tahun 2004 dan UU Kesehatan no.
36 tahun 2009?
a. UU no. 29 tahun 2004 tentang praktik kedokteran Paragraf 2 tentang
Persetujuan tindakan kedokteran atau kedokteran gigi ayat 1-5
(1) Setiap tindakan kedokteran atau kedokteran gigi yang akan dilakukan
oleh dokter atau dokter gigi terhadap pasien harus mendapat persetujuan.
(2) Persetujuan sebagaimana dimaksud pada ayat (1) diberikan setelah
pasien mendapat penjelasan secara lengkap.
(3) Penjelasan sebagaimana dimaksud pada ayat (2) sekurang-kurangnya
mencakup :
a.diagnosis dan tata cara tindakan medis;
b.tujuan tindakan medis yang dilakukan;
c.alternatif tindakan lain dan risikonya;
d.risiko dan komplikasi yang mungkin terjadi; dan
e.prognosis terhadap tindakan yang dilakukan.
(4) Persetujuan sebagaimana dimaksud pada ayat (2) dapat diberikan baik
secara tertulis maupun lisan.
(5) Setiap tindakan kedokteran atau kedokteran gigi yang mengandung risiko
tinggi harus diberikan dengan persetujuan tertulis yang ditandatangani oleh
yang berhak memberikan persetujuan.
(6) Ketentuan mengenai tata cara persetujuan tindakan kedokteran atau
kedokteran gigi sebagaimana dimaksud pada ayat (1), ayat (2), ayat (3), ayat
(4), dan ayat (5) diatur dengan Peraturan Menteri.
b. UU no. 29 tahun 2004 tentang praktik kedokteran Paragraf 6 tentang
Hak dan Kewajiban Dokter atau Dokter Gigi Pasal 50b
a. Dokter atau dokter gigi dalam melaksanakan praktik kedokteran
mempunyai hak:
a. Memberikan pelayanan medis menurut standar profesi dan standar
prosedur operasional

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 b. UU no. 29 tahun 2004 tentang praktik kedokteran Paragraf 6tentang
Hak dan Kewajiban Dokter atau Dokter Gigi Pasal 51 a dan b
b.Dokter atau dokter gigi dalam melaksanakan praktik kedokteran
mempunyai kewajiban :
a. memberikan pelayanan medis sesuai dengan standar profesi dan
standar prosedur operasional serta kebutuhan medis pasien;
b. merujuk pasien ke dokter atau dokter gigi lain yang mempunyai
keahlian atau kemampuan yang lebih baik, apabila tidak mampu
melakukan suatu pemeriksaan atau pengobatan
c. UU no. 36 thn 2009 tentang Kesehatan Paragraf 2 tentang
Perlindungan Pasien pasal 58
(1) Setiap orang berhak menuntut ganti rugi terhadap seseorang, tenaga
kesehatan, dan/atau penyelenggara kesehatan yang menimbulkan
kerugian akibat kesalahan atau kelalaian dalam pelayanan kesehatan
yang diterimanya.
(2) Tuntutan ganti rugi sebagaimana dimaksud pada ayat (1) tidak
berlaku bagi tenaga kesehatan yang melakukan tindakan penyelamatan
nyawa atau pencegahan kecacatan seseorang dalam keadaan darurat.
(3) Ketentuan mengenai tata cara pengajuan tuntutan sebagaimana
dimaksud pada ayat (1) diatur sesuai dengan ketentuan peraturan
perundang-undangan.

2.2.4 What are the Standard Operating Procedure of giving birth in

Puskesmas?
In Asuhan Persalinan Normal (APN) known as the 60 steps of APN, that is:
Signs and Symptoms of stage II
It is characterized by the urge to straining, pressure on anus, perineum stand,
and vulva opening.
A. Ready to deliver assistance
a. Set up like parturition tool sets, containers DTT, preparations mother

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 and baby.
b. Prepare by wearing an apron
c. Washing hands with six rare technique h
d. Wearing gloves
e. preparing oxytocin
B. Ensure Existing Opening
a. Clean the vulva with vulva hygiene techniques
b. Check in
c. Then handscoon used dipped into a solution of chlorine
d. Check the fetal heart rate
C. Maternal and Family Ready To Lead
a. preparing mother
b. Tell your family
c. When his exist, lead the mother to push and give praise to the mother
that mothers can give birth normally. If his does not exist, encourage the
mother to rest, give drink, and listen to the fetal heartbeat.
D. Ready For Helping
a. Prepare a clean towel over the mother's abdomen
b. Place the pedestal butt
c. Open
d. Wear gloves
E. Helping New Baby
a. Protect your baby's head
b. Wipe mouth, nose, and eyes with a sterile cloth Gaas
c. Check there nuchal cord or not
d. Wait a pivot swivel head held outside
e. Labor the shoulders by way of biparietal
f. To deliver the body use sangga susur method
g. Right hand down the baby's body

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F. Handling Baby
a. Put the baby on the mother's abdomen
b. Dry the baby with a clean towel
c. Pinch the cord
d. then cut
e. Change towels attach baby clothes
f. Then give to his mother to breastfeed

