Delivery Room Report

Thursday-Friday July 17th 18th

2014
Consultant:
Dr. Munawar, Obgyn

Resident :
Yudi / Fitri

Reporting
1 C - section

Procedure

1. C-Section

Case

Due to fetal distress

Result

Born male baby , BW 3600 gram, 47

cm, AS 8/9, BS~38-40 wga

Mrs. Rita, 25 yo
clear amniotic fluid

NBC

G1 38-39 wga, singleton live head

presentation, PROM 6 hours, fetal
distress, unrippen cervix

FP: IUD PP

CM 1011096

Now mother and baby in good

condition, already discharged

Mrs. Rita
G1 38-39 wga, singleton live head presentation, PROM 6 hours, fetal distress, unrippen cervix

17/07/2014 06.00
Chief complain : water broke since 6 hours before admission
RPS : Patient admitted 9 month pregnancy, LMP 20/10/2013 ~ 38-39 wga. ANC regularly to
midwife and obgyn, ultrasound (+) said within normal limit. contraction since 7 hours before
admission, water broke (+) since 6 hours before admission, bloody discharge (+), fetal
movement (+). Fluor albus (-), caries dentist (+).
Family & previous illnes : Asthma (-), Hipertension (-), heart disease (-), DM (-), Alergy (-)
Menstruasi diary: menarche 12 yo, regularly, 5-7 day, dismenorrhea (-)

Married history: 1 x
FP history: Obstetric history:
1. This pregnancy

Physichal examination
KU: Good, CM W: 64 kg H : 160 cm
BP 110/70 mmHg, HR 90 x/menit. RR 20 x/menit, T 36,4 C
Generalis Status :
Eye
: No anemis , no ikterik
Cor
: BJ I-II regular, no murmur, no gallop
Pulmo
: Vesikuler right=left, no wheezing, no rales
Abdomen
: Enlargment equal with pregnancy
Extremity
: warm acral, no oedema
Obstetric state:
Fundal height 35 cm, right back, head presentation, EFW: 3565 gr, contraction (+)
FHR 153 bpm,
I
: V/U wnl
Io
: portio was smooth, fluor (-), fluxus (-), opened ostium, valsava (+),
Lakmus (+), LEA (-)
VT
: portio soft, axial, eff 30%, 2cm, amnion membraine (-), hodge I - II

CTG :
Baseline
Variability
Acceleration
Deselerasi
His
Fetal movement
CTG reassuring

: 153 bpm
: 5 - 15bpm
: (-)
: (-)
: (-)
: (+)

USG :
BPD
: 95,7
TBJ
: 3500 gram
AC
: 338
FL
: 73,6
Placenta on fundal
DJJ
: (+)
AFI
: 5,3
Assesment : aterm pregnancy,
oligohidramnion

Laboratory:
Hb
: 10,9 gram/dl ( 12-14 gram/dl )
Leucocyte
:10.900/ul ( 4100-10500 /ul )
Trombocyte
: 287.000 /ul (150000-400000 /ul )
Ht
: 33,2% ( 40-55 % )
Random blood glucose : 98 mg/dl
BT
: 3 ( 1-7 )
CT
: 7 ( 5-15 )

A : G1 38-39 wga, singleton live head presentation, PROM 6 hours,

unrippen cervix
R. Dx/

Observation of vital sign, contraction, FHR

Observation of uterine infection
Observation of umbilical cord compresion

R. Th/

Vaginal delivery
IV ceftriaxone 2 gr/24 hours

R. Ed/

Explaining about patient condition and plan of diagnosis

and plan of therapy for patients and family
Breast milk and contraception motivation

06.00
S/
contraction (+), fetal movement (+),
O/
GC : good, CM, BP : 110/70 mmHg, PR :
90x/mnt, RR : 20x/mnt, Temp : 36.4C,
General status : wnl
Obstetric status :
FHR 153 bpm, contraction 2x/10/30
I: normal V/U
VT: portio soft, axial, eff 30%, 2cm,
hodge I - II
A/
G1 38-39 wga, singleton live head
presentation, PROM 6 hours, unrippen
cervix
P/
- Vaginal delivery
- Induction with oxitosin 5iu 8dpm
increase 4dpn/30 until achieved
adequate contraction
- CTG monitoring
- Reevaluate 3 hours later

07. 00
S/
contraction (+), fetal movement (+),
O/
GC : good, CM, BP : 120/70 mmHg, PR :
86x/mnt, RR : 20x/mnt, Temp : 36.4C,
General status : wnl
Obstetric status :
FHR 152 bpm, contraction 3x/10/40
I: normal V/U
VT: portio soft, axial, eff 30%, 2cm,
hodge I - II
CTG : variabel deceleration
A/
G1 38-39 wga, singleton live head
presentation, PROM 7 hours, unrippen
cervix
P/
- Stop oxitosin resuscitation
normal continue oxitosin 12dpm
- CTG continous
- Reevaluate 3 hours

09.00
S/
contraction (+), fetal movement (+),
O/
GC : good, CM, BP : 130/80 mmHg, PR :
94x/mnt, RR : 24x/mnt, Temp : 36.4C,
General status : wnl
Obstetric status :
FHR 180 bpm, contraction 5x/10/40
I: normal V/U
VT: portio soft, axial, eff 30%, 4cm,
hodge II
CTG : fetal tachycardia (180 dpm)
A/
G1 38-39 wga, singleton live head
presentation, PROM 9 hours, unrippen
cervix
P/
- Stop oxitosin resuscitation
normal
- CTG continues
- Reevaluate 30 minutes later

10. 00
S/
contraction (+), fetal movement (+),
O/
GC : good, CM, BP : 120/70 mmHg, PR :
94x/mnt, RR : 24x/mnt, Temp : 36.4C,
General status : wnl
Obstetric status :
FHR 90 bpm, contraction 4x/10/40
I: normal V/U
VT: portio soft, axial, eff 30%, 4cm,
hodge I - II
CTG : fetal bradychardia (90 dpm)
A/
G1 38-39 wga, singleton live head
presentation, PROM 6 hours, unrippen
cervix, fetal distress
P/
Resuscitation C section cito

Operation report
Caesarean section due to fetal distress
1. Patient was within supine position in spinal anesthesia
2. Aseptic and antiseptic operation field
3. Pfannenstiel incision
4. After peritoneum was opened, there was a gravid uterus
5. Identification lower uterine segment. LUS was incised sharply, penetrated bluntly, extended
sharply
6. By luxated, born female baby , 3600 gram, AS 8/9, BS ~ 38-40 wga
7. Greenish amniotic fluid
8. By gentle traction, placenta was born completely
9. LUS was sutured 1 layer with polysorb no 1
10. Abdominal cavity was washed with NaCL 0.9% 500 cc
11. On exploration, both tubes and ovaries were normal
12. Abdominal wall was closed layer by layer
13. Bleeding 200 cc. Urine 150 cc

Summary
P1 post caesarean
sectionTerm neonate,
appropriate for
gestational age