Duty Report RSUDZA

Sunday, January 11th 2015

Supervisor:
dr. Tgk. Puspa Dewi, Obgyn
Resident:
Farrah

Reporting
2 Cesarean Section
1 Vaginal Deliveries

Procedure

Case

Outcome

1. Spontaneo
us Delivery

Mrs. M, 38 yo
MR 103-58-25

Born male baby 2700, 48 cm, AS

9/10
BS ~ 38-40 wga
Clear scanty amniotic fluid
Placenta born completely
Intac perineum

G3P2 term pregnancy,

singleton live head
presentation, PROM 1 day
(AFI 6), unripe cervix (PS1)

Farrah/dr.
Puspa, Obgyn

Process:
CTG reassuring Induction
with modality misoprostol 4x50
mcg po after 1st misoprostol
rippened cervix
acceleration with oxytocyn
5iu/RL 500 cc titration obs. 2
hours active phase of labor (8
cm) obs. 2 hours 2nd phase of
labor
NBC: Referred by Obgyn

FP : IUD post placenta

Mother and baby are in good

condition plan to discharged
today

Procedur
es

Case

Outcome

2. Cesarean
Section

Doe to breech presentation

Primigravida

Born female baby 2500, 48 cm, AS

9/10
BS ~ 38-40 wg

ICD 10 and 9
O82.1
Z37.0
O42.0
Z30.0

Mrs. DM, 27 yo
NRM: 103-58-92
G1 term pregnancy, breech
presentation PROM 6 hours,
Oligohydramnios, in labor

FP : IUD transesarean

NBC: Referred by Obgyn

Mother and baby are in good

condition, Rooming in

ICD 9
74.1
Farrah/dr.
Puspa, Obgyn

Procedure

Case

Outcome

3. Cesarean
Section

Mrs. N, 38 yo
NRM: 103-35-05

ON PROCESS . . .

G3P1A1 40-41 wga,

singleton live head
presentation, Previous CSection 1x (IDT 8 years),
Latent phase of labor

Farrah/dr.
Puspa, Obgyn

Process:
CTG reassuring 3 cm
observation 8 hours 3 cm,
water broke observation
6 hours 3 cm, his 2/10/30
failed of VBAC decided
cesarean section
NBC: Came by her own will

Thank You

Mrs. M, 38 yo

G3P2 term pregnancy, singleton live head presentation, PROM 1 day

(AFI 6), unripe cervix (PS1)
11/01/2015, 00.00

Chief complaint : Water broke since 1 day before admission

History : Admitted 9 months pregnancy. LMP forget. ANC regularly at midwife,
US examination (-). The patient complaint water broke since 1 day before
admission. Contarction (-), bloody show (-). Fuor albus (-), caries dentis (-).
Active fetal movement.
Family & Previous History of Illness : Asthma, Hypertension, heart disase, DM,
Allergy denied
Menstrual history : menarche 13 yo, regularly, 7 days, 3 pads/day,
dismenorrhea (-)
Married history: 1x, 22 yo
FP history: DMPA
Obstetric history :
1. Boy,15 yo, 3200 gram, normal delivery, born at midwife, now healthy
2. Girl, 9 yo, 3400 gram, normal delivery, born at midwife, now healthy
3. This pregnancy

Physical Examination :
fully alert, BP 110/80 mmHg P : 88x R : 18 x T : 36,4 0C
163 cm/68 kg BMI 25,6
General Status :
Eyes
: no anemic conjungtive, no icteric sclera
Heart
: S1-S2 reguler, no murmur, no gallop
Pulmo : vesicular, no rails, no wheezing
Abdomen : Equal to pregnancy
Extremity: warm, no edema
Obstetrical Status :
FH 32 cm, EFW 2945 gram, right back, head presentation, 5/5, FHR 145
dpm. HIS Irregular
I : V/U wnl
Io : Smooth portio, open OUE, fluor (-), fluxus (-), valsava (+), lakmus (+),
LEA (-)
VT: Firm portio, posterior, effacement (-), 1 cm, amnion membran (-),
head on H I
Clinical Pelvimetri:
Promontorium no palpable, DI > 9.5 cm, linea innominata 1/3-1/3,
Sacrum konkaf, Spina prominent, AP > 90 adequate pelvic

CTG :
Baseline
: 145
bpm
Variability
: 5-25 bpm
Acceleration
: (+)
2x/10
Deceleration
: (-)
His
: (-)
Fetal movement
: (+)
CTG Category 1

