Procedure

Case

Outcome

C-section

Due to PROM, breech

presentation

Born male baby, 3200 g, 48

cm, AS 8/9 BS ~34-36 weeks
Diminish amniotic fluid
Plasenta born completely

Mrs. M, 24 yo
MR 1102420
PPROM 6 hours on G1 40-41 wga
singleton live head presentation,
severe oligohydramnion ( AFI 3),
not in labor
Adit(T2A)
Dr. Yusra
Septivera, SpOG

Process:
Antibiotic profilaksis C-section
NBC
Came by her own will

FP : IUD trans caesarean

Mother and baby were in good

condition, already discharged

Mrs. M, 24 yo
MR 1102420
PPROM 6 hours on G1 40-41 wga singleton live head presentation,
severe oligohydramnion ( AFI 3), not in labor
15/09/2016 pukul 20.00 pm
Chief complain : patient came by her own will
History: Patient admitted 9 month pregnancy, LMP 02/12/15, EDD
9/9/2016~40-41 wga.
ANC regularly to Midwife and OBGYN, the last Ultrasound is 1 month ago, the
result of the US is the baby is in good condition. Now the patient complaint
water broke since 6 hours ago, the water is clear, no febris, no contraction,
no bloody discharge, fluor (+), smell (-), icthy (-) caries dentis (+), no febris,
Active fetal movement (+).
Family & previous illness : Asthma, Hypertension, heart disease, DM, Allergy
was denied
Menstruasi diary: menarche 14 yo, regularly, 6-7 day, dismenorrhea (-)
Married history: 1x, 23 yo
FP history: Obstetric history:
1. Current pregnancy
Social history: housewife, husband: enterpreneur

Physichal examination
KU: Good, CM W: 55 kg H : 153 cm BMI: 22,89
BP 120/80 mmHg, HR 82 x/Minute. RR 18 x/Minute, T 36,5 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 33 cm, EFW: 3410 g, back on the left side, breech presentation,
contraction(-) , FHR 145 dpm
I
: V/U wnl,
Io : Portio livide, OUE was closed, fluor (+), fluksus (-), valsava (+), LEA (-)
VT : firm portio, posterior, no cervical dilatation, breech still floating

USG :FHR (+)

BPD : 92,2
HC : 342
AC : 347
AFI : 1
FL : 77
EFW : 3598 gr
Placenta on corpus anterior
Conclution: Term pregnancy,
singleton live head presentation,
severe oligohidramnion

CTG :
Baseline
: 140 bpm
Variability
: 5-20 bpm
Acceleration
: (+)
Deceleration : (-)
His
: (-)
Fetal movement
: (-)
CTG : Category 1

Laboratory:
Hb
: 11,6 gram/dl ( 12-14 gram/dl )
Leucocyte
: 11.800/ul ( 4100-10500 /ul )
Trombocyte : 242.000 /ul (150000-400000 /ul )
Ht
: 91 % ( 40-55 % )
Random blood glucose : 100 mg/dl
Assesment
: Within normal limit

A/ PPROM 6 hours on G1 40-41 wga singleton live head

presentation, severe oligohydramnion ( AFI 3), not in labor
P/

Observation of vital sign, contraction, FHR/

hours
Observation of cord compression
Observation of intrauterine infection

Th. P/

Emergency c- sction
Inj. Ceftriaxone 2 gr/24 hours

C-Section report
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Patient was within supine position in spinal anesthesia

Aseptic and antiseptic on surgery part with povidon iodine
Pfannenstiel incision
Abdominal wall was opened layer by layer
After peritoneum was opened, There was a gravid uterus ~ term pregnancy
Identification lower uterine segment and plica vesicouterina lowered down
LUS was incised sharply, penetrated bluntly, extended sharply
By traction of the food, born male baby BW 3200 gram, 48 cm, AS 9/10
By gentle traction, placenta was born completely
Inserted IUD
LUS was sutured 1 layer with vicryl no. 1
Both tube and ovary witin in normal limit
Abdominal cavity was washed with NaCL 0.9% 500 cc
On exploration, both tubes and ovaries were normal
Abdominal wall was closed layer by layer
Bleeding 300 cc. Urine 100 cc

Summary/
P1 Post C-Section due
to breech presentation,
PROM 6 hours
Term neonate
Appropriate for
gestational age