Operating Theatre Report

Friday, February 24th 2017

Consultant:
Dr. dr. Eka Rusdianto, OBGYN (C)
dr. T Dewi Anggraeni, OBGYN (C)
dr. Achmad Kemal Harzif, OBGYN (C)

OT Team
Fika-Affan-Fito-Greg-Wicak/Boeyoeng-Dennis
 Reporting
3 Procedures
1 Laparotomy adhesiolysis, adenomyosis resection
and bilateral cystectomy
1 Laparotomy myomectomy and left cystectomy
1 Laparoscopy bilateral cystectomy and bilateral
salpingectomy (will be reported in Minimally
invasive module report)
 Procedure No Case Outcome
Laparotomy 1 Ms. T,36 yo, P0 Patient on supine position under
adhesiolysis
adenomyosis
MR 4117855
Triawa general anesthesia
A and anti septic operation field
resection and Chief Complain:
Midline incision until 2 finger below
bilateral Dysmenorrhea (VAS 7-8)
cystectomy navel
Pre-Op Diagnosis: abdominal wall was open layer by layer
ICD 10
Adenomyosis After peritoneum was opened next
N73.6
Bilateral endometriosis cyst slide
N80.0
N80.1
ICD 9-CM Post-op Diagnosis:
54.59 Adenomyosis
61.70 Bilateral endometriosis cyst
65.29

Wicak T3A level

2 / Dr. dr Eka
Rusdianto Obgyn
(C)
 Procedure No Case Outcome
Laparotomy 1 Ms. T,36 yo, P0
adhesiolysis
adenomyosis
MR 4117855
Triawa
resection and Chief Complain:
bilateral Dysmenorrhea (VAS 7-8)
cystectomy
ICD 10 Pre-Op Diagnosis:
N73.6 Adenomyosis
Bilateral endometriosis cyst
N80.0
N80.1
ICD 9-CM Post-op Diagnosis:
54.59 Adenomyosis
61.70 Bilateral endometriosis cyst
65.29

Wicak T3A level

2 / Dr. dr Eka Patient in good condition in the ward
Rusdianto Obgyn Plan to have oral contraceptive for minimally
(C) 6 month
 Procedure No Case Outcome
Laparotomy 2 Ms. S,34 yo, P1 Patient on supine position under spinal
Myomectomy
and cystectomy
MR 4117855
Triawa anesthesia
A and anti septic operation field
ICD 10 Chief Complain: Midline incision until 2 finger below navel
D25.1 Abdominal mass since 1 year abdominal wall was open layer by layer
After peritoneum was opened
N80.1 Pre-Op Diagnosis: Next slide
ICD 9-CM Uterine fibroid
68.29 Left endometriosis cyst
65.29 ITP on therapy

Post-op Diagnosis:
Intramural uterine fibroid
left endometriosis cyst
Greg T3A level 2 ITP on therapy
/ dr T Dewi
Anggraeni
Obgyn (C)
 Procedure No Case Outcome
Laparotomy 2 Ms. S,34 yo, P1
Myomectomy
and cystectomy
MR 4117855
Triawa
ICD 10 Chief Complain:
D25.1 Abdominal mass since 1 year
N80.1 Pre-Op Diagnosis:
ICD 9-CM Uterine fibroid
68.29 Left endometriosis cyst
65.29 ITP on therapy

Post-op Diagnosis:
Intramural uterine fibroid
left endometriosis cyst
Greg T3A level 2 ITP on therapy
/ dr T Dewi
Anggraeni
Obgyn (C)

Patient in good condition in the ward

Plan to have oral contraceptive for minimally
6 month
 Duty Report
Friday, February 24th 2017

Consultant
dr. Fernandi Moegni, OBGYN (C)

