EMERGENCY OPERATIVE ROOM REPORT

Tuesday, May 14th 2019

Resident on Duty:
Dr. Rivai Baharuddin
Dr. Asep Nurul Huda

Chief on Duty:
Dr. Mustika Dharma

Supervisor :
Dr. H. Rizal Sanif, SpOG(K), MARS, PhD
Recapitulation Emergency Theatre Room
Tuesday, May 14th 2019

Obstetric Gynecology Total

2 0 2
 EMERGENCY OPERATIVE ROOM REPORT
Tuesday, May 14th 2019

OBSTETRIC
POST OP PRESENT CONSULTANT
NUM IDENTITY PREOP DIAGNOSIS ICD 10 PROCEDURE ICD 9
DIAGNOSIS STATUS
G1P0A0 33 weeks
gestational age in labor first P1A0 Post LSCS o.i
Mrs. EMA/
stage latent phase with O60.0 74.1 intrauterine Stable in
1. 27 yo/ UA/ LSCS AC
PROM 2 days + intrauterine O34.21 infection + ward
AC
infection SLF Cephalic anhydramnios
Presentation
G5P3A1 37 weeks
gestational age in labor first
Mrs. MER/ P4A1 Post LSCS o.i
stage active phase with 6 O60.0 LSCS 74.1 Stable in
2. 36 yo/ UA/ malpresentation + AB
hours not fulled dilated + O34.21 Tubal ligation ward
AB post tubal ligation
severe preeclampsia SLF
Cephalic Presentation
 IDENTITY Mrs. EMA/ 27 YO/UA/AC
Chief Complain Preterm pregnancy with amniotic leakage
History ± 3 hour before admission patient complained of amniotic leakage, 2x changes pads clear, odor (-), abdominal
12-05-2019 contraction spreading to waist and back (-), bloody show (-), history of leuchorea (-), history of abdominal
06.00 PM massage (-), history of toothache(-) and fever (-). History of drugs and traditional medicine consumption (-),
history of post coital (-) patient then came to RSMH.
She admitted that her pregnancy was preterm and fetal movement (+).
Marital Status Married 1 time 1 years
Reproduction Menarche since 15 yo, regular cycle, for 5 days, LMP : 23/09/2018
Obstetric History 1. This pregnancy

General BP 120/170 Pulse : 76x/m T: 36.7 RR: 20x/m

Obstetrical Palpation: Fundal height at 1/2 between umbilical and proc xyphoideus (26 cm), longitudinal lie, right back,
Examiination head, U 5/5, uterine contraction (-), FHR: 144 x/minute, EFW: 2170 g.
IT : 6 Insp : portio livide, OUE closed, fluor (-), fluxus (+) not active amniotic fluid, E/L/P (-), nitrazine test (+) red  blue
VT: portio soft, posterior, eff 0 %, Ø closed, H I, amniotic membrane and denominator cannot be assest

Laboratorium Hb. 12.5 RBC 4.100.000 WBC 17.620 PLT 157. 000 Ht 36% MCV: 88 MCH: 31 MCHC: 34 LED: 48 DC: 0/0/87/8/5
12-05-19 HBsAg non reactive CRP kualitatif: reactive CRP kuantitatif: 8 Anti HIV: non reactive TPHA/VDRL: non reactive
Urinalisis: pH: 6.0 protein: negatif glukosa: negatif LEA: negatif leukosit: 2-3/LPB Bacteriuria: negatif
 IDENTITY Mrs. EMA/ 27 YO/UA/AC
- SLF cephalic presentation;
- BPD: 7.80 cm. HC: 27.20 cm. AC: 29.80 cm. FL: 5.79 cm. EFW: 1528 g TCD 4.31~ 33 w
US ER (ITW) - Placenta was fundus
- Amnionic fluid was decrease, SDP : 1.8 cm
- C/ 33 weeks gestational age SLF cephalic presentation + oligohydramnios
Diagnosis G1P0A0 33 weeks gestational age not in labor with PROM 3 hours SLF cephalic presentation + oligohydramnios

