Duty Report

August 11-17, 2014

Consultants :
dr. St. Finekri Abidin, OBGYN (C)
dr. Bintari Puspasari, OBGYN
dr. T. Indang Dewi, OBGYN (C)

RSGS Team August 2014

 Reporting
4 Caesarean sections
CAESAREAN SECTION #1
Day S O A P
11/8/14 SCTPP Physical examination G5P2A2 Term P:
DAY I Compos mentis, BP : 170/100 Pregnancy, Observe
22.15 Mrs. Ella Sofhia, 41 yo mmHg, P: 86x/m, FR 20x/m, T : singleton live hemodynamics,
MR. 129632 36OC fetus, previous contractions, FHR
BB: 90 kg, TB 169 cm: BMI 31.5 C-section 1x, Observe worsening
CC: Referred from RS Bersalin Pasutri with kg/m2 superimposed of preeclampsia
suspected severe preeclampsia. Gen. state: preeclampsia,
Pale conjungtive -/-, susp Emergency CS
Patient admitted 9 month pregnancy. Her abd ~ pregnancy macrosomia, MgSO4
LMP 4/12/13 (unsured) EDD 11/9/14~ 35-36 not in labor Nifedipine 4 x 10
wga. ANC regularly at OBGYN (Bogor). USG Obstetrical Status: FH 36 cm, head mg
at every visit, baby in good condition. presentation, head 4/5, FHR 152 NAC 3 x 600 mg PO
Contraction (-), water broke (-), bloody show I: V/U wnl Vit C 2 x 400 mg IV
(-) Io: smooth portio, closed ostium,
flr (-), flx (-). 02.00 03.00
Blood pressure elevated since 2 months Vt: portio firm, posterior, t 3cm, LUS free of
(140/90 mmHg), not given drugs. closed, H I adhesion
Frontal headache (-), nausea / vomiting (-), Born baby boy,
blurred vision (-) CTG: Category 1 4050 gr, 54 cm AS
Active fetal movement Lab: 8/9
CBC (11/8/14) Clear amniotic fluid
Menarche 12 yo, reguler, GP 3x/day, 9.9/31/9200/182000 Placenta born
dysmenorrhea (-) SGOT 35 SGPT 20 Alb 3.6 completely
Ur 19 Cr 0.6 RBG 115
Married 1x Na 138 K 3.6 Cl 108 FP : Tubectomy
Obs history: G5P2A2 Ul protein +2 Pomeroy
1.1999, boy 3800 g, spontaneous delivery at
RSPAD US exam (7/7/14) Hb Post op: 9.8 g/dl
2.2007, miscarriage, curettage at RS Bogor Singleton live head presentation,
3.2009, girl 3000 g, SC at RSPAD due to cord placenta implanted at fundus,
entanglement normal implantation Outcome:
4.2011, miscarriage, curettage at RS Bogor BPD 9,4/HC 36 / AC 37/ FL 7.4/ AFI Now patient
5.This pregnancy normal/ EFW 4075 (130/90 mmHg) and
baby are in good
CAESAREAN SECTION #2
Day S O A P
11/8/14 SCTPP Physical examination G2P1 38 wga, P:
DAY I Compos mentis, BP : 160/110 singleton live Observe hemodynamics,
14.00 Mrs. Dwi Novianti, 33 yo mmHg, P: 84x/m, FR 18x/m, T : fetus, severe contractions, FHR
MR. 242324 36OC preeclampsia, Observe worsening of
Gen. state: previous CS 1x preeclampsia
CC: irreguler contraction since 5 hours Pale conjungtive -/-,
before admission abd ~ pregnancy Emergency CS
MgSO4
Patient admitted 9 months pregnancy. Obstetrical Status : FH 30 cm, Nifedipine 4 x 10 mg
Her LMP 12/11/13 (unsure) EDD head presentation, head 4/5, FHR NAC 3 x 600 mg PO
19/8/14~ 39 wga. ANC regularly at 146 Vit C 2 x 400 mg IV
KesDip Tangerang then referred to I: V/U wnl
RSGS. USG 4x, baby in good condition. Io: smooth portio, closed ostium, 12/8/14
Contraction (-), water broke (-), active flr (-), flx (-). 14.30 15.30
fetal movement Vt: portio firm, posterior, t 3cm, Anterior part of uterus
closed, H I was adhered to
Blood pressure elevated since previous omentum
pregnancy. In RSGS policlinic patient got CTG: Category 1 Adhesiolysis
Methyldopa 3x500 mg and was already Lab: Born baby girl, 2780 gr,
consulted to internal medicine dept, CBC (11/8/14) 49 cm AS 8/9
already plan for elective c-section at 10.7/32/14000/395000 Clear amniotic fluid
18/8/2014 SGOT 16 SGPT 19 Alb 3.9 Placenta born
Ur 19 Cr 0.6 RBG 83 completely
Frontal headache (-), nausea / vomiting Na 140 K 3.9 Cl 106
(-), blurred vision (-) Ul protein +2 FP: IUD TC

