PERTIWI HOSPITAL / Keny Stefanus

January 20th – January 23th 2019

NO DATE PATIENT DETAIL OF PATIENT TREATMENT RECOMENDATION
1 20/1/2019 Mrs.F/31 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding for
LMP: 20/4/18 G3P2A0 39 weeks of Gestational Age Active Phase 1st Stage - Early Breast Feeding 6 months
of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: IUD
Term Delivery Insertion
Outcome:
Female, BW: 3200 gr, BL: 48 cm, AS: 8/10
2 20/1/2019 Mrs.E/30 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding for
LMP: 23/4/18 G4P2A1 38 weeks 4 days of Gestational Age Active Phase 1st - Early Breast Feeding 6 months
Stage of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: IUD
Term Delivery Insertion
Outcome:
Male, BW: 3300 gr, BL: 49 cm, AS: 8/10
3 20/1/2019 Mrs.L/27 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding for
LMP: 1/5/18 G2P1A0 37 weeks 5 days of Gestational Age Active Phase 1st - Early Breast Feeding 6 months
Stage of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: Hormonal
Term Delivery Progestin
Outcome:
Female, BW: 2900 gr, BL: 46 cm, AS: 8/10
4 20/1/2019 Mrs.A/28 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding
LMP: 29/4/18 G3P1A1 38 weeks of Gestational Age Active Phase 1st Stage - Early Breast Feeding for 6 months
of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: Hormonal
Term Delivery Progestin
Outcome:
Male, BW: 2950 gr, BL: 47 cm, AS: 8/10
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019
5 20/1/2019 Mrs.M/29 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding for
LMP: 2/5/18 G2P1A0 37 weeks 4 days of Gestational Age Active Phase 1st - Early Breast Feeding 6 months
Stage of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: Hormonal
Term Delivery Progestin
Outcome:
Male, BW: 2800 gr, BL: 47 cm, AS: 8/10
6 21/1/2019 Mrs.L/23 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding
LMP: 29/4/18 G1P0A0 38 weeks 1 day of Gestational Age Active Phase 1st - Early Breast Feeding for 6 months
Stage of Labor - Repair of Perineal Laceration - Vaginal Hygiene
Post Treatment Diagnosis: - Family Planning counseling
Term Delivery + Second Grade Perineal Laceration and education: Hormonal
Outcome: Progestin
Female, BW: 2950 gr, BL: 47 cm, AS: 8/10
7 21/1/2019 Mrs.P/21 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding
LMP: 4/5/18 G1P0A0 37 weeks 3 days of Gestational Age Active Phase 1st - Early Breast Feeding for 6 months
Stage of Labor - Repair of Perineal Laceration - Vaginal Hygiene
Post Treatment Diagnosis: - Family Planning counseling
Term Delivery + Second Grade Perineal Laceration and education: Hormonal
Outcome: Progestin
Female, BW: 2700 gr, BL: 47 cm, AS: 8/10
8 21/1/2019 Mrs.R/28 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 27/4/18 G2P1A0 38 weeks 3 days of Gestational age in Latent Phase - Early Breast Feeding for 6 months
1st stage of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: Hormonal
Term Delivery Progestin
Outcome:
Male, BW: 2950 gr, BL: 48 cm, Apgar Score: 8/10
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019
9 21/1/2019 Mrs.R/25 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 2/5/18 G1P0A0 37 weeks 5 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Repair of Perineal Laceration - Family Planning counseling
Post Treatment Diagnosis: and education: Hormonal
Term Delivery + Second Degree Perineal Tear Progestin
Outcome:
Male, BW: 3000 gr, BL: 48 cm, Apgar Score: 8/10
10 21/1/2019 Mrs.S/33 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 21/4/18 G4P2A1 39 weeks 2 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Family Planning counseling
Post Treatment Diagnosis: and education: IUD
Term Delivery Insertion
Outcome:
Male, BW: 3350 gr, BL: 49 cm, Apgar Score: 8/10
11 22/1/2019 Mrs.FN/29 y.o Pre Treatment Diagnosis: - Augmentation of Labor - Exclusive Breast Feeding
