DELIVERY ROOM REPORT

Tuesday, December 5th 2017

Residents on duty :
Dr. Achmadi Sulistyo
Dr. Achmad Taufan
Dr. Eliza Swasti
Dr. Cordova Arridho
Dr. Iman Ruansa
Dr. Raissa Nurwany
Dr. Tian Kaprianti
Dr. Riyan Wira Pratama
Dr. Dian Aviani
Dr. Asep Nurul Huda

Supervisor :
Dr. H. Nuswil Bernolian, SpOG(K), MARS
 Pathologic Obstetric Patients
NO Identity Diagnosis ICD 10 Procedure ICD 9
1. Mrs. NUR/20/RA G1P0A0 38 weeks gestational age in labor with O60 LSCS 669.7
prolonged latent phase with PROM 23 hours SLF O32.1
cephalic presentation + oligohydramnios

2
Identity 1. Mrs. NUR/20/RA
Hospitalized : 05-12-2017 10.00 AM
Chief complaint At term pregnancy with amniotic fluid leakage
History + 9 hours before admission patient complained of amniotic fluid leakage, + 1 change of pads, clear, odor
(-) H/ of bloody show (-). H/ of uterine contraction (-).
H/ abdominal trauma (-). H/ masage (-). H/ leukorrhea (+). H/ fever (-). H/ post coital (-).
She admitted her pregnancy was full term and fetal movement (+)
Marital status 1x, 1 years
Reproduction status Menarche since 13 yo, regular 28-day cycle, lasts 7 days, LMP: 05/2/2017
Obstetric history 1. This pregnancy

Vital Signs BP: 120/80 Pulse : 80x/m T: 36.7oC RR: 18 x/m

BL: 161 cm BW : 69 kg
Obstetrical examination Palpation: Uterine fundal 3 fingers bellow xyphoid process (36 cm), left longitudinal lie, cephalic, U 5/5,
uterine contraction (-), FHR: 135 x/minute, EFW: 3565 g
Insp : portio livide, external uterine ostium closed, flour (-), fluxus (+) amnion not active, nitrazine test
(+), erosion (-), laceration (-), polyp (-)
VT : portio soft, medial, eff 0%, dilatation -, head, amnion and denominator cant be assessed

ER US - SLF cephalic presentation

- Fetal biometri: BPD : 9.34 cm AC: 31.05 cm HC: 35,04 cm FL: 7,01 cm EFW : 3454 g
- Amniotic fluid decrease AFI 1.1 / 0,9 = 4,4 cm
- 1,4 / 1,1
- Placenta on uterine fundus
C/: 38 weeks gestational age SLF cephalic presentation + oligohydramnios
Identity 1. Mrs. NUR/20/RA
Diagnosis G1P0A0 38 weeks gestational age not in labor with PROM 7 hours SLF cephalic presentation +
oligohydramnios
Therapy Observation of vital signs, FHR, contraction
IVFD RL xx drops/minute
Ampicillin 1 g/6 hours IV
Planned for vaginal delivery
Induction of labor with oxytocin drip
Lab examination Hb 9,4 WBC 11,9 Ht 31 PLT 334.000
CRP - , LEA (-)

15.30 WIB G1P0A0 38 weeks gestational age in labor 1st stage latent phase with PROM 15 hours SLF cephalic
Ø 3 cm presentation + oligohydramnios
P/ Accelerate with oxcytocin drip
19.30 WIB G1P0A0 38 weeks gestational age in labor 1st stage latent phase with PROM 19 hours SLF cephalic
Ø 3 cm presentation + oligohydramnios

23.30 WIB G1P0A0 38 weeks gestational age in labor with prolonged latent phase with PROM 23 hours SLF cephalic
Ø 3 cm presentation + oligohydramnios
P/ Abdominal delivery
06-12-2017 Male life neonate was born, BW 4000 g, BL 52 cm, AS 6/8 FTAGA nuchal chord 2x
04.40 WIB Placenta was delivered completely, PW 650 g, UCL 53 cm, diameter 23x24 cm