Laboratory:
Hb
:
Leucocyte
Trombocyte
Ht
:
Random blood
BT
:
CT
:
Conclution

US :
BPD
: 89
EFW
: 2800
gram
AC : 310 FHR
: (+)
FL : 74
AFI : 6
Placenta at anrerior corpus
Conclution: Term pregnancy, live
head singleton baby, diminished
amniotic fluid

11,2 gram/dl ( 12-14 gram/dl )

: 10.600/ul ( 4100-10500 /ul )
: 230.000 /ul (150000-400000 /ul )
33 % ( 40-55 % )
glucose : 98 mg/dl
2 ( 1-7 )
7 ( 5-15 )
: within normal limit

A: G3P2 term pregnancy, singleton live head presentation, PROM 1

day (AFI 6), unripe cervix (PS1)
P : R. Dx/

R. Th/

Observation of vital sign, contraction,

FHR/hour
Observation for cord compression

Plan to vaginal delivery

Initial plan repenned cervix induction with cervical
rippening with misoprostol 4x50 mcg po
AB profilaxis: Inj ceftriaxon 2 gr/24 jam

Informed consent

A: G3P2 term pregnancy, singleton live head presentation, PROM 1

day (AFI 6), unripe cervix (PS1)

Diagnost Observation of vital sign, contraction,

ic Plan
FHR/hour
Observasion cord compression and intra
uterin infection
Therapy
Plan

Plan to vaginal delivery

Initial plan repenned cervix induction with
cervical rippening with misoprostol 4x50 mcg
po
AB profilaxis: Inj ceftriaxon 2 gr/24 jam

Educatio Explaining about patient condition and plan of

n Plan
diagnosis and plan of therapy for patients and
family
Breast milk and contraception motivation

January 11th
2015
01.00 wib
Repenned cervix
induction with
misoprostol I 50 mcg po.
Reevaluate 6 hours later
(08.00)

07.00 wib
S/
Contraction continuously (+), fetal
movement (+),
O/
GC : good, CM, BP : 110/70 mmHg,
PR : 88x/mnt, RR : 22x/mnt, Temp :
36.3C,
General status : wnl
Obstetric status :
FHR 140 bpm, contraction 3x/10/30
I: normal V/U
VT: soft portio, axial, effacement 50%,
3 cm, amnion membranes (-), head
H I-II
A/
G3P2 term pregnancy, singleton
live head presentation, PROM 1
day (AFI 6), unripe cervix (PS1),
ripened cervix
P/
Plan to vagianl delivery
oxytocin 5 IU in 500 cc RL begin at
8mIU/mnt titrated 4mIU/mnt every 30
until adequate contraction
Reevaluate 3 hours after adequate
contraction

07.30 wib
Reach adequate contraction
(4x/10/40) at 12 drop/mnt
Reevaluate in 3 hours

January 11th
2015
09.00 wib
S/
Contraction more regular
(+), fetal movement (+),
O/
GC : good, CM, BP : 110/70
mmHg, PR : 86x/mnt, RR :
20x/mnt, Temp : 36.5C,
General status : wnl
Obstetric status :
FHR 135 bpm, contraction
4x/10/40
I: normal V/U
VT: thin portio, anterior,
effacement 75%, 8 cm,
amnion membranes (-),
small fontanel in right
anterior, head H II-III
A/
G3P2 term pregnancy,
singleton live head
presentation, active phase
of labor
P/
Plan for vaginal delivery
Reevaluate 2 hours later
(22.00)

11.00 wib
S/
Mother wants to bear down,
fetal movement (+),
O/
GC : good, CM, BP : 110/70
mmHg, PR : 88x/mnt, RR :
22x/mnt, Temp : 36.3C,
General status : wnl
Obstetric status :
FHR 150 bpm, contraction
4x/10/50
I: normal V/U
VT: complete cervical dilatation ,
membrane (-), clear amniotic
fluid head
H III-IV, small fontanerl anterior
A/
G3P2 term pregnancy, singleton live
head presentation, second stage
of labor
P/
Lead mother to bear down after
nd stage of labor sign was
the 2nd
present

11.10 wib
Born female baby,2700 gram, 48
cm, A/S 9/10
BS~ 38-40 wga
Baby being dried and warmed
Placenta cord was clamped and
cut
Oxytocin injection intra muscular
for mother, 10 IU
Control cord traction
11.15 wib
Placenta born completely
Central insertion
Fundal massage, good contraction
On exploration found perineum
intac
Performed IUD post placenta
Bleeding was 100 cc
th stage of
Perform evaluation 4th
labor