Stage III
a. Check fundus
b. Tell mom what shall we do
c. injecting oxytocin
d. Stretch Cord Controlled (PTT).
e. Move clamps first.
f. Position the clamps layout
g. Tighten the cord
h. Pull the placenta slowly, the left hand pressing the fundus to dorso
cranial.
i. Rotate the placenta that are already out
j. Perform massage

Checking if Bleeding exists

a. Check the placenta
b. Check if there is a tear of the birth canal

Post Actions
a. See tone baby
b. Clean baby
c. Tie the cord
d. Tie the cord again

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 e. Clamp the umbilical cord
f. Wrap the baby with a clean cloth
g. directly provide breast milk
h. Evaluation of uterine contractions
i. Teach mothers to give a massage
j. Check blood pressure
k. Check the pulse
l. Sterilize tools parturition
m. Dispose of garbage secondhand clothes. Clean the mother
o. Give comfort to the mother
p. Perform decontamination on equipment
q. Dipping into the 0.5% chlorine solution
r. Wash with running water
s. Record all actions in partograf
t. Measure pulse, blood pressure, temperature

2.2.5 What are the criteria or procedure of refrence from local health
provider (Puskesmas) to Hospital?
The factors that influence the evaluation (Katz, 1983):
1. The attitude of the staff towards the evaluation itself.
2. Skills, money / funds and time available.
The purpose of evaluation:
a. Seeing the final service conditions.
b. Looking for ways to improve services.
c. Determining the need for modification of purpose and service.
How to assess a reference service that is:
1. Assessment of Direct
In direct assessment appraisal done on the efficiency and effectiveness
of services to the user reference.
2. Assessment of indirect

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 assessment was conducted on matters pertaining to the budget,
personnel, collections (number, age and value of the reference
collection).
Reference Type
a. Medicalrefrences:
o Referral of patients,
o Referral knowledge, and
o Referral laboratory or examination materials.
b. Referral Health:
o Referral of science, technology and skills, for example: shipping
specialists, especially surgeons, obstetrics and gynecology, internal
medicine and pediatrics of RSU province to the RSU District
o Shipping assistant senior expert to the Regional Hospitals that do not
have a specialist in certain period of time.
o Delivery of health workers from health centers to hospitals
Provincial District Hospital.
o transfer of knowledge and skills in the field of clinical, management
and operation of peralaan.
c. References Management
o Delivery information
o Drug, cost, manpower, equipment
o Request for help: an epidemiological survey, overcome the epidemic
(an outbreak)
Reference Groove

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Medical referral health centers carried out gradually from:
a. cadres and TBAs
b. posyandu
c. maternity / midwives
d. puskesmas maid
e. puskesmas hospitalization
f. district hospital grade D / C
In this regard the referral path for emergency cases can be carried out as
follows:
1. From Kader
Can be directly refer to:
1) community health clinic
2) The cottage maternity / midwives
3) Health Center / Puskesmas inpatient
4) Hospital public / private
2. From IHC
Can be directly refer to:
1) community health clinic

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 2) The cottage maternity / midwives
3) Health Center / Puskesmas inpatient
4) Hospital public / private
3. From the health center
Can directly refer to hospital-type D / C or private hospital
4. From the cottage maternity / Village Midwife
Can directly refer to hospital-type D / C or a private hospital.
Flow Referral Service Emergency Obstetrics and Neonatal
The referral system to maternal and neonatal emergency service
refers to the main principles of speed and accuracy measures, efficient,
effective late in accordance with the ability and authority service facilities.
Each case with emergency obstetric and neonatal coming to health
centers directly managed in accordance PONED must remain in accordance
with the procedures of Reference Books National Maternal and Neonatal
Health Services. After stabilization of the patient's condition, then
determined whether the patient will be administered at the health center level
PONED or referral to hospitals PONEK to get better service in accordance
with the level of kegawat daruratannya.
Polindes village midwife and can provide direct services to pregnant
women / mothers in childbirth and postpartum mothers who came alone or
on rujuka cadres / community. In addition to normal delivery assistance
service delivery, the midwife in the village can do with the case management
of certain complications in accordance with the authority and ability level or
made a referral to the health center, health center and hospital PONED
PONEK in accordance with the appropriate level of service.
PHC non PONED at - least be able to stabilize patients with obetetri
and neonatal emergencies that come themselves or be referred by a cadre /
shaman / midwife in the village prior to referral to a health center and
hospital PONED PONEK.

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 PONED health center has the ability to provide direct services to
pregnant / maternity / puerperal women and newborns who come alone or on
referral cadres / community midwife in the village and the health center.
PHC PONED can do with the case management of certain complications in
accordance with the authority and ability level or made a referral to the
Hospital PONEK.
Terms of Reference
Recording of certain:
1. Letters of reference
2. Health Card for clients who can not afford
3. Recording the appropriate and correct
4. Card reference monitoring maternal and infant (KMRIBB)
5. The existence of reciprocal understanding between the referring and
receiving referrals
6. There understanding of system tasks rujukan
7. Nature of horizontal and vertical reference (towards a more capable and
complete).