Informed consent
Observation of vital signs, FHR, contraction
IVFD RL XX drops / min
Ampicillin 1 g / 6 hours IV
Therapy Gentamisin 80 mg/12 hour
Dexamethason 6mg/12 hours for 2 days
Nifedipine 10 mg/6 hours po
Plan for US confirmation
P/ Termination after lung maturation
- SLF cephalic presentation;
US Confirmation - BPD: 7.91 cm. HC: 28.92 cm. AC: 27.05 cm. FL: 6.02 cm. EFW: 1742 g TCD 4.09 ~ 33 w5D
PB - Placenta was corpus
13-05-19 - Amnionic fluid was decrease, SDP : 2.25 cm
- C/ 33 weeks gestational age SLF cephalic presentation +BPP 8 (without NST)
 IDENTITY Mrs. EMA/ 27 YO/UA/AC
Follow Up S/ Preterm pregnancy with amniotic leakage
May 13th 2019 O/ BP 120/70 Pulse : 76x/m T: 36.7 RR: 20x/m
Palpation: Fundal height at 1/2 between umbilical and proc xyphoideus (26 cm), longitudinal lie, right back, head, U 5/5, uterine
contraction (-), FHR: 144 x/minute, EFW: 2170 g.
A/ G1P0A0 33 weeks gestational age not in labor with PROM 1 day SLF cephalic presentation
P/ Observation of vital signs, FHR, contraction
IVFD RL XX drops / min
Ampicillin 1 g / 6 hours IV
Gentamisin 80 mg/12 hour
Dexamethason 6mg/12 hours for 2 days
Nifedipine 10 mg/6 hours po
P/ Termination after lung maturation
Laboratory test ( CRP and WBC)
Laboratory result WBC: 13.01 CRP kualitatif: reactive CRP kuantitatif: 14
May 14th 2019
Follow Up S/ Preterm pregnancy with amniotic leakage
May 14th 2019 O/ BP 120/70 Pulse : 85x/m T: 37.0 RR: 20x/m
08.00 AM Palpation: Fundal height at 1/2 between umbilical and proc xyphoideus (26 cm), longitudinal lie, right back, head, U 5/5, uterine
contraction (-), FHR: 144 x/minute, EFW: 2170 g.
A/ G1P0A0 33 weeks gestational age not in labor with intrauterine infection + PROM 2 days SLF cephalic presentation
P/ Observation of vital signs, FHR, contraction
IVFD RL XX drops / min
Nifedipine 10 mg/6 hours po
P/ Termination after lung maturation
Report to Consultant incharge : Dr. RM. Aerul Chakra Alibasya, SpOG(K)
Conservative management
Change antibiotic : Inj Ceftriaxone 1g/12hours IV
 IDENTITY Mrs. EMA/ 27 YO/UA/AC
Follow Up S/ Preterm pregnancy with abdominal contraction (+), bloody show (+), fever (+)
May 14th 2019 O/ BP 120/70 Pulse : 106x/m T: 38.1 RR: 20x/m
12.30 PM Palpation: Fundal height at 1/2 between umbilical and proc xyphoideus (26 cm), longitudinal lie, right back, head, U 4/5, uterine
contraction 2x/10’/15”, FHR: 177 x/minute, EFW: 2170 g.
VT: portio soft, posterior, eff 100 %, 1 cm of dilatation, H I-II, amniotic membrane (-), green, odor(+) and denominator cannot be
assest
A/ G1P0A0 33 weeks gestational age inlabor first stage latent phase with intrauterine infection + PROM 2 days SLF cephalic
presentation
P/ Observation of vital signs, FHR, contraction
IVFD RL XX drops / min
Report to Consultant incharge : Dr. RM. Aerul Chakra Alibasya, SpOG(K)
- Emergency LSCS
- Informed consent
- Consult to anestesi dept
May 14th 2019 02.55 PM. Female life neonatus was born, with birth body weight 1600 g, body lenght: 39 cm, APGAR score 6/8
02.45 PM 02.58 PM. placenta was delivered complete, placental weight: 360 grams, umbilical cord length 38 cm ø 15x16 cm
Operation Report
A: P1A0 post LSCS o.i intrauterine infection + anhydramnios
Follow Up Patient was stable in ward
Mrs. EMA/ 27 y.o/ UA/ AC
Procedure Case Outcome
LSCS Mrs. EMA/ 27 y.o/ UA/ AC 02.45 PM WIB. Operation started
IUD insertion Patient on supine position and on spinal anesthesia. Aseptic and antiseptic on operating area
Preop diagnosis: Pfannensteil incisionwas performed. After peritoneum was opened, there was uterine size as
ICD 10 G1P0A0 33 weeks gestational age inlabor preterm pregnancy, amniotic fluid(+), clear, odor (-)
O42.10 first stage latent phase with intrauterine
infection + PROM 2 days SLF cephalic 02.55 PM WIB. Female, life neonatus was born, with birth body weight 1600 g, body lenght:
presentation 39 cm, APGAR score 6/8
ICD 9-CM
74.1 02.58 PM WIB. Placenta was delivered complete, placental weight: 360 grams, umbilical cord
V25.11 Post op diagnosis: length 38 cm ø 15x16 cm
P1A0 post LSCS o.i intrauterine infection + Placenta born completely
anhydramnios Performed IUD insertion
OP : AB/SAT/VAI/IJA Uterine closed with continuous suture with PGA 1.0
Ensured there was no active bleeding, abdominal wall was closed layer by layer.
Bleeding intraoperative 300 cc, urine 200 cc clear.

