Duty Report

Saturday, Jan 16th 2016

Supervisor:
dr. Iman Helmi, M. Ked (OG), Sp.OG. K
Dr. dr. M. Fidel Ganis Siregar, M. Ked (OG), Sp.OG. K
Duty Team :
1. dr. Indra setiawan
2. dr. Mario MT
3. dr. Irvan Arifianto
4. dr. Dyah Nurvita Sari
5. dr. Rizky Fahriza H.
6. dr. M. Iqsan

Department of Obstetric and Gynecology

Medical Faculty of Universitas Sumatera Utara
Adam Malik General Hospital
2016

New Patient: 1 Patient

Mrs. N, 20 yo, G2P1A0 Moslem, Acehnese, Junior High School, Housewife,

wife of Mr. B, 22 yo, Moslem, Acehnese, Junior High School, Employee
came to Adam Malik Hospital on January 17th 2016, 00.30 AM with:
Cc: Labor contraction once in a while
T : This was experienced by the patient since one day ago, Jan 16th 2016,
10.00 AM. The contraction became stronger and more regular. History
of blood slime from genitalia (+) since Jan16th 2016, 8 PM.
watery discharge from genitalia (-) . Micturition(+) normal,
defecation(+) normal.
History of previous illness
: (-)
History of medication
: (-)
History of Menstrual Period
: Irregular
Last menstrual period
: ? 03 2015
Estimated due date
: ? 12 2016
ANC
: Midwife 3x
Sp.OG 1x

History of

History of labor:
1.Male, 3200 gr, Aterm, SVD, Hospital, Midwife, 1,5 yo, Healthy
2.This pregnancy

Present State
Sens
BP
HR
RR
Temp

: Alert
: 120/70 mmHg
: 80 times/min
: 20 times/min
: 36,7 C

Obstetrical state
Abdomen
Fundal Height
Tension part
Lowest part
Fetal movement
Uterine contraction
FHR
EBW
Vaginal examination
Hand glove

Anemic
Icteric
Cyanotic
Dispnoe
Oedem

:
:
:
:

(-)
(-)
(-)
(-)

: Asymmetrical enlarged
: 3 fingers below Procesus Xyphoideus
:
:
: (+)
: (+) 2 x 10/10'
: (+) 138 x/i, reguler
: 3000-3200 gr
: Cx Closed
: Mucous blood (-), amniotic fluid (-)

: (-)

USG TAS

USG TAS

Single fetus, Breech presentation, live fetus

Fetal heart rate (+) 132 x/i, Fetal Movement (+)
BPD
: 9,72cm
HC
: 31,55 cm
FL
: 7,22 cm
Placenta fundal grade III
EFW
: 3413g
Conclusion : IUP (39 - 40) wga + Incomplete Breech + Live fetus

LABORATORIUM REPORT JAN 17ST 2016

Hb

: 8,10 gr/dl

N: 12-14/gr/dl

Leukocyte

: 9.060/mm3

N: 4000-11000/uL

Hematocrit

: 26,10 %

Trombocyte

: 261.000 /mm3

MCV

: 72,70

N : 85-95 fL

MCH

: 22,60

N : 28-32 pg

MCHC

: 31,00

N : 33-35 g %

Ad Rand Glucose: 102.00

aPTT

: 28,9

PT

: 11,6

INR

: 0,84

TT

: 15,3

N: 36,0-42,0/%
N: 150.000-400.000/Ul

N: < 200 mg/dl

C= 34,0
C= 13,90
C= 17,0

Diagnosis : SG + IUP (39-40) wga + Incomplete Breech + Live

fetus + In labor
Therapy :
IVFD RL xx gtt/i
Inj. Cefazoline 2 gr skin test
Plan

: C- Section immediately d/t Incomplete Breech

SIO
Consult to Anasthesiology Departement.
Foley Catheter
Prepare PRC 350 cc ( 2 bags )

Report to supervisor on duty Approved

Report of C-Section, Jan 17th 2015

Born baby girl, BW 3100 gram, length 50cm,
AS: 8/9, anal ( + )
The patient was positioned on the operating table in supine position
under spinal anesthesia with intravenous and catheter indwelled
properly.
Aseptic and antiseptic protocol was performed using povidone
iodine 10% and 70% alcohol in the abdominal wall. The abdomen
was then covered with sterile doek except the operating field
Pfanenstiel incision performed. Incision deepened from cutis, sub
cutis to fascia
By inserting the underlying anatomical tweezers, fascia was cut to
right and left. Muscle is bluntly separated due.
Peritoneum was clamped, hang up, and then cut cranially, distally
and laterally
Uterus seems appropriate to the gestational age.
The lower uterine segment was identified. A low cervical incision in
the uterus performed until subendometrium layer. Endometrium
penetrated bluntly, the amniotic fluid was minimal, not clear.

By grasping the legs baby girl with BW 3100 gr, BL 50 cm, AS 8/9,
anal ( + ) was born. The umbilical cord was clamped in two places and cut
inbetween. The placenta was born with an emphasis on the corpus anterior
and traction on the umbilical cord
Uterine cavity was cleaned with gauze and cleaned from residual amniotic
fluid and blood.
The ends of the incision on the uterus were clamped by the oval clamp ,Tip
of the uterine incision sutured with hemostatic sutures figure of eight,
Then the incision of the uterus was sutured by continuous interlocking
stitches, following overhecting, and reperitonealisation.
Observation of uterine incision scar, suggesting that the bleeding was
under controlled
Abdominal cavity was cleaned from blood and Stoll cell.
Uterine was contracted adequately.
Peritoneum sutured with no. 0 continuously, then do muscle approximation
, suturing the abdominal wall with Catgut plain no. 0 by simple suture.
Both ends of the fascia is clamped with a Kocher, then stitched
continuously with a vicryl no. 1

Subcutaneous were stitches by simple suture with Catgut plain no 0

Cutis sutured with vicryl 3.0 with subcuticuler suture
Surgical wound was closed with sufratulle, sterile gauze and hypafix
Vagina was cleaned from the rest of blood and clean Stoll cell with a
cotton gauze to clean the blood
Mother was stable the after the operation

Post C-Section therapy :

Th/ IVFD RL + Oxytocin 10 10 -5 -5 20 gtt/i
- Inj. Cefoperazone 1 g/12 hr
- Inj. Metronidazole drips 500mg /8 hr
- Inj. Ranitidine 50 mg/12 hr
- Inj. Ketorolac 30 mg/8 hr
- Inj Transamin 500 mg/8 hr
Planning
Tranfusion PRC 350 cc ( 2 bag )
Check CBC 6 hr post tranfusion
Monitor vital sign, contraction, and vaginal bledding

THANK YOU