2.2.6 What are the content of informed consent?

Based on Undang-Undang Republik Indonesia No. 29 tahun 2004 about
medical practice, in pasal 45 said that:
(1) Setiap tindakan kedokteran atau kedokteran gigi yang akan dilakukan
oleh dokter atau dokter gigi terhadap pasien harus mendapat
persetujuan.
(2) Persetujuan sebagaimana dimaksud pada ayat (1) diberikan setelah
pasien mendapat penjelasan secara lengkap.
(3) Penjelasan sebagaimana dimaksud pada ayat (2) sekurang-kurangnya
mencakup :
a. diagnosis dan tata cara tindakan medis;
b. tujuan tindakan medis yang dilakukan;

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 c. alternatif tindakan lain dan risikonya;
d. risiko dan komplikasi yang mungkin terjadi; dan
e. prognosis terhadap tindakan yang dilakukan.

2.2.7 In what condition do the doctor needs informed consent from the
patient ?
Conditions About General Medical Statement Measures (Informed Consent)
a. Understanding
1. Approval of medical action (informed consent) is the statement
given patient or family on the basis of a description of the medical
action is both treatments, diagnostic or therapeutic to be performed
on these patients.
2. medical action is a diagnostic therapeutic action on a patient.
3. The action is invasive medical action that could directly affect the
integrity of the network.
b. These types of measures that need to be informed consent
Informed consent is consent orally medical given orally, among
others:
1. Taking blood for diagnostic purposes.
2. Provision of a drug for therapeutic purposes in intrakutan,
subcutaneously, intramuscularly or intravenously.
3. Installation chateter venous infusion / IV needle.
4. The stabbing the needle with a particular area (eg acupuncture).
5. Installation of certain tools:
a) Catheter Nelaton for men and women.
b) a metal catheter just for women.
c) Installation nasograstrie tube.
d) Installation of a splint.
e) Installation of traction.
f) Aspiration lenders from the nose, mouth, or from endotracheal

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 tube.
g) foreign body retrieval from the nasal cavity or ear canal.
h) treatment of the wound, wash the wound with local anesthetic.
i) Decision gerpusalineumpada eye (eg: gram cornea /
conjuncition).
j) Provision lavement (washing of the colon), for inspection
radiology / preparatory operations.
k) The function of ascites or pleura.
c. Written informed consent
Medical action is consent given in writing. Medical actions
associated with different measures or actions Invasive or potentially
endanger patients' lives, should be given a specially informed consent
(written), among others:
1. Surgical treatment of small, medium, large and special.
2. The action of local anesthesia, regional, general.
3. Measures invansife.
4. The act of amputation (removal of body tissue).
5. Sophisticated medical action (IVP, Endoscopy, photos with the
contras) (pratita,2013)

2.2.8 What are medical malpractice, negligence, and error ?

A. Medical malpractice is defined as any act or omission by a physician
during treatment of a patient that deviates from accepted norms of
practice in themedical community and causes an injury to the patient
(Bal, 2008)
A doctor or dentist who deviate from professional standards and
make mistake profession is not necessarily doing medical malpractice
that can be imprisoned, medical malpractice convicted require evidence
of the element of culpa lata or negligence that fatal or serious. This is in
accordance with the provisions of pasal 359 KUHP, pasal 360, pasal 361

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 KUHP that needed the culpa lata proof from a doctor or dentist. (
Marleni, 2010)
Thus for proving malpractice under the criminal law includes the
following elements:
1) It has been deviated from the standard of the medical profession;
2) Fulfil the element of culpa lata or negligence; and
3) Measures serious consequences, fatal and violation of pasal 359,
pasal 360, KUHP.
The elements of pasal 359 danpasal 360as follows:
1) The existence of an negligence (culpa).
2) There is a particular form of action.
3) The result of severe injuries or death.
4) The existence of a causal relationship between the form of the act
with the death of someone else's.
Three levels culpa:
a. Culpa lata: a serious mistake, a reckless (gross fault or neglect)
b. Culpa levis: regular errors (ordinary fault or neglect)
c. Culpa levissima: errors mild (slight fault or neglect)
Proof of the civil lawsuits, the parties that argue something must submit
evidence. In this case can call an expert witness for the requested
opinion. If a mistake is done by the doctor (res IPSA loquitur, the thing
speaks for itself) so an expert witness is not needed again , the burden of
evidence may be burdened to the doctor. ( Marleni, 2010)

B. Medical negligence defined as whether the care provided failed to meet

the standard of the care reasonably expected of an average physician
qualified to take care of the patient in question (F. Oyebode, n.d )

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 C. Medical error defined as the failure of a planned action to be completed
as intended or the use of a wrong plan to achieve an aim (Ethan D.
Grober, 2005)