03.45 PM WIB. Operation over

US CONFIRMATION
US CONFIRMATION
US CONFIRMATION
US CONFIRMATION
LUBCHENCO x x
vv

CURVE
BALLARD
3
2
2
2
2
2
13

2
2
2
2
2
2

12
Identity Mrs. MER/ 36 y.o/ UA May, 14th 2019 02.20 PM
Chief complain Inlabor with high blood pressure
History 6 hours before admission, Patient admitted History of abdominal contraction spreading to waist and back
(+), bloody show (+), history of amniotic leakage (-), Hypertension in current pregnancy (+), hypertension
before pregnancy (-), hypertension in previous pregnancy (-), hypertension in family (-) severe headache (-)
nausea (-), vomiting (-), epigastric pain (-), blurry vision (-). History of abdominal massage (-). History of
abdominal trauma (-), history of leukorrhea (-), post coital (-), history of toothache (-), history of fever (-)
She admitted that her pregnancy was aterm and fetal movement (+)
Patient was referred from AK Ghani
Marital status Married 1 time, 16 years
Reproduction status Menarche since 13 yo, regular cycle, for 5 days, LMP : 10.08.2019
Obstetric history 1. 2004. female. 2600g. Spontaneous delivery. Midwife. Healthy
2. 2008. male. 3700g. Spontaneous delivery. Midwife. Healthy
3. 2013. male. 3700g. Spontaneous delivery. Midwife. Healthy
4. .2018. 16 week. Abortion. Curettage. Graha mandiri
5. Current pregnancy
Vital Sign BP 180/100 Pulse : 87x/m T: 36.5 RR: 20x/m PB 150cm BB 70kg
Obstetrical examination Palpation: Fundal height 3 fingers below Proc. xyphoideus (37 cm), longitudinal lie, right back, head, U 4/5,
GI : 6 uterine contraction (2x/10’/30”), FHR: 142 x/m, EFW: 3720g
VT: Portio soft, medial, eff 50 %, 3 cm of dilatation, cephalic, HI-II, amnionic membrane (+) and denominator
transverse sagitalis suture
Identity Mrs. MER/ 36 y.o/ UA May, 14th 2019 02.20 PM
US ER (DAN) • SLF cephalic presentation
• Fetal Biometry
• BPD : 9.75 HC : 33.72mm AC : 35.64 mm FL 7.63 cm EFW 3768g
• Placenta at corpus posterior
• Amnionic fluid sufficient
• c/ 39 week gestational age
Lab results Hb: 12.8 g/dL, WBC: 14.200/mm3, PLT: 360.000/mm3, Ht 38%
Diagnosis G5P3A1 37 weeks gestational age inlabor first stage latent phase with severe preeclampsia SLF cephalic
presentation
Management • Stabilization 3 hours
• Observation vital signs ,FHR, contraction
• IVFD RL drops XXX/m
• Laboratory test
• Urinary catheter
• Nifedipine 10 mg/8 hours PO
• MgSO4 40% according to the protocols
• Assessment of opthalmology and internal dept
• Evaluation gestosis task
• Plan for vaginal delivery
Ophtalmology Dept A: Theres no sign of retinopathy
A: Gestational hypertension
Internal Dept.
P: Metyldopa 250mg/12 hr/po
Identity Mrs. MER/ 36 y.o/ UA May, 14th 2019 02.20 PM
O/ BP: 140/90 mmHg, HR: 81 x/m, RR: 20x/m, T: 36.2oC
Palpation: Fundal height 3 fingers below Proc. xyphoideus (37 cm), longitudinal lie, right back, head, U 4/5, uterine
Follow up
contraction (4x/10’/35”), FHR: 135 x/m, EFW: 3720g
Post stabilization
14/5/2019 A/ G5P3A1 37 weeks gestational age inlabor first stage active phase with severe preeclampsia SLF cephalic
05.30 presentation
GI 3 P/ Observed vital sign, FHR, uterine contraction
• IVFD RL gtt xx/mnt
• Plan for vaginal delivery
Follow Up O/ BP: 140/90 mmHg, HR: 81 x/m, RR: 20x/m, T: 36.2oC