Summary/
P3 Post Vaginal Delivery
with Induction
Appropriate for
gestational age

Partograf

Thank You

Mrs. DM, 27 yo
G1 term pregnancy, breech presentation PROM 6 hours, Oligohydramnios, in
labor
11/01/2015 19.30 pm
Chief complain : Contraction since 4 hours before admission
RPS : Patient admitted 9 month pregnancy, LMP April 2014 ~ term pregnancy.
ANC regularly to midwife and OBGYN, last ultrasound 1 week ago with
result baby in good condition, breech presentation. Contraction since 4
hour before admission. Water broke danied, and bloody discharge (+).
leucorrhea (+), smelly (-), itchy (-). Active fetal movement.
Family & previous illnes : Asthma, Hypertension, heart disease, DM, Allergy
denied
Menstrual diary: menarche 12 yo, regularly, 7 day, dismenorrhea denied
Married history: 1 x, 26 yo
FP history: Obstetric history:
1. Current pregnancy

Physical examination
General condition: Good, CM weight: 60 kg height: 155 cm BMI : 25
BP 120/80 mmHg, Pulse 88 bpm. RR 20 x/minute, Temp. 36,4 C
General status :
Eye
: No Anemic conjunctiva, no icteric sclera
Heart : I-II reguler normal heart sound, no murmur, no gallop
Lung : vesikuler left=right, no wheezing, no rails
Abdomen : Equal to pregnancy
Extremity : warm extremity, edema (-)
Obstetric status :
FH: 30 cm, EFW: 2675 gr, contraction 2/10/35, FHR 145 bpm
I
: v/u calm, no active bleeding
Io : smooth livid portio, open ostium, flour (+), fluxus (+), valsava (+),
LEA (-)
VT : Thin portio, axial, effecement 75%, 2 cm, amniotic membrane (+),
breech on H1
Clinical pelvimetri:
Promontorium no palpable, DI > 9.5 cm, linea innominata 1/3-1/3,
Sacrum konkaf, Spina prominent, AP > 90 adequate pelvic

CTG :
Baseline
: 145
bpm
Variability
: 5-25 bpm
Acceleration
: (+)
2x/10
Deceleration
: (-)
His
: (+) 2/10
Fetal movement
: (+)
CTG category 1

USG :
FHR (+), single, breech
presentation
BPD
: 90
EFW
: 2800
gram
AC : 320 AFI : 10
FL : 74
Placenta on anterior corpus
Assesment : singleton live
breech presentation

Laboratory:
Hb
: 12,3 gram/dl ( 12-14 gram/dl )
Leucocyte : 9.200/ul ( 4100-10500 /ul )
Trombocyte
: 220.000 /ul (150000-400000 /ul )
Ht
: 34 % ( 40-55 % )
Random blood glucose : 96 mg/dl
BT
: 2 ( 1-7 )
CT
: 7 ( 5-15 )
Conclution
: WNL

A: G1 term pregnancy, breech presentation PROM 6 hours,

Oligohydramnios, in labor

Diagnost Observation vital sign, contraction and

ic Plan
FHR/hour
Observation of cord compression sign and
intrauterin infection
Therapy
Plan

Emergency C-section
Informed consent
Consult to Anastesiologist
Consult to Perinatology department

Educatio Explaining about patient condition and plan of

n Plan
diagnosis and plan of therapy for patients and
family
Breast milk and contraception motivation

Operation report
January, 11th 2015, 21.00-22.00
Cesarean Section due to breech presentation on primigravida,
1. Patient was within supine position in spinal anesthesia
2. Aseptic and antiseptic on surgery part with povidon iodine
3. Pfannenstiel incision around the old scar
4. Abdominal wall was opened layer by layer, no adhesion
5. After peritoneum was opened, there was a gravid uterus ~ term pregnancy
6. Identification lower uterine segment. LUS was incised sharply, penetrated
bluntly, extended sharply
7. By luxated the breech, born female baby BW 3500 gram, 50 cm, AS 9/10
8. Amniotic fluid wa clear
9. By gentle traction, placenta was born completely
10. LUS was sutured 1 layer with polysorb no 1
11. Both tube and ovary witin in normal limit
12. Abdominal cavity was washed with NaCL 0.9% 500 cc
13. On exploration, both tubes and ovaries were normal
14. Abdominal wall was closed layer by layer
15. Bleeding 300 cc. Urine 150 cc

Summary/
P1 Post Cesarean Section
doe to breech presentation
on primigravida
Appropriate for gestational
age

