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Duty Report

Saturday, December 10th 2016


Supervisor:

dr. Hiro Hidayah Nst.,M.Ked(OG), SpOG


dr. Khairani Sukatendel, M.Ked(OG), SpOG(K)
Resident

1. dr.
2.
3.
4.
5. dr.

Tonny Simarmata
dr. Tri Ebta Mayniar
dr. Ria Suci Nurlianti
dr. Alfiani Sari
Ivan C. Pasaribu

Department of Obstetric and Gynecology


Faculty of Medicine University of Sumatera Utara
Adam Malik General Hospital
2016

New Patient
Prior Patient

:
:

2
-

Patients
Patient

1. Mrs.P,32 y.o,G3P2A0
Diagnosis
: HIV + Previous C Section 1 x + MG + IUP (37-38) wga +Head
Presentation + Live Fetus + In labor
Planning :
Immediately C Section + Pomeroy Sterilization
Inj. Cefazoline 2 gr skin test
Consult to Anesthesiology
Consult to Perinatology
Informed Consent
On Saturday, Desember 11th 2016, at 03.40 AM, with cesarean section a male
baby was delivered, BW: 3000 gr, BL: 48cm, A/S: 8/9, Anal (+)

2. Mrs. R, 31 yo, G2P0A1


Diagnosis
: SG + IUP (38-40) wga + HP + Alive Fetus
Planning :
- Check CBC, HST, Blood Glucose
- Watchful waiting for labor sign

Mrs.P,32 y.o,G3P2A0 Bataknese, Protestant, Junior High School, Housewife, married to


Mr. A, 34 y.o, bataknese, Protestant, Junior High School, Enterpreuner
Was admitted to Adam Malik General Hospital on November, 12th 2016, at 03:30 am with:

CC : BloodY Show from vagina


This has been experienced by the patient since 6 hours ago , History of uterine
contraction (+), history of watery leakege (-). patient was treatment in VCT Adam Malik
hospital with HIV (+). Micturition and defecation in normal limit.
LMP
: 20-4-2016
EDD : 27-1-2016
ANC
: 4 x Sp.OG
Prev ilness : HIV
Prev medical history : ARV

Obstetric History :
1. , Aterm, 3400gr, SVD, Hospital, healthy, 8 years
2. , Aterm, 2700gr, C Section, Hospital, healthy, 5
years
3. This Pregnancy

Vital Signs
Cons
: Fully Alert
Anemic
: (-)
BP
: 120/80 mmHg
Icteric : (-)
Pulse
: 88 x/i
Cyanosis : (-)
RR
: 20 x/i
Dypsnoe : (-)
Temp : 36,8C
Edema : (-)
Localized Status :
Head : Anemic inferior Palpebra Conj (-)/(-), icteric (-)/(-)
Neck : within normal limits
Thorax : Respiratory sound : vesiculer(+/+)
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)

Obtetric State
-Abdomen
: asymetrically enlarged
-Fundal Height : 3 fingers below xypoid proccess (34 cm)
-Tension part
: Left
-Lower part
: head
-Fetal Movement : (+)
-Uterine contraction : (+) 2x20/10
-Fetal Heart Rate : 148 bpm
-EFW
:3000-3200gr
Ginecology State
VT Cervix : Cx axial, dilated 4 cm, effacement 80%, amniotic
membrane (+), head H I-II, fontanela minor?

TAS

TAS
Singleton, head presentation, live fetus
FM(+), FHR(+)
BPD : 9.19 cm
FL : 7.22 cm
AC : 33.84 cm
Placenta : fundal grade III
AFI : In Normal Limit
EFW : 3200 -3300 gr
Conclusion : IUP(37-38)wga + head presentation + Live
Fetus

LABORATORY FINDINGS on November 12th 2016


at 11.30 am

Hb

: 11.0

N: 12-14 gr/dL

Leukocyte

: 10.610

N: 4000-11000/uL

Hematocrit

: 32

N: 36,0-42,0/%

Platelet

: 241.000 N: 150.000-400.000/uL

Ad Rand Glucose
Ureum
Creatinine

: 89

: 11
: 0.56

N: < 200 mg/dl

N: 15-40 mg/dl
N: 0.6-1.1 mg/dl

Natrium

: 140

N: 135-155mEq/L

Kalium

: 3.7

N: 3.6-5.5mEq/L

Chloride

: 110

N: 96 106mEq/L

HBsAg

: Non-Reactive

Diagnosis: HIV + Previous C Section 1 x + MG + IUP (3738) wga +Head Presentation + Live Fetus + In labor

Planning :
Immediately C Section + Pomeroy Sterilization
Inj. Cefazoline 2 gr skin test
Consult to Anesthesiology
Consult to Perinatology
Informed Consent
Reported to Supv. dr. Khairani Sukatendel, M.Ked(OG),
Sp.OG(K) Approved
On Saturday, Desember 11th 2016, at 03.40 AM, with
cesarean section a male baby was delivered, BW: 3000 gr,
BL: 48cm, A/S: 8/9, Anal (+)

THANK YOU

C-Section report d/t Prev. C Section 1 x + HIV + Post

Sterilization
Delivered female baby was delivered, BW: 3000 gr, BL:
Mother
was
laid on
the Anal
operating
45cm,
A/S:
8/9,
(+)table, with IV line and urine catheter well instilled

Antiseptic and aseptic procedures were performed using povidone iodine and
alcohol solution (70%) on the abdomen, and then draped leaving the surgical field
exposed.

