FETOMATERNAL WARD REPORT

Saturday, January 19th 2019

Supervisor:
dr. Riza Hendrawan Nasution, Sp.OG

Residents : 1. dr. Haruddin Safutra Surbakti

2. dr. Willy Kurnia Almon
3. dr. Armin Wijaya

Department of Obstetrics and Gynecology

Medical Faculty – Universitas Sumatra Utara
Pirngadi General Hospital
2019
NO Case Result
1. Mrs. R, 27 y.o, G1P0000 Therapy :
• IVFD Ringer Lactat 20 dpm
Diagnosis: • Inj. Ceftriaxon 2 gram (Skin
Contracted Pelvic + Hepatitis B + PG + Test)  Prophylaxis
IUP (39-40) wga + Head Presentation +
Alive Fetus

Plan:
• Elective C-Section
(Wednesday, Januari 16th
2019)
• Consult to Anasthesiology
• Consult to Perinatology
• Conseling for birth control
 IUD
PATIENT 1
Mrs. R, 27 y.o, G1P0000, Bataknese, Catholic, Senior High School,
Housewife married with Mr. L, 32 y.o, Bataknese, Catholic, Senior
High School, Entrepreneur. The patient was admitted to Pirngadi
General Hospital on January 15th 2019 at 11.00 am with :

CC : Elective C-Section
Patient was admitted from Feto maternal out patient clinic planed
to Elective C-Section d/t Contracted Pelvic + Hepatitis B + PG + IUP
(39-40) wga + Head Presentation + Alive Fetus
History of labor contraction (-), History of blood slime (-), History
of amniotic fluid leakage (-). Patient was referred from Samosir
Hospital with diagnosis Contracted Pelvic + Hepatitis B + Gravida +
IUP (39-40) wga . Micturition and defecation was no abnormality
Previous Illness : Hepatitis B (on January 2019)
Previous Medication :-
LMP : 10 / 4 / 2018
EDD : 17 / 1 / 2019
ANC : Midwife 5x, Obstetrician 2x

History of Pregnancy
1. Current Pregnancy
Present state
Cons : Fully Allert Anemic : (-)
BP : 110/80 mmHg Icteric : (-)
Pulse : 84 times/min Cyanosis : (-)
RR : 20 times/min Oedem : (-)
Temp : 36,6 °C Dyspnoe : (-)

Body weight : 62 kg
Height : 148 cm
BMI : 28,31 kg/M2 (Overweight)
Obstetrical State :
• Abdomen : Asymmetrical enlargement
• Fundal Height : 3 fingers below xyphoid processus (38 cm)
• Tension part : Right
• Lower part : Head
• Head : 5/5
• Movement : (+)
• Uterine Contraction : (-)
• FHR : (+) 136 bpm, regular
• EBW : 3800 – 4000 gr

Vaginal Examination :
VT : Cx Closed
Hands gloves : Blood slime (-) amniotic fluid (-)
 Pelvic adequacy
• Promontorium : palpable
Conjugata Diagonal :10.5 cm Conjugata Vera :9cm
• Innominate line : palpable overall
• Spina ischiadic spine : protruded
• Sacrum : concave
• Arcus pubis : blunt
• Os coccygeus : mobile

• Conc : Contracted Pelvic

USG TAS
USG TAS
USG TAS
 USG TAS
• Singleton Pregnancy, Head Presentation, Alive Fetus
• Fetal Movement (+), Fetal Heart Rate (+) 132 bpm
• BPD : 9,7 cm
• AC : 35,6 cm
• FL : 7,4 cm
• EFW : 3840 grams
• Placenta Fundal Grade III
• Amniotic fluid : Enough

Conclusions:
IUP (39) wga + Head Presentation + Alive Fetus
 LABORATORY FINDINGS on January 12th 2019

• Hb : 11,8 N: 12-14 gr/dl

• Ht : 33,6 N: 36-42 gr/dl
• RBC : 3,59x106 N: 4-5,4X106 uL
• WBC : 4.990 N: 4000-11000/mm3
• Platelet : 259.000N: 150000-400000/mm3
• PT : 8,4” N: 11,6”-14,5”
• APTT : 29,8” N: 28,6”-42,2”
• INR : 0,79 N: 1-1,3
• MCV : 93,60 N: 80-97 fL
• MCH : 32,90 N: 27-33.7pg
• MCHC : 35,10 N: 31.5-35g/dL
• Glucose ad R : 79 N: < 200 mg/dLs
 LABORATORY FINDINGS on January 12th 2019

• Ureum : 16,0 N : 10-50 mg/dL

• Creatinin : 0,84 N : 0,60-1,20 mg/dL
• SGOT : 16,00 N : 0-40 U/L
• SGPT : 11,80 N : 0-40 U/L
• Total bilirubiun : 0,42 N : 0,0-1,20 mg/dL
• Direct bilirubin : 0,09 N : 0,05-0,30 mg/dL
• Natrium : 140 N : 136-155 mmol/L
• Kalium : 3,85 N : 3,5-5,5 mmol/L
• Chlorida : 109,5 N : 95-103 mmol/L
Diagnosis:
Contracted Pelvic + Hepatitis B + PG + IUP (39-40) wga + Head
Presentation + Alive Fetus