Thank You

Mrs. N, 38 yo
G3P1A1 40-41 wga, singleton live head presentation, Previous C-Section 1x
(IDT 8 years), Latent phase of labor
11/01/2015 pukul 17.00 wib
Chief complain : contraction since 5 hours before admission (came alone)
RPS : Patient admitted 9 month pregnancy, LMP 03/04/2014 ~ 40-41 wga .
ANC regularly to midwife, Obgyn. Ultrasound 3x. Last US 3 week ago said the
baby is good condition. Patients complaint contraction since 5 hours before
admission. Water broke denied, bloody discharge (+). Active fetal movement
(+).
Family & previous illness : Asthma, Hypertension, heart disease, DM, Allergy
was denied
Menstruasi diary: menarche 13 yo, regularly, 7 day, dismenorrhea denied
Married history: 1x, 28 yo
FP history: pill
Obstetric history:
1. Boy, 8 y, 3900 gram, SC ec failed induction, RSUD ZA hospital
2. Mescarriage, 2 mont pregnancy, curretage histiry (-)
3. Current pregnancy

Physichal examination
KU: Good, CM W: 80 kg H : 157 cm BMI 32,9
BP 110/80 mmHg, HR 80 x/Minute. RR 20 x/Minute, T 36,4 C
Generalis
Eye
Cor
Pulmo
Abdomen
scar
Extremity

Status :
: No anemis , no ikterik
: BJ I-II regular, no murmur, no gallop
: Vesikuler right=left, no wheezing, no rales
: Enlargment equal with pregnancy, appear operation
: warm acral, no oedema

Obstetric state:
Fundal height 34 cm, left back, head presentation, EFW: 3255 gr,
contraction (+) 2/10/30, FHR 150 dpm,
I
: V/U wnl, active bleeding (-)
VT : soft portio, axial, eff 50, 3 cm, amnion membranes (+), head H III
Clinical pelvimetri:
Promontorium no palpable, DI > 9.5 cm, linea innominata 1/3-1/3,
Sacrum konkaf, Spina prominent, AP > 90 adequate pelvic

CTG :
Baseline
: 150
bpm
Variability
: 5-25 bpm
Acceleration
: (+)
2x/10
Deceleration
: (-)
His
: (+) 2x/10
Fetal movement
: (+)
CTG category 1

USG :
BPD
: 94
FHR (+)
AFI : 10
EFW
: 3400
gram
AC : 345
FL : 75
Placenta on fundal
Assesment : singleton live
breech presentation

Laboratory:
Hb
: 11,2 gram/dl ( 12-14 gram/dl )
Leucocyte : 12.200/ul ( 4100-10500 /ul )
Trombocyte
: 215.000 /ul (150000-400000 /ul )
Ht
: 31 % ( 40-55 % )
Random blood glucose : 80 mg/dl
BT
: 3 ( 1-7 )
CT
: 8 ( 5-15 )
Assesment : within normal limit

A/ G3P1A1 40-41 wga, singleton live head presentation, Previous CSection 1x (IDT 8 years), Latent phase of labor
P/

R. Dx/

Observation of vital sign, contraction,

FHR/hours
Observation RUI sign

R. Th/

Initial plan for vaginal delivery with VBAC

Reevaluate 8 hours later (05.00)

January 12th 2015

01.00 wib
S/ Water broke (+), Contraction
(+), fetal movement (+)
O/
GC : good, CM, BP : 120/80
mmHg, PR : 88x/mnt, RR :
22x/mnt, Temp : 36.5C,
General status : wnl
Obstetric status :
FHR 140 bpm, contraction
3x/10/40
I: normal V/U
VT: soft portio, axial, eff 50, 3
cm, amnion membranes (-), head
H I-II
A/
G3P1A1 40-41 wga, singleton
live head presentation, Previous
C-Section 1x (IDT 8 years),
Latent phase of labor
P/
Observation of vital sign,
contraction,FHR
Observation RUI sign
Plan vaginal delivery with VBAC,
Reevaluate 6 hours later (1.00)

07.00 wib
S/ Mo
S/ Water broke (+), Contraction
(+), fetal movement (+)
O/
GC : good, CM, BP : 110/70
mmHg, PR :94x/mnt, RR :
22x/mnt, Temp : 36.5C,
General status : wnl
Obstetric status :
FHR 144 bpm, contraction
4x/10/45-50
I: normal V/U
VT: VT: soft portio, axial, eff 50,
3 cm, amnion membranes
(-), head H I-II
A/
G3P1A1 40-41 wga, singleton
live head presentation, Previous
C-Section 1x (IDT 8 years),
Latent phase of labor, failed
VBAC
P/
Presarean section

ON PROCESS..

Thank You