C-section

Indication of pregnancy failure to progress, history of C-Section

Muhammad Fahmi B Mohd Zuber
Consultant:

Dr. H. Achmad Djaenudin

Patient s Identity
Patient Name Age Sex Education Religion Ethnic Group Occupation Date of admittance Status Spouse Name Age Religion Education Occupation Address : Mrs. M P : 31 yrs old : Female : High School : Moslem : Javanese : Housewife : 26th June 2011 : Married

: Mr. G A : 31 yrs old : Moslem : High School : Private Sector Employee : Jl. Stasiun Depok Lama RT. 5/3-46

II. History taking

Taken on 27th June 2011 at 9.00 pm
Chief complaint: Admitted by Dr . Ari Kusuma J SpOG after doing regular ANC check-up. Other complaint: Abdominal tightness Present history illness: Patient claimed that she was doing regular ANC check-up at Bahkti Yudha Hospital O&G s clinic. An USG done by the doctor indicating the lowest part of the baby hasn t enter pelvic cavity. After all, patient had a history of C-section during her first pregnancy. Patient also experienced some abdominal tightness but denied any sensation of contraction. Patient occasionally had an episode of asthma.

Past Pregnancies History

Obstetric History: 1) A boy, IUFD, weight : 3200gr, body length: 47cm, spontaneous labor. 2) A boy, 3 years old, weight : 3200gr, body length : 49cm, C-section Menstrual History Menarche : 12 yrs old Menstrual Duration : 7 days Menstrual Cycle : 28-30 days Last Menstrual Periode (LMP): 8th October 2010 Expected due date : 15th of July 2011 Past History Illnesses There is no history of hypertension, diabetes mellitus, tuberculosis and allergies.

III. PHYSICAL EXAMINATION

27th June 2011 at 9.00 pm
GENERAL STATUS

General Appearance Consciousness Height Weight Vital Signs

Nutrition Status Eyes Heart M (-), G (-). Chest Abdomen present, Extremities

: Relatively healthy : Compos mentis : 162cm : 76,5 kg : Blood Pressure : 120/80 mmHg Pulse Rate : 80 beats/minute Respiration Rate : 20 breaths/minute Temperature : 36, 8C : Average : CA -/-, SI -/: Heart sound 1 and Heart sound 2 present and normal, : Bilateral vesicular breath sound, Rh -/-, Wh -/: Abdominal enlargement present, prominent gravid line stretch marks present, bowel sounds (+) : Edema (-)

OBSTETRIC STATUS Inspection : Abdominal enlargement present, prominent gravid line present, stretch marks present. Palpation : Leopold 1 : Fundal height 36 cm. Tender palpation is present at uterine fundus. Leopold 2 : Fetal back is palpable on maternal the left. Leopold 3 : Fetal head is palpable. Leopold 4 : Lowest part did not descend to pelvic cavity. Contractions : (+) Fetal heart rate: 148 beats/minute. Specific Examination: Vaginal Examination: Not done

IV. LABORATORY FINDINGS

Taken on 26th July 2011 Hemoglobin : 12, 5 g/dL Leucocytes : 9,100/mm3 Hematocrytes : 34% Thrombocytes : 296,000/ mm3 Clotting time: 9,3 seconds Bleeding time: 3,3 seconds

VI. Resume A 30 years old G3 P2 woman is delivering at 39 weeks of gestation admitted to Bhakti Yudha Hospital after doing a regular ANC check-ups. After doing an USG examination patient presented with problem lowest part of the baby hasn t enter pelvic cavity and a history of C-section in earlier pregnancy. Patient have several episode of asthma. Patient experiencing abdominal tightness. On physical examination, the baby s lowest part did not descend pelvic cavity. There are no odd s found in laboratory result. V. DIAGNOSIS Mother: G3 P2 A0, 39 weeks of pregnancy with failure to progress, post C-section. Neonate: Single neonate, alive

VI. MANAGEMENT
Diagnostic Planning
Observation: vital signs, uterus contractions (his), fetal heart rate.

Therapy Planning
8 hours fasting before operation. Caesarian section operation is carried out.

Educational Planning Explaining to the patient and patient s family about the action that would be taken immediately and the risks that will happen after the action taken

VII. PROGNOSIS
Mother : Ad Vitam Ad Sanationam Ad Functionam Neonate: Ad Vitam Ad Functionam Ad Sanationam : Dubia ad Bonam : Dubia ad Bonam : Dubia ad Bonam : Dubia ad Bonam : Dubia ad Bonam : Dubia ad Bonam

 PRE-OPERATION DIAGNOSIS G3 P2 A0, 39 weeks of pregnancy, failure to progress, post C-section. POST-OPERATION DIAGNOSIS Post C-section G3 P2 A0, 39 weeks of pregnancy, failure to progress, post C-section.

CAESARIAN SECTION REPORT

Patient in spinal anesthesia is put into supine position. Aseptic and antiseptic measures taken out at abdomen and surroundings with 10 % Betadine. Fahnen-Stihl incision. Lower uterine segment is insicised in semilunar outline. Post matured neonate. Neonate s sex: Male, Weight: 3400 g, Length: 48 cm, AS: 8/9. Amniotic fluid is clear and sufficient. Encircle umbilical cord (-). Placenta at uterine fundal is delivered complete. Lower uterine segment is stitched layer by layer with black thread. Bleeding is treated, abdomen cavity is rinse with NaCl solution. Bleeding during operation is 300 cc, urine output 200 cc.

POST CAESARIAN SECTION OPERATION INSTRUCTION 24 hours immobilization. Consume nutritious food. Breasts care and breast feeding. THERAPY Amoxan inj 3x1 Tramal sup 3x1 Prolic 3x1

FOLLOW UP
27th June 2011, 06.00 a.m

S O

: Post operation incision s pain : Consciousness : Compos mentis General Appearance : Patient is well General Status : BP : 120/80 mmHg PR : 62 beats/minute RR : 20 breaths/minute Temp: 37,2C Eyes: CA -/Pulmo: Bilateral vesicular breath sound, Rh -/-, Wh -/Cor: Heart sound 1 and Heart sound 2 present and normal, M (-), G (-). Abdomen: Post operation wound is sealed with sterile gauze. Obstetrical Status : Breasts milk -/: Fundal height 2 fingers below umbilical : Contractions (+) : Lochia rubra (+)

 A : P3 puerpeurium day 1, post C-section delivery with failure to progress and history of C-section. P : 24 hours immobilization : Consume nutritional foods : Breasts care and breastfeeding : Vulva and vagina hygiene : Therapy: Amoxan inj 3x1 Tramal sup 3x1 Prolic 3x1