Essy-Fadil/Rachmat-Affan/Martin-Disty/Jan-Adhit/Olin/Adri
 Reporting

1 Procedure :
1 Cesarean Section
 Procedure No Case Output
1 Impending eclampsia, Fetus with Absent Girl, 900 gr, 34 cm, AS 6/7/8
end diastolik HC 230 mm, AC 185 mm.
BS ~ 26-28 wga
Mrs. DA, 24 yo Scanty amniotic fluid
O14.1 O82.1 MR 4163670 Placenta born completely
O99.8 O42.9
Impending eclampsia on G1 28 wga, Fetal BGA:
N18.6 Z35
singleton live intrauterine pregnancy, pH 7.2/pCO2 42.7/ pO2 19.1/ O2 Saturation
oligohydramnios (AFI 4) with: 21.6/ BE -9.3/ HCO3 17.5/ Total CO2 18.8 ~
fetal acidemia
- Chronic kidney diseases stage V due to
autoimmune diseases
- Fetus with absent end diastolic
FP: IUD TC
- PPROM 1 day

Process: Mother is in ER 3rd floor with, BP 130/90

BP 170/110 mmHg, UL protein +2, persistant
frontal headache +, epigastric pain +, nausea and
vomiting +History of hypertension (-)
25/2 : Ur 213/Cr 11.3
29/1 : ANA (+), Anti ds DNA (-)
C3/C4 26.6/101
Esbach 1.1 g/24 hours
US exam: Absent end diastolic, oligohydramnios
NBC
Came by her own will.
mmHg, HR 101x/m, RR 21x/m on Canula
nasal 4 L/m, O2 sat 99%, Post Hemodyalisis
1x Ur : 165, Cr : 8.9, diusresis 0.5
cc/kgbw/hours, and plan to 2nd hemodialiysis
today.
Baby is in SCN 4 with CPAP PEEP 5, FiO2 80%,
O2 sat 95%, baby diagnosed with respiratory
distress syndrome due to HMD gr II dd EONS.
Chest X-Ray result ~HMD grade II.
Hb 13.1, Leu 11.130, CRP 0.1 , IT ratio 0.13,
still waiting blood culture result. Given
ampicilin sulbactam 45mg/12 hours and
 Duty Report
Saturday, February 25th 2017
Consultants:
Dr. dr. Budi Iman Santoso, OBGYN(C)
Dr. dr. Yuditiya Purwosunu, OBGYN(C), PhD

Residents:
Ogi-RIchie/Finish-Denny/Mini/Andro-Mauli/Dita/Shinta
 Reporting
2 Cesarean Sections
1 Maternal Mortality Report
 Procedure No Case Result
Cesarean Section 1 PROM, oligohydramios, low pelvic score Boy, 2810 g, 47 cm, AS 8/9

ICD 10 Triawa
Mrs. SH, 46 yo
BS 36-38 wga
Scanty amniotic fluid
Z37.0 MR 4165048 Placenta born completely
O82.1
O41.0
Z30.2 PROM 1 day on G1 37 wga, singleton live head
presentation, oligohydramnios (AFI 1.7),
ICD 9-CM Preeclampsia with severe features, not in
74.1 labor, Primary Infertility (2.5 years)
88.78 FP: IUD TC
75.34 Process:
66.3 PROM, oligohydramios (AFI 1.7), not in labor
N97 (PS 2) emergency C-Section

Data:
BP 170/100 mmHg, protein urine +2
Now mother and baby are in
good condition in the ward,
rooming in. Mother with
NBC controlled blood pressure
Mauli (T2A) Referred from RSUK Matraman due to old (140/80 mmHg) on Nifedipine
DOPS primigravida slow release 1x 30 mg, po.
Procedure No Case Outcome
2 PPROM, Previous C-Section 1x, not in labor Boy, 4300 g, 50 cm, AS 8/9

MR 4182041
Triawa
Mrs. YH, 37 yo
HC 365 mm, AC 360 mm
BS 36-38 wga
Clear amniotic fluid
Placenta born completely
PPROM 3 hours on G3P1A1 36 wga, singleton
live head presentation, previous C-Section 1x,
not in labor with:
- Superimposed Preeclampsia
- Diabetes Mellitus Gestational
- Macrosomia Fetus FP: Sterilization