2.2.9 What are the criteria of normal & caesar childbirth facility?
NORMAL CHILDBIRTH
Utilization of health services among others visit antenatal checks
carried out, preparation for labor, birth attendants election, and the election of
the place of delivery. Antenatal visit is antenatal health care workers where
the frequency of inspection visits at least 4 times is 1 times in the first
trimester, 1 time in trimester II, two times in the third trimester.
The results showed antenatal care visits related to the incidence of
complications of labor, but this relationship is protective in which the mother
who did not visit antenatal care at least four times likely to experience birth
complications by 0.86 times compared to women who visit antenatal care at
least four times. Likelihood of this happens because mothers more often
during their pregnancy are those who feel their complaints or notified that
they lead a pregnancy high risk. Reports maternal health programs shows that
the percentage of pregnant women who visit antenatal checks at least 1 time is
quite high, but the percentage who visited antenatal clinics four times the
national standard is lower. The report also showed that pregnant women
consider the quality of service is low (Department of Health, 2001a).
According Carolli, Rooney and Villar (2001) on research in
Zimbabwe, effectiveness of antenatal visit four times as effective as the visits
six times or more. And the effectiveness of antenatal care provided by a
midwife or GP as effective as antenatal given by obstetricians.
Childbirth women done is discussed with the family about the place of
birth, transportation to the place of birth, birth attendants, and the cost for
labor, incidence of complications related to childbirth. However, after being
controlled by other factors, childbirth is not associated with the incidence of

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complications of childbirth. Childbirth and referral at this time is one
component in the standard antenatal care 7T criteria. With the existence of
this preparation is expected to circumstances related to the Three Delays have
been discussed with the family during pregnancy.
The results showed no association between birth attendants with an
incidence of complications of labor, but this relationship is protective in
which mothers who choose birth attendants instead of health workers tend to
experience birth complications by 0.79 times compared to mothers who
choose birth attendants with health professionals. The percentage of mothers
who choose birth attendants with health workers as much as 53.5%. Qualifies
as a birth attendant health personnel is only birth attendant health workers
which general practitioners, obstetricians, midwives, nurses or midwives
without interference birth attendants who are not health professionals such as
a shaman, or other relatives.
According to Sihombing (2004) on analysis of Household Health
Survey 2001 found that birth attendants are the factors that influence the
incidence of birth complications (p = 0.015, OR 2.412). According to Djaja
and Suwandono (2006) of the Regional Health Forum WHO South-East Asia
Region (Vol.4), births attended by skilled health is not at risk 1.8 times higher
chance of developing a fever during the postpartum than births attended
byhealth workers. In this case the birth attendant morbidity associated with
the mother during childbirth.
Still the number of births attended by health personnel is not like a
shaman because shamans understand the local culture and understand the
emotional needs of the mother. However shaman can not provide effective
services in the management of complications of pregnancy and childbirth. In
the study Goodburn, et al. (2000) in Bangladesh, providing training for clean
delivery at the TBA in terms of washing hands with soap, clean cord care, and
a clean delivery was not associated significantly in preventing postpartum

24
infection. That is the role of the shaman still can not be an alternative in the
choice of birth attendants.
According to the WHO definition, skilled health workers as birth
attendants are health professionals who have knowledge and skills in handling
normal birth and is able to provide basic emergency obstetric care. A skilled
health personnel in attending births should be able to do the things below
(UNICEF, WHO, UNFPA, 1997):
1. normal delivery care using aseptic technique
2. Active management of the third stage in labor
3. Provide newborn care, including resuscitation
4. managing postpartum hemorrhage with oxytocin use parenteral and
abdominal massage
5. placenta manual
6. managing eclampsia with parenteral administration of
antihypertensive
7. Recognize and manage postpartum infection with parenteral
antibiotics
8. Helping labor with action through the use of vacuum extraction
9. Manatalaksana incomplete abortion with manual vacuum aspiration
10. Knowing how to refer the mother to a higher service and stabilize
the state of the mother during the trip
According Utomo, et al. (2007) on the results of research IMMPACT in
Indonesia, the use of health services is still low even though in areas with
sufficient density midwife. Rural areas and remote areas underserved because
they do not have a midwife who lived in the village. Mothers in the village
with a midwife who lived in the village and more experienced tend to be
reported more births assisted by skilled health personnel and maternal
mortality is lower.
Value OR <1, which means protective on a visit antenatal and birth
attendants election should be more careful in interpreting it so that it does not

25
mean that more frequent antenatal and birth attendants with health workers are
even at risk for complications of delivery. Should be analyzed more deeply to
see the characteristics of the mothers in the group. It turns out antenatal
mothers more than four times and women who chose birth attendants with
more health workers in mothers with higher education and high economic
status. The group of mothers with higher education and higher economic
status will be more concerned with health and easier to get / receive
information about her pregnancy and has the option to receive better health
care.
In theory the search behavior and use of health services, the actions of a
person affected by a perceived vulnerability, perceived seriousness, benefits
and obstacles, as well as signs experienced. In this case the mother who have
symptoms of complications and considers the issue important for the safety of
herself and her baby will be looking for better health care, which is more
frequent antenatal and choose a birth attendant with power and not according
to standards could lead to the negative attitude of the public as users of
services so that they are reluctant to re-use existing health services.
SECTIO CAESAREA
Preparation for a caesarean section
To prepare for your caesarean:
1. You will need to fast no food or drink, including water for six hours
before a planned caesarean. If it is an emergency caesarean, the doctor will
ask you when you last had any food or drink so they know how to proceed
with your operation.
2. You will have blood tests taken.
3. You may have a support person with you, unless there are serious
complications or you need a general anaesthetic. It is generally possible for
someone to take photos of your baby being born, so ask your support person
to bring a camera if they have one.