Therapy:
• IVFD Ringer Lactat 20 dpm
• Inj. Ceftriaxon 2 gram (Skin Test)  Prophylaxis

Plan:
• Elective C-Section (Wednesday, January 16th 2019)
• Consult to Anasthesiology
• Consult to Perinatology
•Conseling for birth control  IUD

Reported to Supervisor on duty dr. Riza Hendrawan Nasution, Sp.OG

→ Approved
 C-Section d/t Contracted Pelvic + Hepatitis B
Born baby boy with BW 3900 gr,
BL 50 cm, AS 8/9 , Anus (+)
• The patient was laid on the operating table, with IV line and urinary catheter
inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine on
the abdomen, and then draped leaving the surgical field exposed.
• Under spinal anesthesia, Pfannenstiel incision was made in the abdomen,
through to the underlying layer of fascia. The fascia was incised in the midline
and extended laterally using scissor. Superior aspect of the fascia was elevated
using Kocher, and the underlying rectus muscles were separated.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the bladder.
• The lower uterine segment was identified. A low cervical incision in the uterus
performed until subendometrium layer. Endometrium penetrated and
widened bluntly.
• By luxating the head, born baby with BW 3900gr, BL 50cm, AS 8/9,
Anus (+). The umbilical cord was clamped in two places and cut in
between
• The placenta was born with fundal pressure and traction on the
umbilical cord. Uterine cavity was cleaned with gauze.
• IUD Copper T was inserted inside uterine cavity .
• Uterus was sutured by continuous interlocking stitches.
• Abdominal cavity was cleaned from blood and stoll cell.
• Peritoneum sutured continuously, muscle approximation using
simple suture and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was
sutured with subcuticuler suture.
• Surgical wound was closed with sofratulle, sterile gauze and
hypafix.
• Mother’s condition was stable after the operation.
Th/
• IVFD RL + Oxytocin 10 IU → 20 dpm
• Inj. Ceftriaxone 1 gr/12 hrs
• Inj. Ketorolac 30 mg/8 hrs
• Inj. Ranitidine 50 mg/12 hrs

Plan:
1. Evaluation vital sign, Uterine contraction and Signs of
bleeding
2. Check CBC 2 hours after operation
 Laboratorium Findings (Post C-Section)

Hb : 10,2 N: 12-14 gr/dl

Ht : 32,1 N: 36-42 gr/dl
WBC : 11,180 N: 4000-11000/mm3
Platelet : 255.000N: 150000-400000/mm3
 FOLLOW UP Thursday, January 17th 2019

S -

O Presens State Abdomen : laxed, peristaltic (+) Normal

Sens : CM Fundal Height : 2 finger below navel
BP : 110/70 mmHg Surgical wound : covered by gauze appeared
HR : 90x/min dry
RR : 20x/min Vaginal bleeding : (-), lochia (+) rubra
T  : 36,50C Micturition : (+) via urine catheter uop:
60cc
Defecation : (-) , flatus (+)
A Post C-Section d/t Contracted Pelvic + Hepatitis B + PD 1

P • IVFD RL 20 dpm
• Inj. Ceftriaxon 1gr /12 hrs
• Inj. Ketorolac 30/8 hrs
• Inj. Ranitidine 50mg/ 12 hrs

Planning :
• Urine Catheter Removal
• Mobilization
 FOLLOW UP Friday, January 18th 2019

S -

O Presens State Abdomen : laxed, peristaltic (+) Normal

Sens : CM Fundal Height : 2 finger below navel
BP : 120/70 mmHg Surgical wound : covered by gauze appeared
P : 84 bpm dry
RR : 20 bpm Vaginal bleeding : (-), lochia (+) rubra
T  : 36,70C Micturition : (+) spontan
Defecation : (-) , flatus (+)
A Post C-Section d/t Contracted Pelvic + Hepatitis B + PD 2

P • Cefadroxyl tab 2x500 mg

• Mefenamic Acid tab 3x500 mg
• B-Comp tab 2x1

Planning :
• IV Line Removal
• Oral Therapy
• Mobilization
 FOLLOW UP Saturday, January 19th 2019

S -

O Presens State Abdomen : laxed, peristaltic (+) Normal

Sens : CM Fundal Height : 2 finger below navel
BP : 120/80 mmHg Surgical wound : covered by gauze appeared
P : 78 bpm dry
RR : 22 bpm Vaginal bleeding : (-), lochia (+) rubra
T  : 36,40C Micturition : (+) Spontan
Defecation : (+)
A Post C-Section d/t Contracted Pelvic + Hepatitis B + PD 2

P • Cefadroxyl tab 2x500 mg

• Mefenamic Acid tab 3x500 mg
• B-Comp tab 2x1

Planning :
• Ambulatory Today
THANK YOU