Data:
- BP: 190/120 mmHg, protein +3
- FH 39 cm, clinical EFW 4030 g, head above pelvic
inlet. US EFW 4199 g.
- 24-02-17 at Hermina Hospital: FBG 187, 2hrBG 137, Now mother is in good condition in
HbA1C 6.8 DMG treated with insulin 3x5u, sc
ward with controlled blood pressure
(130/80 mmHg) on Nifedipine slow
release 1x30 mg, po.
NBC
Baby is in transitition room with
Referred from RSUK Matraman due to PPROM,
spontaneous breathing, RBG 97
previous C-Section 1x
mg/dl.
 Maternal Mortality Report
Mrs. EP, 36 yo
MR 4165090

Cardiac Arrest on P2A1 post vacuum extraction outside 2 hours before admission
-Irreversible shock due to uterine atonia
-Suspected amniotic fluid embolism

COD: Irreversible shock

 DUREN TIGA HOSPITAL

Feb 25th 2017 Feb 25th 2017 Feb 25th 2017

13:15 19:30 20:40
S: Patient came to ER at Duren tiga Hospital due to
Contraction since 4 hours BA S: contraction was positive
Patient did ANC in Duren Tiga Hospital 7x. LMP O: Gen Stat: wnl
forgot. Based on US exam at 13th wga, EDD 14-03- S: Patient said she felt more Obs Stat: His
2017 ~ 37-38 wga. During ANC theres no contraction
remarkable history. She had history of bloody show
3x/10/30 ,FHR 144 x/m
and no water broke. VT: portio was smooth,
She was G3P1A1: O:BP:110/70mmHg, HR 86 axial, 6 cm, amniotic
I. Miscarriage at 3 months of pregnancy, no x/m, RR:18 x/m, T: 36,5oC membran (+)
curretage Gen Stat: wnl
II. Boy, midwife, spontaneous delivery, 2700 g, Head in H III
4 yo, live Obs Stat: His 1-2x/10 ,
III. This pregnancy FHR 147 bpm A: Inertia active phase of
I: V/U wnl labor on G3P1A1 37-38 wga,
O: BP: 110/80 mmHg, HR 84 x/m, RR: 16 x/m,
VT: 6 cm, amniotic singleton live head
T: 36.50C membran (+), Head on H II III presentation
Gen Stat: wnl
Obs Stat: FH 32 cm, Back on the right, A:
head, His: 2x/10/30, FHR 140 bpm, clinical
P: Performed the amniotomy,
EFW 3100 g Active phase of labor on the amniotic fluid was
I: V/U wnl G3P1A1 37-38 wga, singleton normal. Performed
Io: not performed live head presentation augmentation with oxytocyn
VT: 4 cm, amniotic membran (+), Head
on H II
CTG: Reassuring P: Evaluation progress of
A: Active phase of labor on G3P1A1 37-38 labor
wga, singleton live head presentation
P: Evaluation progress of labor in the next 4
hours
 DUREN TIGA HOSPITAL
Feb 25th 2017 Feb 25th 2017
21:05 21:15
Patient felt dyspnea, want
to bear down
By the Vacuum Extraction Born Baby Girl 3200 gram
VT: fully dillated, Active management third stage of labor: Placenta born
amniotic membran (-), clear completely 10 minutes after baby born 350 cc
amniotic fluid, Head H III+ bleeding
Given oxytocin 20 UI in 500cc RL
Misoprostol 600 mcg rectal
Dyspneu ec suspected Methylergometrine 0.2 mg, IV
amniotic fluid embolism on
second stage of labor on
Found Perineal Rupture grade II Perineoraphy
G3P1A1 37-38 wga,
singleton live head
presentation, extraction
prerequisite fulfilled

30 minutes after Perineoraphy found

Call for Anesthesiologist
and Vacuum Extraction active vaginal bleeding Uterine Atonia
 DUREN TIGA HOSPITAL

