Reported:

Previous SC 3x+ multipara + Intrauterine Pregnancy (3738) wga + Head Presentation+ Alive Fetus + in Labor
observation

No
1

Income
Mrs. D, 33 yo, G4P3A0
Diagnosis:
Previous SC 3x+
multipara + Intrauterine
Pregnancy (37-38) wga +
Head Presentation+ Alive
Fetus + in Labor
observation

Outcome
Therapy :
- IVFD RL 20 gtt/i
- Inj. Ceftriaxone 2 gr IV bolus

Planning
-Blood work up :
routine blood test
hemorrhagic screening test
blood sugar
HIV test
Hepatitis B test
Recent condition:
- Dower catheter inserted
Fully alert, BP: 120/90
- Monitor vital signs, uterine
mmHg, HR: 84 x/I, RR: 22 x/I,
contractions and FHR
T: 36,5 oC
- Observe progress of labor
- Consult to perinatology

Reported:
In Labor

No
1

Income
Mrs. D, 33yo, G4P3A0
Diagnosis:
In Labor
Recent condition:
Fully alert, BP: 120/80
mmHg, HR: 90 x/I, RR: 20 x/I,
T: 36,5 oC

Outcome
Therapy:
- IVFD RL 20 gtt/i
- Inj. Ceftriaxone 2 gr IV bolus
Planning :
-Observation Labor Progress

PATIENT 1

Mrs D, 33yo, G4P3A0, Minangnese, Moslem,

Housewife, w/o Mr. S, 45 yo, Minangnese,
Moslem, enterpreneur, admitted to Dr. Pirngadi
General Hospital on May 29th 2016 at
CC : Pervaginam water leakage
This was experienced since 29/05/2016 at 04.00 .
Pervaginam bloody show (+) , Abdominal Cramp
(+) was experienced since 28/05/2016 at 20.00 .
Previous history of myoma extirpation (+) 2 years
ago.

Previous illness: myoma uteri

Previous medication : uncleared
Last menstrual period : ?/8/2015
Estimated due date
: ?/5/2016
ANC
: Midwife twice, obstetrician 3 times
History of labor:
1. Exit
2. Female / C-section / obstetrician/ hospital/ 8 yo/ 1900 g/ healthy
3. Female / C-section / obstetrician/ hospital/ 5 yo/ 3400 g/ healthy
4. This pregnancy

Present State
Sens : Alert
Anemia :
(-/-)
BP
: 120/90 mmHg
Icteric
:
(-/-)
HR
: 84 times/min
Cyanosis :
(-)
RR
: 22 times/min
Dypsnea :
(-)
Temp : 36,5C
Edema
: (-/-)
Generalized state
Head :
Eye : Concunctiva inferior anemia
(-), Icteric (-)
Thorax
Vesiculair respiratory
Rhales (-)
Wheezing (-)
Obstetrical state
Abd : enlarged asymetrically
TFU : 3 fingers under
Xyphoideus
Tension part : Left
Lowest part : Head
Movement : (+)
Uterine contraction
: (+)
2x10/10
Fetal Heart rate
: 148x/I

Previous SC 3x+
multipara +
Intrauterine
Pregnancy (37-38)
wga + Head
Presentation+ Alive
Fetus + emergency
C section

Planning :
- Observation progress of
labor
- Monitor vital signs,
uterine
contractions and FHR
Report to supervisor dr.
Indra Hasibuan
SpOG.
-Perform C-section
-Blood transfusion
-Consullt to
anesthetist
-Consult to
pediatrician

Supportive examination
USG TAS :
- Singleton fetus, head presentation,
alive fetus
- FM (+), FHR (+) 148x/I
- Placenta anterior
- BPD : 93,5 mm
- AC : 285 mm
- FL
: 73,5 mm
- EFW : 2537 gr
- Amniotic Fluid : enough
- Conclusion
: IUP (37-38) wga +
head presentation + alive Fetus

Diagnosis
Previous SC
3x+ multipara +
Intrauterine
Pregnancy (3738) wga + Head
Presentation+
Alive Fetus +
emergency C
section

Management
Planning :
- Monitor vital signs, uterine
contractions and FHR
Report to supervisor dr.
Indra Hasibuan, Sp.OG
-Perform C-section
-Blood transfusion
-Consullt to anesthetist
-Consult to pediatrician

Laboratorium report May 29th 2016

Hb
: 6.5 gr/dl
N: 12-14 g/dl
Leukocyte : 7.230/mm3

N: 4000-10000/uL

Hematocrit : 23.6 %
N: 36.0-42.0 %
Thrombocyte
:
269.000/mm3 N:
150.000400.000/uL
Blood Sugar
: mg/dl
HIV test
: (-)
HbsAg
: (-)

Diagnosis:
Previous SC 3x+ multipara + Intrauterine Pregnancy (37-38)
wga + Head Presentation+ Alive Fetus + emergency C section

Planning :

- Observation progress of labor

- Monitor vital signs, uterine
contractions and FHR

Report to supervisor dr. Indra Hasibuan SpOG.

-Perform C-section
-Blood transfusion
-Consullt to anesthetist
-Consult to pediatrician

C-Section Report
The patient was brought to the operating room after her epidural,
preparation, and Foley had been performed. The abdomen was prepped
and draped in a sterile fashion. A repeated Pfannenstiel incision was made
with the first knife and carried down to the fascia with a second knife. The
fascia was cleared of subcutaneous tissue.
The rectus muscles were separated by sharp dissection. The rectus
muscles were divided in the midline by sharp dissection. The
parietoperitoneum was grasped with hemostats and carefully entered with
a scalpel, and the incision extended with Metzenbaum scissors. The
bladder blade was inserted. The visceroperitoneum was grasped with
smooth pickups, entered with Metzenbaum scissors, and extended laterally.
A living female infant weighed gr, cm in length, A/S /, and anus (+) was
delivered. The baby was suctioned and cried immediately, and was handed
to the pediatric team in attendance. The placenta was delivered manually.
The abdominal cavity was cleansed and sutured by layers. Urinary output
was adequate. The patient left to the recovery room in good condition.

THANK YOU