Duty Report

Monday, August 19th 2013

Consultant:
dr. Indra Z Hasibuan, SpOG.

Residents:
Edward Manurung/Nureliani Amni/Robby Pakpahan
/Hendrik Tarigan/Citra Lestari/Devi Syam

Reporting

1
1
1
1

Vaginal delivery
Cesarian Section
Abortus incomplete
Retention Placentae

Procedure
s

N
o

Description

Plan & Outcome

Vaginal
Labor

Due to aterm pregnancy in labor

Plan:
Spontaneous
vaginal delivery

Mrs. E, 37 yo
G1P0000, IUP (38 40)wga,
singleton, live, head
presentation, in labor

1
C section

Due to absolut narrow pelvis,

reffered by SpOG,
Mrs, E, 26 yo
G1P0000, IUFD ( 38-40 ) wga,
singleton, live, head
persentation, in labour

at 18.30 wib
With Spontan
delivery, baby boy
was born BW
2600 gr , BL 46
cm, A/s 8/9, Anal
(+)
Now mother and
baby in good
condition
Plan : C Section
Baby boy was
born, 3300 gram,
50 cm , AS 7/9,
anus (+)

Procedure
s

N
o

Description

D and C

Due to history of vaginal

bleeding
Mrs. a, 28 yo

Plan & Outcome

Plan: D & C

G4P2012 , on G 4 wga, incomplete

abortion
Manual
Plasenta

Manual Plasenta
Due to placentae not deliver after
A complete
baby born
outcome of
plasenta
Mrs. S, 43 yo
G6P5005, retentio placentae

Mother in good
condition

PATIENT #1

1. Mrs. E, 37yo, G1P000,Bataknese, Christian, primary

school, enterprenur, i/d. Mr. E, 38 thn, bataknese,
Christian, entrepreneur. admitted to ER at 19 August
2013, 15.00 am
CC: Labor contraction
T : since 19 August 2013, 03.00 pm, history blood
slime (+), history of water broke (+) since 19
August 2013, 14 pm.
RPT/RPO : - / obstetrical history:
LMP
: 21-11-2012
1. This pregnancy
EDD
: 28-08-2013
ANC
: midwife >2 x
SpOG 1 x

Status Presens
Sens
: CM
Anemic
BP
: 110/70 mmHg Icteric
HR
: 96 x/I
Cyanotic
RR
: 20 x/i
Dispnoe
Temp
: 36,10C
Oedem

: (-)
: (-)
: (-)
: (-)
: (-)

Obstetrical state :
Abdomen
: asymmetrical enlarge
FH
: 4 fingers below xiphoidy proc, 28 cm
Tension part : Left side
Lowest part : head
movement : (+)
Uterine cont. : 3x 40/10menit
FHR
: 148 x/I, reguler
EBW
: 2635 gr

 VT : cx anterior, 8 cm in diameter, eff

100%, amniotic membran (-), SRM
1jam, clear liquid, head on H II-III, 2
oclock minor fontanella

USG TAH

USG TAS
singleton, head presentation , live baby
FM (+), FHR (+)
BPD : 92,6 mm
FL : 71,9 mm
AC
: 337 mm
Plasenta antarior corpus grade III
AFI : 6,2 cm
EFW : 2896 gr
Concl : IUP (37-38 week) + head presentation +
alive

 Diagnosis : PG + IUP (38- 5/7 week)

+ Head Presentation + singelton +
Alive baby+ inpartu

LAB
19/8/2013
Hb/Ht/Leu/PLT : 12,2/36,2/13800/200000
APT : 28,5
at 18.30 wib
With Spontan delivery, baby boy was
born BW 2600 gr , BL 46 cm, A/s 8/9,
Anal (+)
Now mother and baby in good condition