26
 4. Dont be afraid to ask questions or to tell the doctors or midwives if you are
feeling worried. If you have any special preferences, please talk to your doctor
or midwife beforehand, so they can try to support your choices.
5. If the doctor believes you are at increased risk of blood clots, you may be
measured for compression stockings to wear during the operation.
6. The theatre team will clean your abdomen with antiseptic and cover it with
sterile cloths to reduce the risk of infection. In many hospitals, the hair around
the area to be cut is shaved so that it is easier to clean. You will have a
catheter (plastic tube) inserted into your bladder so that it remains empty
during the operation.

During a caesarean section

The actual operation usually takes between 30 and 60 minutes. It will involve:
The doctor will make a cut in your abdomen and your uterus (both
about 10 cm long).
Your baby will be lifted out through the cut. Sometimes the doctor
may use forceps to help lift out your babys head.
Your baby will be carefully checked.
You will be able to hold your baby soon afterwards. Skin-to-skin
contact can strengthen your early bond with your baby and make
breastfeeding easier.
If you cannot hold your baby in the operating theatre, your support
person will most likely be able to hold your baby instead.
The umbilical cord will be cut and your placenta removed.
An injection will usually be given to make your uterus contract and to
minimise bleeding.
Antibiotics will be given to reduce the risk of infection.
The layers of muscle, fat and skin will be stitched back together and a
dressing will be applied over the wound.

27
After a caesarean section
A number of things will occur after you have a caesarean, including:
1. You will be cared for in the recovery room until you are ready to go to
the ward.
2. If you have had a general anaesthetic, you will most likely wake up in
the recovery room. You should be able to see your baby once you are
awake.
3. You will be encouraged to breastfeed. The earlier you start to
breastfeed, the easier it is likely to be for both you and your baby.
Having a caesarean can make breastfeeding harder to start, so ask for
all the support you need. Breastfeeding is the best possible food to
help your baby grow healthy and strong, and the midwives are there to
help you. Some hospitals encourage women to breastfeed their baby in
the recovery room if there is a midwife to assist.
4. Tell your midwife or doctor when you are feeling pain so they can
give you something to ease it. Pain-relieving medication may make
you a little drowsy.
5. You may have a drip for the first 24 hours or so, until you have
recovered from the anaesthetic.
6. You can start to drink after any nausea has passed.
7. The midwife or doctor will tell you when you can eat again.
8. Your catheter will stay in until the anaesthetic has worn off and you
have normal sensation in your legs to walk safely to the toilet. This
may not be until the next day.
9. Walking around can help with recovery. It can also stop blood clots
and swelling in your legs. A midwife will help you the first time you
get out of bed.
10. You may also have an injection to stop blood clots.
11. You may need antibiotics after the operation.

28
 12. You may have trouble with bowel movements for a short time after the
operation. It should help to drink plenty of water and eat high-fibre
food. The doctor or midwife can give you more advice.
13. When your dressing is taken off, you will be instructed to keep the
wound clean and dry. This will help it to heal faster and reduce the risk
of infection.

2.2.10 What are the Caesarea Section Surgery Procedure?

1. Pre-operation procedure
Clinical decision made for caesarean section by obstetric team in
collaboration with the woman, support person and Local Medic Committee
(LMC). The woman (the patient) and the husband or family receive adequate
explanation about the surgery procedure from the surgeon and the woman
gives verbal informed consent. Agreement to Treatment form is completed by
woman and surgeon unless the condition is extreme emergency.
2. Operation procedure
Before the caesarean section, the abdomen will be cleansed. A tube
(catheter) will likely be placed into the bladder to collect urine. Intravenous
(IV) lines will be placed in a vein in your hand or arm to provide fluid and
medication. The patient may be given an antacid to reduce the risk of an upset
stomach during the procedure. Most caesarea sections are done under regional
anesthesia, which numbs only the lower part of the body, allowing the patient
to remain awake during the procedure. The doctor will make an incision
through the abdominal wall. It's usually done horizontally near the pubic
hairline. the doctor will then make incisions , layer by layer, through the fatty
tissue and connective tissue and separate the abdominal muscle to access the
abdominal cavity. The uterine incision is then made, usually horizontally
across the lower part of the uterus. The baby will be delivered through the
incisions. The doctor will clear the baby's mouth and nose of fluids, then

