Mrs.

W, 35 yo, G3P2A0, Javanesse, Moslem, Junior High School,

Housewife, married to Mr. T, 35 y.o, Javanesse, Moslem,
Enterpreneur.
Cc : Labor Contraction
E : This was experienced by the patient since 5 last hour. This
patien has already led to push for 3 hours and the baby was not
born. History of blood slime (+). History of amniotic fluid leakage
(+). History of micturition and defecation within no abnormalities.
 History of Previous illness: -
History of Medication :-
History of Surgery :-
LMP : /02/ 2019
EDD : /11/ 2019
ANC : Midwife 3x

History of Pregnancy:
1. Male, aterm, 3300 gr, svd, Midwife, 9 y.o, Healthy
2. Male, aterm, 3400 gr, svd, midwife, 4 y.o, Healthy
3. This pregnancy
Vital Signs

Cons : Fully Alert Anemia : (-)

BP : 120/80 mmHg Icteric : (-)
Pulse : 80 x/i Cyanosis : (-)
RR : 18 x/i Dyspnoe : (-)
Temp : 36.5ºC Edema : (-)

General State : Moderate BW : kg

Nutritional State : moderate BL : cm
Illness State : Moderate Upper Arm Circumference
Localized Status :
Head : Inferior Palpebra Conj Anemic (-), Icteric (-)
Neck : Within no abnormality
Thorax : Respiratory sound : Vesiculer
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Abdomen : Asymetrical Enlagement
Exremities Sup/Inf : Edema (-)/(-)
Obstetric State
• Abdomen : Asymmetrically enlarged
• Fundal Height : 35 cm
• Tension part : left
• Lowest part : head
• Fetal Movement : (+)
• Uterine contraction : 4x30”/10’
• Fetal Heart Rate : 170 bpm, regular
• EFW :

Gynecology state:
VT :
Gloves :
Inspeculo :
Transabdominal sonography
Transabdominal sonography report :
 Laboratory Findings
November, 9 th 2019
• Hb : 10.8 N: 12-14 gr/dL
• Leukosit : 17.400 N: 4.000-11.000/u
• Hematokrit : 34,1 N: 36,0-42,0/%
• MCV : 83,0 N: 81-99 fL
• MCH : 26,3 N : 27 – 31 pg
• MCHC : 31.7 N: 31 – 37 g/dl
• Platelet : 317.000 N:150.000400.000/uL
• KGDs : N: <200mg/dl
• Ureum : N: 15 - 40 mg/dl
• Creatinine : N: 0.6 – 1.2 mg/dl
• PT : C: 14.0 s
• APTT : C: 33.0 s
• INR : N: 0.8 – 1.3
• Anti HIV : Non reactive N: Non reactive
• HbsAg : Non reactive N: Non reactive
Diagnosis :

• Post SC d/t PTM + MG + KDR (38-39) + Head presentation + live fetus + Inpartu
active phase

Therapy :
– IVFD RL 20 dpm

Report to supervisor on duty dr. Elida R. Sidabutar, Sp.OG(K)  Approved

Plan : - Check Blood count, HST, RFT, Electrolite, inspekulo, USG

- S-Cection CITO
 C-Section d/t PTM + MG + KDR (38-39) + Head
presentation + live fetus + Inpartu active phase
On November 9th 2019, Born baby girl, with BW 3470 gr, BL
48 cm, AS 6/8, Anal (+)

• The patient was laid on the operating table, with IV line and urinary
catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine
on the abdomen, and then draped leaving the surgical field exposed.
• Under spinal anesthesia, a pfanensteil incision was performed, cutis and
subcutis was dissectes to the underlying layer of fascia. The fascia was
incised in the midline and extended laterally using scissor. Superior aspect
of the fascia was elevated using Kocher, and the underlying rectus muscles
were separated.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the bladder.
Seen uterus appropriate to gestational age. The lower uterine segment was
identified. A transversal incision in the uterus performed until
subendometrium layer. Endometrium penetrated and widened bluntly.
Amniotic fluid color clear.
• By luxating the head, Born baby girl with BW 3470 gr, BL 48 cm, AS 6/8, Anal
(+)
• The placenta was born with fundal pressure and traction on the umbilical
cord. Uterine cavity was cleaned with gauze.
• Uterus was sutured continuously, evaluate  Bleeding was controlled.
• Evaluating both adnexae  No abnormalities
• Pomeroy Sterilization performed
• Abdominal wall closed layer by layer
• Peritoneum sutured continuously, muscle approximation using simple suture
and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was sutured
with subcuticuler suture
• Surgical wound was closed with sofratulle, sterile gauze and hypafix
• Mother was stable the after the operation
THANK
YOU