Patient feel dyspnea but still can The operator inserted a baloon
communicate with the doctor tamponade and there were two Femoral
HR 100-160 bpm IV line with Ringer Lactat on Both Line
BP 80/60 mmHg 100/80 mmHg

EBL 500 cc and given RL 1500 cc

and 500 cc Colloid
And plan for emergency
laparotomy
Sent to RSCM
Anesthesiologist disagree due to
there is no ICU and HCU and
planned referred to RSCM
 Feb 25th 2017
22.55-23.15
AMBULANCE
22.55-23.15
Referral Team:
-General Practitioner (GP)
-Midwife
-Driver

During 20 minutes of refferal time

the vital sign was tachycardia and
the blood pressure cannot
measured.

In ambulance patient got cardiac

arrest about 2 minutes before
arrived at RSCM performed CPR
by GP, give injection epinephrine 1x.
 Feb 25th 2017
23:18 CIPTO MANGUNKUSUMO
HOSPITAL
S: Patient no contact

O:E1M1V1 Primary survey

A: clear 23.18-23.53
B :no respiratory and breathing effort CPR Pulseless Electrical Activity
C: No pulsation on carotid artery (PEA) continue CPR for 15
Gen status:
Eye: Conjungtiva anemis +/+, pupil midriasis +/+ 00.10
Abdomen :overdistention no response, pupil midriasis,
CRT > 3 asystolic ECG declared died in
Dry and cool in extremity, with petechie in body in extremity front of doctor, nurse, and family

Obstetric status:
FH at navel (already applied condom cathether from outside) COD:
I: v/u perineal wound already sutured with hematoma on vulva dextra,
active vaginal bleeding (+)
Irreversible shock
Io and VT: not performed (already applied condom cathether from outside)

A: Cardiac Arrest on P2A1 post vacuum extraction outside 2 hours before

admission
-Irreversible shock due to uterine atonia
-Suspected amniotic fluid embolism

P:Anesthesiology performed cardiopulmonary rescuscitation (intubation

and CPR, adrenalin injection)
- Rescuscitation 2 IV line IVFD RL 2000 cc and Colloid 500 cc
-Take a sample blood for Laboratorium and crossmatch for transfusion
 Duty Report
Sunday, February 26th 2017

Consultant:
Dr. dr. R. Muharam, OBGYN (C)
Kartiwa Hadi Nuryanto

Residents:
Irfan-Evi/ Greg-Fito / Danang-Mimil / Charly-Achi / Azmi / Lingga
 Reporting
7 Procedures :
1 Haemostatic and repair of perineum
2 Vaginal deliveries
3 Caesarean sections
1 Caesarean section continued with
cystectomy
 Procedure No Case Output
1 Mrs. AR, 30 yo Patient on lithotomy positition
MR 4165110 Under local anesthesia
On exploration found wound of the
vagina and perineum was opened with
Hypovolemic shock grade I due to late HPP due to active bleeding, decided to perform
perineal ruptured grade II on P2A1 post vaginal haemostatic suture and continued with
O70.1 delivery 5 days outside repair of perineum rupture with PGA no.
D64.9 Normocytic normochromic anemia due to blood 2.0
loss (Hb 7.4)

99.0 Primary survey: Analysis of late HPP

70.71 A: clear
B: RR 22x/minute, NC 4 L/minute, SaO2: 100%
C: TD 120/80 mmHg, HR 109x/minute 2 IV
Line, loading RL 1000 cc, Urine (+)
Active vaginal bleeding (+) 1 underpad
Tone: Good uterine involusion
Tissue: Empty uterine cavity and positive
endometrial line on US exam
Tear: Perineal rupture grade II with
active bleeding
Thrombin: Trombosit 311.000, PT/APTT
0.9x/1x
Conclussion: Tear

NBC Mother is in good condition in the ER 3rd

Referred from midwife due to late HPP floor. Already got 360 cc PRC, waiting for
Hb result post transfusion
 Procedure No Case Outcome
1 Mrs. VF, 21 yo Boy, 1920 gram, 45 cm, AS 8/9