29
 clamp and cut the umbilical cord. The placenta will be removed from the
uterus, and the incisions will be closed with sutures.
3. Post-operation procedure
a. Assess the patients level of consciousness
b. Record the blood pressure, temperature, pulse, for 4 hours
c. Initiating breastfeeding
d. Optimum ventilation and haemodynamic status is maintained
e. Bonding between mother and baby
f. Fluid and electrolyte balance is maintained
g. Comfort is maintained Patient anxiety is minimized
4. Pre-operation procedure
Clinical decision made for caesarean section by obstetric team in
collaboration with the woman, support person and Local Medic Committee
(LMC). The woman (the patient) and the husband or family receive adequate
explanation about the surgery procedure from the surgeon and the woman
gives verbal informed consent. Agreement to Treatment form is completed by
woman and surgeon unless the condition is extreme emergency.
5. Operation procedure
Before the caesarean section, the abdomen will be cleansed. A tube
(catheter) will likely be placed into the bladder to collect urine. Intravenous
(IV) lines will be placed in a vein in your hand or arm to provide fluid and
medication. The patient may be given an antacid to reduce the risk of an upset
stomach during the procedure. Most caesarea sections are done under regional
anesthesia, which numbs only the lower part of the body, allowing the patient
to remain awake during the procedure. The doctor will make an incision
through the abdominal wall. It's usually done horizontally near the pubic
hairline. the doctor will then make incisions , layer by layer, through the fatty
tissue and connective tissue and separate the abdominal muscle to access the
abdominal cavity. The uterine incision is then made, usually horizontally
across the lower part of the uterus. The baby will be delivered through the

30
 incisions. The doctor will clear the baby's mouth and nose of fluids, then
clamp and cut the umbilical cord. The placenta will be removed from the
uterus, and the incisions will be closed with sutures.
6. Post-operation procedure
a. Assess the patients level of consciousness
b. Record the blood pressure, temperature, pulse, for 4 hours
c. Initiating breastfeeding
d. Optimum ventilation and haemodynamic status is maintained
e. Bonding between mother and baby
f. Fluid and electrolyte balance is maintained
g. Comfort is maintained Patient anxiety is minimized

2.2.11 What are the indications of caesarean section?

Caesarean section is one of main and the oldest section in medical.
Cesarean section is a way to deliver baby by doing dissection at abdomen
and uterus (Ahern, 1981). There are 3 main factors in labour:
1. Power of the mother
2. Condition of birth canal
3. Condition of the fetal
Indications of caesarean section are:
1. Condition of the mother
a. Failure to progress in labour
Tardiness growth of the fetal can caused by condition of
unsupported uterus so that delay labour happen. This condition can be
accompanied by others factor, such as excessive soft-tissue resistance
and malposition of the fetal head.
b. Pre-eclampsia
Pre-eclampsia is one of the danger condition in gestation, signaled
by hypertension, edema, and proteinuria. This condition in past always
did the caesarean section, however, nowadays have found the methods

31
 of controlling acute hypertension, oxytocin infusion that give a chance
to do vaginal delivery.
c. Eclampsia
Eclampsia is pre-eclampsia condition accompanied by convulsions.
Caesarean section needs to do rapidly for late pregnancy.
d. Ovarian tumors
The tumors should be removed during pregnancy or perform
laparotomy. In other cases the tumour should be removed as soon as
practicable after delivery of the child.
e. Cardiac disease
In giving birth needs powerful heart, so that in this condition the
best solution is doing the caesarean section.
f. Infectious disease
Cesarean section can decrease the risks in infectious transmitted
disease such as HIV and herpes genitalis.
g. Caphalopelvic disproportion
This cases marked by pelvic deformity. In early pregnancy pelvic
circumferences measurements needs to do so can predict whether the
pelvic at the normal state while giving birth.
h. Power to give birth
Vaginal delivery needs extra energy to push the baby out. So
mother in weak condition, cesarean section is the solution.
i. Repeat caesarean section
Patient that had a previous caesarean section, needs concern from
obstetric specialist. However there is a statement once a caesarean
not always a cesarean. This statement shows that a caesarean can do
vaginal delivery and still needs to consul to the specialist.
2. Condition of the baby
a. Fetal distress

32
 This condition has become a common indication, signaled by
electronic fetal monitoring and confirmed by pH of scalp blood. The
condition which the heartbeat of fetal getting slower, the normal vale
is 120-160. This fetal needs caesarean section.
b. Placenta praevia
Placenta praevia is position of placenta in a wrong place at uterus
or close the birth canal.
c. Prolapse of cord
Prolapse of cord is a condition that position of cord at the birth
canal before the baby. Entwined baby needs to do caesarean section,
but sometimes it is not dangerous for the baby, it depends how tight
the cord.
d. Malpresentations and malpositions of child
Breech, face, brow or shoulder presentation in persistently unstable
position have high risk in doing vaginal delivery. This condition be
accompanied by others factors such as maturity and size of the infant,
size of the pelvic, and age of the patient.