LMP: 22/4/18 G2P1A0 39 weeks 1 day of Gestational age in Latent Phase 1st - Vaginal Delivery for 6 months
stage of Labor - Early Breast Feeding - Family Planning counseling
Post Treatment Diagnosis: and education: Implant
Term Delivery
Outcome :
Male, BW: 3150 gr, BL: 49 cm, Apgar Score : 8/10
12 22/1/2019 Mrs.M/32 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 3/5/18 G3P1A1 37 weeks 4 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Family Planning counseling
Post Treatment Diagnosis: and education : IUD
Term Delivery Insertion
Outcome:
Female, BW: 3000 gr, BL: 48 cm, Apgar Score : 8/10
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019
13 22/1/2019 Mrs.Y/22 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 28/4/18 G1P0A0 38 weeks 3 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Repair of Perineal Laceration - Vaginal Hygiene
Post Treatment Diagnosis: - Family Planning: counseling
Term Delivery + Second Degree Perineal Tear and education: Hormonal
Outcome: Progestin
Male, BW: 2850 gr, BL: 48 cm, Apgar Score : 8/10
14 22/1/2019 Mrs.M/23 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 26/4/18 G2P1A0 38 weeks 5 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Repair of Perineal Laceration - Vaginal Hygiene
Post Treatment Diagnosis: - Family Planning: counseling
Term Delivery + Second Degree Perineal Tear and education: Hormonal
Outcome: Progestin
Female, BW: 3250 gr, BL: 49 cm, Apgar Score : 8/10
15 22/1/2019 Mrs.P/34 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 21/4/18 G4P3A0 39 weeks 3 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Family Planning: counseling
Post Treatment Diagnosis: and education: IUD
Term Delivery Insertion
Outcome:
Male, BW: 3150 gr, BL: 49 cm, Apgar Score: 8/10
16 22/1/2019 Mrs.F/31 y.o Pre Treatment Diagnosis: - Augmentation of Labor - Exclusive Breast Feeding
LMP: 23/4/18 G2P1A0 39 weeks 1 day of Gestational age in Latent Phase 1st - Vaginal Delivery for 6 months
stage of Labor - Early Breast Feeding Family Planning counseling
Post Treatment Diagnosis: and education: IUD
Term Delivery Insertion
Outcome :
Male, BW: 2900 gr, BL: 49 cm, Apgar Score : 8/10
17 23/1/2019 Mrs.LN/20 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive Breast Feeding
LMP: 28/4/18 G1P0A0 38 weeks 4 days of Gestational age in Active Phase - Early Breast Feeding for 6 months
1st stage of Labor - Repair of Perineal Laceration - Vaginal Hygiene
Post Treatment Diagnosis: Family Planning: counseling
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019
Term Delivery + Second Degree Perineal Tear and education: Hormonal
Outcome: Progestin
Female, BW: 3100 gr, BL: 49 cm, Apgar Score : 8/10
18 23/1/2019 Mrs.L/22 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding
LMP: 1/5/18 G2P0A1 38 weeks 1 day of Gestational Age Active Phase 1st - Early Breast Feeding for 6 months
Stage of Labor - Repair of Perineal Laceration - Vaginal Hygiene
Post Treatment Diagnosis: Family Planning counseling
Term Delivery + Second Grade Perineal Laceration and education: Hormonal
Outcome: Progestin
Female, BW: 3150 gr, BL: 48 cm, AS: 8/10
19 23/1/2019 Mrs.G/24 y.o Pre Treatment Diagnosis: - Spontaneous Vertex Delivery - Exclusive breast feeding for
LMP: 26/4/18 G2P1A0 38 weeks 6 days of Gestational Age Active Phase 1st - Early Breast Feeding 6 months
Stage of Labor Family Planning counseling
Post Treatment Diagnosis: and education: Hormonal
Term Delivery Progestin
Outcome:
Male, BW: 2950 gr, BL: 47 cm, AS: 8/10
G2P1A0
Family Planning : Hormonal
Vaginal Bleeding (+) since 12 hours ago
Progestin
External OS/Internal OS : Dilated/ Dilated
Mrs. T/26
Consult for Next Pregnancy
20 21/1/2019 y.o/LMP Pre- Treatment Diagnosis - Curettage
8/11/2018 Incomplete Abortion
- Explain about Risk Factor in
Post- Treatment Diagnosis
1st Trimester of Pregnancy
Incomplete Abortion
and ANC