ICD 10
MR 4165124
Triawa BS ~ 32-34 wga
Clear diminished amniotic fluid
Placenta born completely
O80.0 Second stage of labor on G1 33 weeks gestational Rupture perineum gr I Haemostatic
Z37.0 age, singleton live head presentation suture
Z3A.33
O70.0
Process: FP : DMPA
ICD 9-CM Second stage of labor lead to bear down
88.78 Analysis of preterm labour:
70.71 Maternal: no infection and no over
distention
~ Unknown

Lingga (T1A) NBC Mother is in good condition in the ward,

Independent Referred from Jatinegara PHC due to preterm labor baby is transition room, spontaneous
breathing
 Procedure No Case Outcome
2 Mrs. SP, 25 yo Boy, 2740 gram, 47 cm, AS 9/10

ICD 10
MR 4165157
Triawa BS ~ 36-38 wga
Clear diminished amniotic fluid
Placenta born completely
O80.0 Second stage of labor on G2P1 38 weeks of Rupture perineum gr I Haemostatic
Z37.0 gestational age, singleton live head presentation suture
Z3A.38
O70.0

ICD 9-CM Process:

88.78 Second stage of labor lead to bear down FP : DMPA
70.71

NBC Mother and baby are in good condition,

Lingga (T1A) Came by her own will rooming in.
Independent
 Procedure No Case Output
1 Fetal distress Baby Girl, 3025 gr, 47 cm, AS 9/10
BS ~ 40 wga
Mrs. DS, 25 yo Greenish amniotic fluid
MR 4195924 Placenta born completely
O77.9
Z37.0 Fetal distress on active phase of labor on G1 40- FP: IUD TC
Z3A.40 41 wga, singleton live head presentation

Process
74.1 US exam: AFI 15, EFW 2900 gr BGA:
88.78 His 1x/10/20 , 3 cm latent phase of labor, CTG pH 7.26/ pCO2 51.6/ pO2 31.1/ O2 sat
category I 8 hours of observation, His 53.2/ BE -3.3/ Stand BE -3.6/ Stand HCO3
75.34
1x/10/30, 3cm, HI-II 8 hours observation 20.7/ HCO3 23.6/ Total CO2 25.2
69.7 rupture of membrane, evaluation of AFI 9, CTG ~ normal BGA
category I acceleration with titration of oxcytocin
5 IU start from 8 dpm his adequate at 40 dpm
Analysis of fetal distress:
observation 4 hours his 3-4x/10/45, 5 cm, H II-
Cord compression
III on observation: greenish amniotic fluid, FHR
inside and outside his: until 80 dpm fetal distress

NBC
Referred from Matraman PHC with prolonged Mother and baby are in good condition
pregnancy in the ward, rooming in
 Procedure No Case Output
2 Footling presentation Baby Girl, 2840 gr, 46 cm, AS 8/9
HC 340 mm, AC 330 mm
Mrs. W, 39 yo BS ~ 40 wga
MR 4165139 Clear amniotic fluid
Placenta born completely
O32.8
Z37.0
Z3A.40 Active phase of labor on G4P2A1 40 weeks of FP: IUD TC
gestational age, singleton live footling
presentation
Analysis of footling presentation:
74.1 Mother : Multiparity
75.34 Process: Fetal : No macroscopic anomaly
69.7 His: 4x/10/40, 8 cm, baby foot palpated in Placenta : Implantation at fundal, no
the introitus vagina emergency cesarean cord entanglement
section Conclusion : Multiparity

NBC Mother is in good condition in the ER 3rd

Refered from Keramat Jati PHC with footling floor, baby is in transition room,
presentation spontaneous breathing