2.2.12 Which KUHP is indicating the scenario?

Relatedness doctors against legal provisions in their profession are the
legal responsibilities that must be fulfilled by doctors, one of which is the
responsibility of criminal law against the doctor stipulated in the Law on
Criminal Law, namely Article 90, Article 359, Article 360 paragraph (1) and
(2 ) as well as Article 361 Book of Law Criminal Law. (Isfandyarie dalam
Diputra et al., 2013)
One of these Criminal Code Article 360 states:
1. Barangsiapa karena kekhilafan menyebabkan orang luka berat, dipidana
dengan pidana penjara selama-lamanya satu tahun.
2. Barangsiapa karena kekhilafan menyebabkan orang luka sedemikian rupa
sehingga orang itu menjadi sakit sementara atau tidak dapat menjalankan

33
 jabatan atau pekerjaannya sementara, dipidana dengan pidana penjara
selama lamanya sembilan bulan atau pidana dengan pidana kurungan
selama-lamanya enam bulan atau pidana denda setinggi-tingginya empat
ribu lima ratus rupiah.
As for Article 359 of the Criminal Code, which states:
Barang siapa karena kesalahannya (kealpaannya) menyebabkan orang
lain mati, diancam dengan pidana penjara paling lama lima tahun atau pidana
kurungan paling lama satu tahun
First, when an element of negligence on the actions of doctors can be
proved, then the Criminal Code Article 359 or 360 can be imposed on
physicians who perform acts that result in serious injury or loss of life of
patients. Second, sanctions against medical malpractice is rendered
disciplinary action is determined by a panel of health workers to discipline
physicians who, according to the Council of negligence. As for the
compensation that must be fulfilled by the concerned doctor carried out in
accordance with the legislation in force. Applicable legistlation governing
compensation can refer to the book of the law of Civil Law. (Diputra et al.,
2013)

2.2.13 How the informed consent in an emergency situation?

There are two forms of informed consent:
1. Implied constructive Consent (Extraordinary Circumstances), the
measures that are to be wont to do, it is known, has been understood by
the general public, so no longer need to be made in writing, for example
blood sampling for laboratory, injections, or open wounds.

2. Emergency Implied Consent (state of emergency), in general form of

consent that is given by patients to the executor services of medical
measures to perform medical actions can be divided into three types:
a. Written agreement

34
 b. Spoken agreement
c. Agreement based on condition
Application of Informed consent:
1. In cases involving surgery / operation
2. In cases involving treatment that uses new technologies not yet fully
understood the side effects
3. In cases of therapy or medication that may cause many side effects, such
as laser therapy, etc.
4. In cases of refusal of patients
Informed consent in an emergency situation is not necessary because
some of the things that there is no chance to ask for informed consent,
andthere is no time to procrastinate, an action must be taken immediately,
to save lives or limbs (life or limb saving) based onPermenkes No. 290
2008 Article 4
This is also confirmed in Permenkes about informed consent Article
11, which written : "In the situationthat the patient is not conscious /
unconscious and not accompanied by his closest family, and medically in
an emergency condition or in an emergency requiring immediate medical
action for their own interests, not necessary approval from anyone ".

2.3 Summary of Literature Review

Based on the group discussion, Mrs. Ita is on the emergency conditions.
After 8 hours, there are no conditions which show progress in her labor. After
that, the meconium, which is the first feces of fetus is shown within the mothers
womb. That condition means that the baby is undergo stressful conditions. The
meconium could also affect the fetus by mixing in the amnion fluid , causing
meconial aspiration syndrome, which affects the respiratory of the fetus, making
the emergency conditions and the baby must be delivered as soon as possible.
The doctor had already explained and asking for the informed consent orally, and
the family has answered yes (because Mrs. Ita is accompanied by her family, and

35
shes not in the conditions of having the rights to give the consent). But 20
minutes after caesarian section, Mrs. Ita is dead, and the family sue the doctors
for malpractice. Malpractice here means theres something wrong when the
caesarian section is given to Mrs. Ita. But the operation has been done according
to standard operational procedure (SOP). Below are comparation of the laws that
support the doctors and support the patient.
Support the doctor Support the patient
Permenkes no. 290/Menkes/Per/III/2008 UU no. 36 tahun 2009 Article 8
Article 4 act 1,2,3 Setiap orang berhak memperoleh informasi
Dalam keadaan gawat darurat, untuk tentang data kesehatan dirinya termasuk
menyelamatkan jiwa pasien dan/atau tindakan dan pengobatan yang telah maupun
mencegah kecacatan tidak diperlukan yang akan diterimanya dari tenaga
persetujuan tindakan kedokteran kesehatan
Keputusan untuk melakukan tindakan
kedokteran sebagaimana dimaksud pada ayat
(1) diputuskan oleh dokter atau dokter gigi
dan dicatat di dalam rekam medik.
Dalam hal dilakukannya tindakan kedokteran
sebagaimana dimaksud pada ayat (1), dokter
atau dokter gigi wajib memberikan penjelasan
sesegera mungkin kepada pasien setelah
pasien sadar atau kepada keluarga terdekat
UU no. 29 tahun 2004 Article 51d UU no. 29 tahun 2004 Article 45 act 5
Dokter atau dokter gigi dalam melaksanakan Setiap tindakan kedokteran atau
praktik kedokteran mempunyai kewajiban : d. kedokteran gigi yang mengandung risiko
Melakukan pertolongan darurat atas dasar tinggi harus diberikan dengan persetujuan
perikemanusiaan, kecuali bila ia yakin ada tertulis yang ditandatangani oleh yang
orang lain yang bertugas dan mampu berhak memberikan persetujuan
melakukannya
UU no. 36 tahun 2009 Article 32 act 1
Dalam keadaan darurat, fasilitas pelayanan
kesehatan baik pemerintah maupun swasta