PATIENT #2

2. Mrs. E, 26yo, G1P0A0, Mandailing, moslem, High

school, housewife w/o. Mr. D, 29 thn, moslem,
entrepreneur, was reffered by SpOG with pelvic
narrow + gravida+ in labour, was plan for cesarean
section, admitted to ER at 19 August 2013
CC: Labor contraction
T : since 19 August 2013, 7 pm, history blood
slime (+) 19 August 2013, 7 pm, history of water
broke (-).
RPT/RPO : - / Obstetrical history:
LMP
: 20-11-2012
1. This pregnancy
EDD
: 17-08-2013
ANC
: midwife >3 x

Status Presens
Sens
: CM
Anemic
BP
: 110/70 mmHg Icteric
HR
: 90 x/I
Cyanotic
RR
: 22 x/i
Dispnoe
Temp
: 36,80C
Oedem

: (-)
: (-)
: (-)
: (-)
: (-)

Body Height : 140 cm

Obstetrical state :
Abdomen
: asymmetrical enlarge
FH
: 2 fingers below xiphoidy proc, 40 cm
Tension part : Left side
Lowest part : head (floating 5/5)
movement : (+)
Uterine cont. : 2x 20/10menit
FHR
: 148 x/I, reguler
EBW
: 3800-4000 gr

 VT : sacral servics, 1 cm, eff 100

%, amniotic membran (+), floating
head, minor fontanella can not be
predict.
Hand scoen : blood slime (+)

USG

USG TAS

singleton, head presentation, live baby

FM (+), FHR (+)
BPD : 95,8 mm
FL : 74,3 mm
AC
: 330 mm
Plasenta anterior corpus
Amnion fluid : enough

Concl : IUP (39-40) week+ Head Presentation +

alive

Pelvic Adequation
Palpable Promotorium
Palpable linea terminalis
CD:9,0 cm
CV: 7,5 cm
Os Spina ischiadica : not prominent
Os sacrum : concave
Os coccygeus : Mobile
Conclusion : pelvic narrow

Diagnose: Pelvic Narrow + PG + GA (38

40 wk) + Head Presentation + Baby
alive + Inpartu
P: C Section
With C Section Baby boy was born,
3300 gram, 50 cm , AS 7/9, anus (+)

PATIENT #3

3. Mrs. A, 28yo, G4P2A1, jawa, moslem, entrepreneur

i/d. Mr. D, 29 thn, moslem, jawa, entrepreneur.
admitted to ER at 19 August 2013, 19.00 pm
CC: vaginal bleeding
T : Since 4 days ago, 7 pm, volume aqua cup
black clotted, tissue like bubble (-), history of
tissue delivery (+), history of trauma (-), history of
abdomen massage (+) on 8 August 2013,
abdominal pain (-).
RPT/RPO : - / LMP
: 20-7-2012
EDD
: 27-04-2013
ANC
:-

Obstetrical history:
1. boy, aterm, PSP, Midwife, 3300gr,
healthy, 6 yo
2. boy, aterm, PSP, Midwife, 4500gr,
healthy, 3 yo
3. abortus at 16 weeks intrauterine
4. This pregnancy

Status Presens
Sens
: CM
Anemic
: (-)
BP
: 120/80 mmHg Icteric
: (-)
HR
: 96x/I
Cyanotic
: (-)
RR
: 20 x/i
Dispnoe
: (-)
Temp
: 36,80C
Oedem
: (-)
Obstetrical state :
Abdomen
: soepel, peristaltik (+)Normal
TFU: ttb
P/v : (+)
VT : Cervix close,

Inspekulo: blood was (+) in vaginal canal , cleaned,

impression : no blood flowing from OUE, erosio (-)
smooth portio , lividae (+) , F/A : (-)

USG TAS
USG : full blast
UT : AF BB size 9,6 x 4 cm
there s hyper echoic in the uterine
cavity, impression: rest tissue
adnexa in normal limit
free fluid ( - )

Resume: rest abortion

Hb/Ht/L/Tr: 11,6/34,60/13700/275000
PT: 12,7 (13,4) INR: 0,94 (30,4)APT
45,3
D dimer 980
A: Incomplete abortion
P: Dilatatation & Curretage in delivery