01.15
Born 2nd
Baby
 Procedure No Case Output
3 Transverse lie, in labor Baby Girl, 2400 gr, 50 cm, AS 8/9
HC 320 mm, AC 300 mm
Mrs. A, 20 yo BS ~ 36-38 wga
MR 4195350 Clear abundant amniotic fluid
Placenta born completely
O32.2
O40
Z37.0 G1 37 weeks gestational age, transverse lie FP: IUD TC
Z3A.37 dorsosuperior, head on the right, fetal with
suspected hypertrophic pyloric stenosis,
polihydramnios (AFI 29), in labor Analysis of transverse lie:
Mother : Polihydramnios
74.1 Supporting Data: Fetal: : No macroscopic anomaly
FM US exam February 22nd 2017
75.34 Placenta: implantation at posterior
Transverse lie dorsosuperior head on the right, placenta at
corpus posterior corpus, no cord entanglement
69.7
2480 gr, AFI 24.7 Conclussion: polihydramnios
Biometric ~36 wga
Fetal with suspected hypertrophic pyloric stenosis

His: 1-2x/10/30, Fundal height: 36 cm, back and the small

part of the fetus cannot be palpated, 1 cm.

Mother is in good condition in 3rd floor,

NBC baby is in SCN 4 with spontaneous
Came by her own will breathing, plan to have abdominal x-ray
 Procedure No Case Output
3 Antepartum Haemorrhage After peritoneum was opened, seen chocolate fluid
surrounded and stained the uterus ~ endometriosis
cyst
Mrs. NA, 32 yo LUS was incised semilunar, born baby girl, 2900 g,
MR 4193340 48 cm, AS 9/10
HC 320 mm, AC 280 mm BS ~ 40 wga
Clear amniotic fluid
O44.33 Placenta born completely, inserted IUD TC
N80.1 Antepartum haemorrhage due to placenta previa marginalis LUS was stitched 2 layers continously with PGA 1
Z37.0 on G1 38-39 weeks of gestational age, singleton live head On further exploration: seen cystic mass from left
Z3A.38 presentation with susp microcephaly ovary already ruptured with chocolate fluid ~
Cystic ovarian neoplasm sinistra endometriosis cyst, adhered to posterior uterine
corpus. Right tube and ovary were within normal
Supporting Data: limit
74.1 FM US exam February 7th 2017 Performed adhesiolysis and left cystectomy
88.78 Singleton live head presentation, placenta at posterior corpus Ensure no active bleeding, complete instruments
75.34 until OUI, clear zone (+), lacuna (-) and gauze
69.7 BPD 7.93 HC 28.22 Abdominal layer was closed layer by layer
EFW 2700 gr Intraoperative bleeding 300 cc, urine 200 cc clear
65.21 Fetus with microchepaly
Ovarium consit of cystic mass size 86x84 non vascular.

BC Mother and baby are in good condition in the

Patient already scheduled for elective cesarean section on ward, rooming in
March 3rd 2017
 Delivery Suite Report
Friday, February 24th 2017

Consultant:
dr. Andon Hestiantoro, OBGYN(C)

Residents:
ER Team
 Reporting
3 Procedures
1 Spontaneous Bracht
2 Cesarean sections
 Procedure No Case Outcome
1 Mrs. S, 35 yo Girl, 2000 gram, 37 cm, AS 4/7
MR 4164986
Triawa BS ~ 32 wga
HC 27 AC 34
ICD 10 Active phase of labor on G2P1 32-33 wga, Clear amniotic fluid
O83.0 singleton live breech presentation, fetus Placenta born completely
Z37.0 with right hydronephrosis dd/ right ovarian Perineal ruptured ~ episiotomy
Z3A.31 cyst.
O70.1 Mother with preeclampsia severe feature, FP : IUD PP
bilateral ovarian cyst
ICD 9-CM Analysis breech presentation:
652.2 Process: Maternal: Bilateral ovarian cyst
69.7 Active phase of labor ( 6cm, breech on H Fetal: Intraabdominal cyst
75.34 II-III) , contraction 4x/10/45) 3 hours Placenta: No abnormality
88.78 observation Second stage of labor Possible cause: Maternal and fetal
lead to bear down condition