Under spinal anesthesia, a midline incision was made, the subcuticuler layer was
sharply incisied until the fascial layer was exposed. By inserting a surgical pinset
under fascial layer and ensuring no attached muscles underneth, the fascial layer
was sharply dissected to the right and left. The muscular layer was bluntly
separated exposing the peritoneal layer.

The peritoneal layer was was clamped in two places, and after confirming no intra
abdominal organs underneath, was cut in betwen and widened by sharply
dissection downwards and uppwards.

A gravid uterus was seen, the round ligaments were identified, followed by the
lower uterine segment. After separating the vesicouterine fold, a concave incision
was made on the lower uterine segment. The incison was bluntly penetrated and

By luxating the head, a male baby was delivered weighing 3000 gr , BL 48


cm, apgar score was 8/9 , anus (+)
Umbilical cord was clamped in two places and cut in between. The placenta
was delivered my controlled umbilical cord traction.
The uterine cavity was cleaned.
The uterus was sutured by continuous interlocking suture using vicryl no I RB.
On Evaluating the suture no active bleeding was present.
Sterilisation pomeray was applied, evaluating the tuba no active bleeding
Peritoneal, muscular, fascial, subcuticular and cuticular layers were sutured
layer by layer.
Patient operative condition was stable.

PATIENT 2

2. Mrs. R, 31 yo, G2P0A1


Diagnosis : SG + IUP (38-40) wga + HP +
Alive Fetus
Planning :

- Check CBC, HST, Blood Glucose


- Watchful waiting for labor sign

Mrs. R 31 y.o, G2P0A1, Javanese, Moslem, Senior High School, House wife, married
to Mr. S, 36 y.o, Javanese, Moslem, Junior High School, Enterpreneur, was admitted
to Adam Malik General Hospital on December, 10th 2016, at 23.15 with:
Cc : Bloody show from vagina
Explaination: Its experienced by the patient since 9 pm. She felt labor pain too
since 10 pm, history of amniotic fluid discharge (-). History of abdominal trauma (-),
history of abdominal massage (-). Micturition and Defecation within normal limits.
LMP : 3/3/2016
EDD: 10/12/2016
ANC : 5x Midwife
History of Previous illness : History of Medication : History of Surgery
:History of pregnancy :
1.

Miscarriage 2 years ago

2.

This pregnancy

Present Status
Cons

: compos mentis (GCS 15)

BP

: 110/80 mmHg

Pulse

: 84 x/min

RR
Temp

: 20 x/min
: 36,7OC

Anemic

Icteric

: (-)

: (-)

Cyanosis : (-)
Dyspnoe

: (-)

Edema

: (-)

Obstetric Examination
Abdomen
: asymetrically enlarged
Fundal height : 2 fingers below Xyphoid Proccess
Tension

: Left

Lowest part

: Head

Fetal Movement : (+)


Uterine Contraction: (+) 1x10/10
Vaginal Examination :
Cervix sacral, 1 cm dilated, effacement 100%, H I, small

USG TAS

USG (Transabdominal)
- Singleton fetus, Head Presentation, Alive
- FM (+), FHR (+)
- BPD 94 cm
- AC 33,4 cm
- FL 7,8 cm
- Amniotic Fluid adequate
- Placental Fundal gr. III
- EBW : 3813 g
Conclusion : IUP (38-40) wga + Head Presentation + Live
Fetus

LABORATORY FINDINGS on December 11th 2016 at


12.14 AM

Hb

: 10.6

N: 12-14 gr/dL

Leukocyte

: 18.150

N: 4000-11000/uL

Hematocrit

: 32

N: 36,0-42,0/%

Platelet

: 274.000 N: 150.000-400.000/uL

Ad Rand Glucose

: 109

N: < 200 mg/dl

Natrium

: 141

N: 135-155mEq/L

Kalium

: 4.3

N: 3.6-5.5mEq/L

Chloride

: 112

N: 96 106mEq/L

PT
aPTT

: 15.5
: 28.9

Mrs. R, 31 yo, G2P0A1


Diagnosis : SG + IUP (38-40) wga + HP + Alive Fetus
Planning

- Check CBC, HST, Blood Glucose

- Watchful waiting for labor sign


Reported to Supv. dr. Khairani Sukatendel, M.Ked(OG),
Sp.OG(K) Approved

THANK YOU