Menarche 12 yo, reguler, GP 3x/day, US exam (7/7/14) Hb Post op: 11.8 g/dl
dysmenorrhea (-) Singleton live head presentation,
placenta implanted at right Outcome:
Married 1x corpus, normal implantation Now patient (BP 130/90
Obs history: G2P1 BPD 8.8/HC 314/ AC 330/ FL 76/ mmHg) and baby are in
1.2005, SC at RSPAD due to breech AFI 3.5 SP / EFW 3000 good condition, ready
presentation, girl 2500 g. for rooming in
CAESAREAN SECTION #3
Day S O A P
13/8/14 SCTPP Physical examination Latent phase of P:
DAY I Compos mentis, BP : 100/70 labor in G3P1A1 Observe hemodynamics,
15.00 Mrs. Arum A, 31 yo mmHg, P: 92x/m, FR 18x/m, T : 38 wga, contractions, FHR
MR. 419713 36OC singleton live
Gen. state: fetus, HbsAg Emergency CS
CC: irreguler contractions and bloody Pale conjungtive -/-, reactive Consult to perinatology
show since 1 day before admission abd ~ pregnancy for HepB Ig

Patient admitted 9 months pregnancy. Obstetrical Status : FH 32 cm, 12/8/14

Her LMP 10/11/13 EDD 17/8/14~ 39 head presentation, head 4/5, FHR 20.00 21.00
wga. ANC regularly at RSGS. USG 3x, 146, his 1-2 x/10/40 Born baby boy, 3100 gr,
baby in good condition. Planned for I: V/U wnl 50 cm AS 8/9
elective CS on 19/8/2014 due to Io: smooth portio, closed ostium, Clear amniotic fluid
HbsAg(+) flr (-), flx (+). Placenta born
Water broke (-), active fetal movement Vt: portio firm, axial, t 2 cm, 2 cm completely
dilatation, head H I-II

Menarche 13 yo, reguler, GP 2-3x/day, CTG: Category 1 Hb Post op: 10.4 g/dl
dysmenorrhea (-) Lab:
CBC (7/8/14) Outcome:
Married 1x 10.6/31/11830/221000 Now patient and baby
Obs history: G3P1A1 SGOT 20 SGPT 19 are in good condition,
1.2008, miscarriage Ur 14 Cr 0.6 RBG 79 already discharged
2.2011, girl 2600 g, spontaneous Ul wnl
delivery at RSAL.
3.This pregnancy US exam (7/7/14)
Singleton live head presentation,
placenta implanted at leftcorpus,
normal implantation
BPD 90/HC 311/ AC 344/ FL 71/
AFI 12 / EFW 3159
CAESAREAN SECTION #4
Day S O A P
13/8/14 SCTPP Physical examination Inertia of active P:
DAY I Compos mentis, BP : 110/50 phase of labor in Observe hemodynamics,
20.30 Mrs. Grace A, 26 yo mmHg, P: 90x/m, FR 18x/m, T : G1 40-41 wga, contractions, FHR
MR. 440720 36.5OC singleton live Observe signs of
Gen. state: fetus intrauterine infection
CC: Referred from Tebet PHC due to Pale conjungtive -/-, and cord compression
prolonged active phase of labor abd ~ pregnancy
Initial plan: vaginal
Patient admitted 9 months pregnancy. Obstetrical Status : FH 33 cm, delivery
Her LMP 29/10/13 EDD 5/8/14~ 41 head presentation, head 2/5, FHR Acceleration with
wga. ANC regularly at PHC. 156, his 1-2x/10/45 Oxytocin 5 IU/500 cc RL,
Contraction (+) since 10 hours, water I: V/U wnl start at 8 tpm, escalated
broke (+) 18 hours. Active fetal Vt: portio thin, 7 cm dilatation, 4 tpm/30 mins until
movement head H II-III, small fontanel left- adequate contractions
transverse or max 40 tpm.
Patient was given oxytocin drip 24
drip/minute for 12 hours at PHC. CTG: Category 1 Ceftriaxone 1 x 2 g IV
Dilatation 4 cm 6 cm 7 cm 7 cm Lab:
(every 4 hours) CBC (13/8/14)
12.6/36/24000/226000
Menarche 12 yo, reguler, GP 3x/day, SGOT 3 SGPT 20
dysmenorrhea (-) Ur 15 Cr 0.6 RBG 108
Ul protein wnl
Married 1x
Obs history: G1 US exam (7/7/14)
1.This pregnancy Singleton live head presentation,
placenta implanted at anterior
corpus, normal implantation
BPD 91/HC 314/ AC 310/ FL 79/
AFI 4.1 / EFW 3100
Day S O A P
13/8/14 Oxytocin drip is administered (8 tpm)
DAY I
21.00

13/8/14 Frequent contractions, active fetal His 3-4 x /10 / 45 Adequate contractions Sustain oxytocin drip,
DAY I movement FHR 142 dpm on active phase of labor evaluate after 3 hours
22.00 in G1 40-41 wga,
singleton live fetus

13/8/14 Frequent contractions, active fetal Physical examination Second stage of labor in Observe hemodynamics,
DAY I movement Compos mentis, BP : G1 40-41 wga, singleton contractions, FHR
24.00 110/70 mmHg, P: 86x/m, live fetus
FR 18x/m, T : 36.5OC Management of second
Gen. state: wnl stage
Obstetrical Status : FHR
150, his 4x/10/45
I: V/U wnl
Vt: complete cm
dilatation, head H III, small
fontanel left-transverse

14/8/14 Frequent contractions, active fetal Physical examination Distosia of second stage Emergency CS
02.00 movement Compos mentis, BP : of labor in G1 40-41
120/80 mmHg, P: 90x/m, wga, singleton live fetus
FR 18x/m, T : 36.5OC 03:00
Gen. state: wnl Born baby girl, 3150 gr,
Obstetrical Status : FHR 50 cm AS 8/9
150, his 4x/10/45 Nil amniotic fluid
I: V/U wnl Placenta born
Vt: complete cm completely
dilatation, head H III,
caput H III+, small fontanel Now patient and baby
posterior are in good condition
already discharged
THANK YOU