PATIENT #4

4. Mrs. s, 43yo, G6P2, batak, Christian, housewife i/d.

Mr. H, 46 thn, Christian, entrepreneur. admitted to ER
at 19 August 2013, 02.00 oclock with
CC: Plasenta didnt come out
T : since 1 hour ago, after vaginal birth in midwife
clinic. Baby boy was bornwith BW 3000gr.
RPT/RPO : - / LMP
: 2011-2012
EDD
: ?-08-2013
ANC
: 3x midwife
History of contraseption : injeksi contraseption 3 month
+

Obstetrical history:
1. boy, aterm, PSP, clinic, 3000gr, healthy, 17 yo
2. Girl, aterm, PSP, Midwife, 3000gr, healthy, 11 yo
3. Boy, aterm, PSP, clinic, 2900gr, healthy, 10 yo
4. Boy, aterm, PSP, midwife, clinic, 2900gr, healthy,
9 yo
5. Boy, aterm, PSP, midwife, clinic, 2800 gr, healthy,
8 yo
6. Girl, aterm, PSP, midwife, clinic, 3000 gr, 1 hour

Status Presens
Sens
: CM
Anemic
: (-)
BP
: 110/70 mmHg Icteric
: (-)
HR
: 88x/I
Cyanotic
: (-)
RR
: 20 x/i
Dispnoe
: (-)
Temp
: 36,80C
Oedem
: (-)
Obstetrical state :
Abdomen
: lax, peristaltik (+)Normal
FU
: 1 finger above umbilicus
Vaginal bleeding: (+)
Inspection : umbilical cord was clamped
Dx :Retensio Plasenta
P/ : Manual Plasenta

At 02.15 oclock
Manual placentae was performed succesfully, impression
placentae complete, no vaginal lacerations.
Mother in good condition.

Manual Plasenta Report

Mother was laid in ginecology table with iv
line. Bladder was emptied, with obstetric
hand down the umbilical cord, and then
plasenta released slowly with palmar part
hand, after the plasenta released, then
fulled out slowly. Evaluation of plasenta,
we can find that the plasenta was
complete. Evaluation of birth canal,
novaginal
laseration. Mother condition
ofter manual plasenta stabil.

C-Section report d/t absolut narrow pelvis

Born baby boy , BW 3300 gram, BH 50 cm, AS: 7/9,
Ani (+)
Mother was laid in operation table, with iv line and urine
catheter installed well
Antiseptic and aseptic procedure was performed, with betadine
and alcohol solution (70%), and covered by sterile fabric
except operation field
Under spinal anesthetic, pfannenstiel incision was made until
fascia revealed
Fascia was cut from middle to left and right
Muscle was opened bluntly
Peritoneum was cut from middle upward and downward

 Gravida uterine was seen, locating the low servical region

Vesicouterine plica cut concavely to the left and right side,set
aside to the vesica urinary site.
Uterine was cut concavely and widen bluntly
With grabbing the head, the baby boy was born with 3300gr of
weight and 50 cm of height, apgar score was 7/9, anus (+)
Umbilical cord was withered cut and placenta was taken out
completely
Uterine cavity was cleaned
Uterine was sewed ,hemostatic suture figure of eight
continuously interlocking

 Peritoneum, muscle, fascia, subcutis and cutis was

sewed consecutively
The mother condition after c-section : stable

Spontaneous Vaginal Delivery report

Mother laid in ginecology table with i.v. line
installed properly, in an adequate contraction the
head was forward and backward in vaginal inlet.
And then persist. In the next adequate contraction
mother was leading to push, and then born baby
head and all the body. And then born baby boy,
BW : 2600 gr, BL :46 cm, AS 8/9, anal (+).
With PTT, plasenta was born, impression complete.
Explore vaginal canal found first grade laceration
and repaired.
Mother condition after vaginal delivery is stabil.