Oline(T1B) NBC Mother in good condition, observation

Independent Came by her own will of acute abdomen, already discharged.
Baby in NICU with PIP 25/5 FiO2 21%,
IT ratio 0.09, CRP 0.2 diagnosed with
RD ec HMD dd/ susp SNAD space
ocupying, ampicilin 90 mg/12h
getamicin 9mg/36h, babay plan for
abdominal US for diagnostic work up.
 Procedure No Case Outcome
1

Mrs M, 41 y.o
Triawa
Unstable lie, in labor Born baby 1400 gr, 36 cm, AS 5/7
HC 24 AC 22
Clear amniotic fluid
RM 4183305 BS ~ 32 wga
Placenta born completely
G2P1 31wga, singleton live unstable lie, polihydramnios, Baby with proboscis, cyclops
baby with hydrocephalus communicans type due to
holoprosencephaly alobar type, multiple congenital
anomaly (proboscis, palatoschisis), previous c section OMIM Phenotype number 236100:
1x, in labor Holoprosenchephaly 1;HPE 1

Process:
31wga, his 1x/10/35, unstable lie, previous c section FP : IUD TC
1x C-section

Mimil (T2B)/
Irfan (T4A) Now mother is in good condition,
Independent NBC: plan to be discharged.
Referred from Policlinic due to fetus congenital Baby died 90 minutes after delivered
anomalies
 Procedure No Case Outcome
Caesarean section 2 Preterm breech presentation, prev C- Boy, 1500 gr, 46cm, AS 6/8
section HC 28, AC 26
ICD 10 Diminished amniotic fluid
O82.1 Mrs. Y, 37 yo BS ~ 32 wga
Z37.0 MR 4164992 Placenta born completely
Z39.0
O42.0
FP : IUD TC
Active phase of labor on G4P3(2 Living
ICD 9-CM
74.1 child) 29-30 wga, singleton live breech Possible cause of breech
75.34 presentation, oligohydramnios due to presentation:
88.78 PPROM, previous c-section 1x Maternal: no anatomical condition
69.7 Fetal: Preterm
Placenta: no abnormality
Process:
Breech presentation, 4cm, his 3x/10/40
Mimil (T2B)/ dexamethason 6 mg iv C-section
Irfan (T4A) Now mother is in good condition, in
Independent the ward.
NBC Baby is in NICU with CPAP PEEP 7
Reffered from RS Kramat 128 with PPROM, FiO2 21%, IT ratio 0.09, CRP <0.1
no NICU with diagnose Respiratory Distress
ec susp HMD dd/ SNAD, Ampicillin
7.5 mg/12 hrs, Gentamicyn 7.5/36
hrs
 High Care Unit Report
Monday, February 27th 2017

Consultant:
Dr. dr. Yuditiya P, OBGYN (C), PhD

Ward Team February 2017

1 PATIENT
No Patient Todays Problem

1. Sepsis due to UTI with liver

failure, kidney failure and
encephalopathy
HCU 6th Floor 2. Acute on Chronic liver failure due
1
Mrs. J, 28 yo to Hepatitis B with hepatic
MR 4192585 encephalopathy
P2 (1 live child) post spontaneous 3. Anemia normocytic normochrom
delivery puerperal day 6 due to Blood loss ec melena (Hb
8)
4. DIC non overt
5. Hypoalbuminemia (2.4)
 Todays Condition
February 27th 2017, 05.30

S : inadequate contact, melena since 2 days

O : GCS E2M2V2, delirium
BP : 154/92 mmHg, HR 101x/min, temp 37.80C, RR 20x/min, SpO2 96% (on Nasal canule 3 lpm)
General status:
Eye: CA (-/-), SI (-/-)
Heart: S1-2 regular, murmur/gallop (-)
Lung: Vesiculer +/+, rhales -/-, wheezing -/-
Extremity: warm, CRT<2, edema (-/-)

Obs st :
Fundal height at 2 finger below navel, good involution
I: V/U wnl, no active bleeding

Fluid balance
Patient is taking care by
Fluid Balance Input 3010cc
(Cumulative) Internal medicine since
Output 1300cc
February 24th 2017
Balance +710.8cc

Diuresis 1.5 cc/kg/hr