36
wajib memberikan pelayanan kesehatan bagi
penyelamatan nyawa pasien dan pencegahan
kecacatan terlebih dahulu.

Based on Permenkes no. 290/Menkes/Per/III/2008 Article 4 act 1,2,3

andUU no. 36 tahun 2009 Article 32 act 1 the doctor needed to help the patient
which is in the emergency and the action could be done with or without the
consent based on humanity (from UU no. 29 tahun 2004 Article 51d). And the
doctor already done the operationbased on SOP and has the right medical
records. But based on UU no 36 tahun 2009 article 8 and UU no 29 tahun 2004
article 45 act 5, the invasive action (which is caesarean section) which is given
to the patient requring the written informed consent. But from our point of
view, the written informed consent could be asked to the family and patient as
soon as the patient regained her consciousness ( based on Permenkes no.
290/Menkes/Per/III/2008 Article 4 act 3). But, when we are in the position of
the doctor, 20 minutes is not enough to prepare the consent, because of the
atmosphere (emergency and after operation atmosphere), even 20 minutes is
enough to prepare 1 piece of paper of written consent. Here, its already clear
that the doctor didnt do anything related to malpractice because
1. The doctor is competent and has the requirements needed to help the patient
2. The action is given in an emergency situation
3. The operation is already based on standard operational procedure
So, when Mrs. Ita is dead, the cause of the death was because of medical
risks, not the action which is given to her. But in this case, the doctor may be
sue for not asking for written informed consent after the operation to Mrs.Ita (if
in the 20 minutes has regained her consciousness) or to her family (if she hasnt
regained her consciousness in the 20 minutes after operation) ( based on
Permenkes no. 290/Menkes/Per/III/2008 article 12)

37
 PART III PROBLEM SOLVING
3.1 Final Concept Mapping

Pregnant woman is on
emergency

Mechonial aspiration
Mechonial detected
syndrome

doctor gave oral informed right

Medical risk consent to the mother and
her family (based on permenkes no
290/menkes/per/III/2008)

There is medical records

caesario sec6on Appropriate to SOP

Mrs. Ita die

20 minutes after caesarean section

Not a malpractice

Principle of law

There isnt written informed Informed consent

consent before or after consists of one paper
operation

Gap to sue Only need 20 minute

38
to fill it
3.2 Final Hypothesis
The doctor didnt commit malpractice and the deaths of Mrs. Ita is the medical risk.

3.3 Group Discussion and Opinion

After we collect the data, we discuss about the learning issues. We discussed the
doctor did malpractice or not during the Caesar surgery, although the doctor didnt write the
Informed Consent after the surgery. From the additional information we know that the
surgery done a complete procedure and there was a medical report, it means that nothing is
wrong with the surgery. Our opinion, the doctor did the surgery well and not a malpractice.
The absence of written Informed Consent in this case was still permitted because in
emergency situation, written informed consent is given after the surgery. We know that the
patient died 20 minutes after the surgery, it menas the doctor didnt have much time to make
a written Informed consent.

3.4 Conclusion
Mrs. Itas family sue the doctor that suspected doing malpractice after having
Caesarian section that done by the doctor to Mrs. Ita. Mrs. Ita came to the hospital in a state
of prolonged parturition, had previously come to the clinic with a diagnosis already in the
second stage of the opening of labor, but after 8 hours, there was no progress, even looked
presence of meconium. This causes Mrs. Ita referred to the hospital. Meconium appears may
cause Meconial aspiration syndrome which would harm the fetus and the mother. The
decision for immediate Caesarian section is the right decision. For that the doctors asked for
informed consent to the family verbally, it is permissible because Mrs. Ita condition was in
emergency situation.
The doctor who did Mrs. Itas Caesarian sectionis a doctor who has a competency,
the whole action was done according to the SOP and was written in the record medic.
However Mrs. Ita died 20 minutes after surgery. It is demanded by Mrs. Itas family .
Because the whole action according to SOP and was undertaken by a team of doctors who
are competent, then there is no malpractice suits, and the results of medical records can be

39
used as supporting evidence even the death of Mrs.Ita is a medical risk. So Mrs. Itas family
can not demand the doctor as malpractice suits. However, up to the time of prosecution, the
doctor did not have the written informed consent from Mrs. Itas family for doing Caesarian
section, so that can be the evidence for demanding the doctor.

40
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