08.00 AM Palpation: Fundal height 3 fingers below Proc. xyphoideus (37 cm), longitudinal lie, right back, head, U 4/5, uterine
GI 3 contraction (4x/10’/35”), FHR: 135 x/m, EFW: 3720g
A/ G5P3A1 37 weeks gestational age inlabor first stage active phase with severe preeclampsia SLF cephalic
presentation
P/ Observed vital sign, FHR, uterine contraction
• IVFD RL gtt xx/mnt
• Plan for vaginal delivery
Follow Up O/ BP: 140/90 mmHg, HR: 81 x/m, RR: 20x/m, T: 36.2oC
10.00 AM Palpation: Fundal height 3 fingers below Proc. xyphoideus (37 cm), longitudinal lie, right back, head, U 3/5, uterine
GI 3 contraction (4x/10’/45”), FHR: 140 x/m, EFW: 3720g
A/ G5P3A1 37 weeks gestational age inlabor first stage active phase with severe preeclampsia SLF cephalic
VT: Portio soft, medial, eff 75
%, 7 cm of dilatation, cephalic, presentation
HII-III, amnionic membrane (+) P/ Observed vital sign, FHR, uterine contraction
and denominator transverse • IVFD RL gtt xx/mnt
sagitalis suture • Plan for vaginal delivery
Identity Mrs. MER/ 36 y.o/ UA May, 14th 2019 02.20 PM
Follow Up O/ BP: 140/90 mmHg, HR: 81 x/m, RR: 20x/m, T: 36.2oC
10.00 AM Palpation: Fundal height 3 fingers below Proc. xyphoideus (37 cm), longitudinal lie, right back, head, U 3/5, uterine
GI 3 contraction (4x/10’/45”), FHR: 140 x/m, EFW: 3720g
A/ G5P3A1 37 weeks gestational age inlabor first stage active phase with 6 hours not fulled dilated + severe
VT: Portio soft, medial, eff 75
%, 8 cm of dilatation, cephalic, preeclampsia SLF cephalic presentation
HIII amnionic membrane (+) P/ Report to Consultant incharge : Dr. Abarham Martadiansyah, SpOG(K)
and denominator transverse - Emergency LSCS
sagitalis suture - Informed consent
- Consult to anestesi dept
Operative Report 05.10 PM, female life baby was born, body weight: 3250 gr, body length: 49 cm, A/S: 8/9, FT AGA
14-05-2019 05.13 PM, Placenta was delivered completely, weight: 490 g, UCL : 48 cm,  18 x 19 cm,
05.00 PM DX/ P4A1 Post LSCS o.i malpresentation + post tubal ligation
Follow up Patient was stable in ward
Mrs. MER/ 37 y.o/ UA/ AB
Procedure Case Outcome
LSCS Mrs. MER/ 37 y.o/ UA/ AB 05.00 PM WIB. Operation started
Tubectomy Pomeroy Patient on supine position and on spinal anesthesia. Aseptic and antiseptic on operating area
Preop diagnosis: Pfannensteil incisionwas performed. After peritoneum was opened, there was uterine size as
ICD 10 G5P3A1 37 weeks gestational age inlabor preterm pregnancy, amniotic fluid(+), clear, odor (-)
O14.13 first stage active phase with 6 hours not
fulled dilated + severe preeclampsia SLF 05.10 PM WIB. Female, life neonatus was born, with birth body weight 3250 g, body lenght:
ICD 9-CM 49 cm, APGAR score 8/9
cephalic presentation
74.1
66.3 05.13 PM WIB. Placenta was delivered complete, placental weight: 490 grams, umbilical cord
Post op diagnosis: length 48 cm ø 18x19 cm
P4A1 Post LSCS o.i malpresentation + post Placenta born completely
OP : AC/SAT/VAI/IJA Uterine closed with continuous suture with PGA 1.0
tubal ligation
Performed tubal ligation
Ensured there was no active bleeding, abdominal wall was closed layer by layer.
Bleeding intraoperative 300 cc, urine 200 cc clear.

06.00 PM WIB. Operation over

TERIMA KASIH