G1P0A0 Family Planning : Hormonal

Mrs. C/22 Vaginal Bleeding (+) since 2 day ago Progestin
21 22/1/2019 y.o/LMP External OS/Internal OS : Dilated/ Dilated - Curettage
30/10/2018 Consult for Next Pregnancy
Pre- Treatment Diagnosis
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019
Incomplete Abortion - Explain about Risk Factor in
Post- Treatment Diagnosis 1st Trimester of Pregnancy
Incomplete Abortion and ANC

22 20/1/2019 Mrs.J/32 y.o 1st Caesarean Section due to Breech Presentation in October, - Lower Transverse Caesarean - Exclusive Breast Feeding
LMP: 21/4/18 2017 Section for 6 months
- IUD Insertion - Mobilization
Pre-Operative Diagnosis: - Control for surgical wound
G4P2A1 39 weeks 1 days of Gestational Age + suture
1 Previous Caesarean Section + IUD Acceptor Candidate - Control for IUD
- Explain the patient and her
Post-Operative Diagnosis: family about the high risk
1 Previous Caesarean Section + Term Delivery + IUD Acceptor of the next pregnancy
Routine antenatal care for
Outcome: the next pregnancy
Male, BW: 3500 gr, BL: 50 cm, AS: 8/10
23 21/1/2019 Mrs.K/34 y.o 1st Caesarean Section due to Placenta Previa in 2014 - Lower Transverse Caesarean - Exclusive Breastfeeding for
LMP: 21/4/18 2nd Caesarean Section due to 1 Previous Caesarean Section in Section 6 months
December 2016 - Bilateral Tubectomy with - Early Mobilization
- Wound surgery follow up
Modified Pomeroy
Pre-Operative Diagnosis:
G4P2A1 39 weeks 2 days of Gestational Age +
2 Previous Caesarean Section + Female Sterilization Acceptor
Candidate

Post-Operative Diagnosis:
2 Previous Caesarean Section + Term Delivery + Female
Sterilization Acceptor

Outcome:
Female, BW: 3350 gr, BL: 49 cm, AS: 8/10
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019
1st Caesarean Section due to Prolonged 2nd Stage of labor in
September, 2017
EFW : 3965 gram - Exclusive Breast Feeding
for 6 months
- Mobilization
Pre-Op Diagnosis :
- Lower Transverse Caesarean - Control for surgical wound
Mrs. NY/28 G2P1A0 38 weeks 4 days of Gestational age + Breech suture
Section
24 22/1/2019 y.o/LMP Presentation + 1 Previous Caesarean Section + IUD - Control for IUD
- IUD Insertion
26/4/2018 Acceptor Candidate - Explain the patient and her
Post-Op Diagnosis : family about the high risk
Frank Breech Presentation + 1 Previous Caesarean of the next pregnancy
- Routine antenatal care for
Section + Term Delivery + IUD Acceptor
the next pregnancy
Outcome:
Male, BW : 3850 gr, BL : 49 cm, A/S : 8/10
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019

Total Cases : 24

Vaginal Delivery : 19 Incomplete :2

Dilatation & Curettage :2 Missed Abortion :-
Lower Segment Transverse Caesarean Section :3 Hydatidiform Mole :-
Hysterectomy :- Cystectomy/Salphyngooforectomy :-

Mortality/Nearmiss Total
Maternal :-
Perinatal :-

Family Planning :
Natural :- Hormonal Combination : - Female Sterilization :1
Barrier :- Hormonal Progestin :- IUD :2
 PERTIWI HOSPITAL / Keny Stefanus
January 20th – January 23th 2019

Makassar, 24/01/2019

Known By

Chief Resident:

dr. Rahayu dr. Beni

Supervisor,

dr. Johnsen Mailoa, Sp.OG(K)