Delivery Suite Report

Tuesday, April 4th 2017

Consultants:
Dr. dr. IPG Kayika, OBGYN (C)
dr. Andi D. Putra, OBGYN (C)

Residents
ER Team April 2017
 Reporting
4 Procedures:
• 2 Vaginal deliveries
• 1 Cesarean section
• 1 Laparotomy Exploration Adhesiolysis, Evacuation
Multiple Pocket Abcess, Omentectomy, Total
Hysterectomy, Left Salpingoophorectomy, and
Right Salpingectomy
 Procedure No Case Outcome
Vaginal 1 Mrs. V, 28 yo Baby boy, 3180 gram, 49 cm, AS 8/10
Delivery MR 4092481 BS ~ 38 weeks
Placenta born completely
ICD 10 perineal rupture grade II 
Latent phase of labor on G6P1A4 38 wga, singleton perineorraphy
O80.0 live head presentation, Anti Phospolipid Syndrome
Z37.0 FP : IUD PP
D68.61
APS criteria:
ICD 9 CM Clinical
Process: 1. Spontaneous abortion, 12 wga, fetus
73.59 Latent phase of labor, Normal CTG  observation 8 (+), 2007
88.78 hours  active phase of labor ; contraction 2. 9 yo, girl, 3600 gram, spontaneous,
75.34 4x/10’/45”,  6 cm, amniotic membrane (+), head midwife, 2008
69.7 on hodge III  observation 2 hours  2nd Stage of 3. Spontaneous Abortion, 8 wga, fetus
labor (+), 2008
4. Abortion, 8 wga, performed
curettage, fetus (+), 2015
5. Spontaneous Abortion 8 wga, fetus
(+), 2016
Laboratory
BC (ANC at High Risk Clinic RSCM) Positive Lupus anti coagulant at
December 2015 and September 2016

Lucas (T1B)
Independent Mother and baby are in good condition in
the ward, plan to be discharged
 Procedure No Case Outcome
Vaginal delivery 2 Mrs. F, 30 yo Girl, 3600 gram, 50 cm, AS 8/10
MR 3896239 BS ~ 40 wga
ICD 10 Clear amniotic fluid
O80.0 Placenta born completely
Z37.0 Active phase of labor on G2P1 40 wga, singleton live Episiotomy ~ perineal rupture grade II
head presentation  perineorraphy
N25.8 Mother with renal tubular acidosis
ICD 9-CM
73.59
88.78 ANC Data:
75.34 2014: Recurrent hypokalemia, acidemia (pH 7,3), low
69.7 HCO3 (14), hyperchloremia (121)  ~ Renal Tubular FP: IUD PP
Acidosis  Bicarbonate and KSR medication

Process:
 8 cm, his 4x/10’/45”  observation 1 hours 
second stage of labor

Mother and baby are in good

Raden (T1B)/ condition in the ward plan to be
Independent discharged. Mother already join care
BC with renal hypertensive division.
 Procedure No Case Outcome
Cesarean section 3 Intrauterine infection Baby Girl, 3300 g, 48 cm, AS 9/10
BS ~ 38 wga
ICD 10 Mrs. RA, 27 yo Greenish amniotic fluid
O41.1 MR 420-94-39 Placenta born completely
O42.9
L40.3 Intrauterine infection on G1 38 wga, singleton
O62.1 live head presentation, PROM 1 day, not in
Z30.1 labor
Z37.0
99.21 FP: IUD TC
Process:
ICD 9-CM PROM 1 day, Mother HR 109x/minute, T 38,90C,
70.71 LEA ++, leukocytosis (27.700), fetal tachycardia 168
69.7 bpm  intrauterine infection emergency C-
88.78 section
75.34

NBC:
David (T2A) Mother and baby are in good condition in
Referred from midwife with waterbroke
Independent the ward, rooming in.
 Procedure No Case Outcome
Laparotomy 4 Mrs. TWA, 26 yo Patient in supine position under general
Exploration MR 4209244 anesthesia
Adhesiolysis, A and antiseptic at operating site
Evacuation Multiple
Pocket Abcess, Preoperative diagnosis:
Omentectomy, Total POD 32 on P1 Post C-Section due to Failed
Hysterectomy, Left Induction, PROM, with problems:
Salpingoophorectomy, 1. Sepsis due to CIAI (SOFA Score 1)
and Right 2. Hypokalemia (2.9)
Salpingectomy 3. Hypoalbuminemia (2.99)
4. Hypomagnesemia
ICD 10 5. Hypocalcemia
O98.9 O90.0
N74.8 E87.6
A41.9 E 88 Post operative diagnosis:
Deep Surgical Site Infection, Multiple pocket
ICD 9-CM abscess, tubo ovarian abscess, Uterine wound
88.78 68.49 dehiscence
66.4 99.0
54.59

Ogi (Chief) /
Richie (Chief) /
Dr. Romi, OBGYN /
Dr. Subandi, OBGYN / NBC
Digestive Department Referred from Urip Sumohardjo Hospital, Patient is in ICU 2nd floor spontaneous
Lampung due to peritonitis, , POD 32 on P1 breathing with simple mask 8 lpm,
Post C-Section adequate contact

Pfannenstiel incision. Found
pocket abscess at
subcutaneous area.
Cranial Cranial
Peritoneum was opened, Found multiple pocket
found severe adhesion abcess at right and left
between omentum, paracolica, Douglas
bowel, peritoneum, and pouch.
uterus  consult to
digestive surgery 
perform adhesiolysis
 Cranial

Cranial

Perform evacuation by digestive Incision was extended

surgery until 3 fingers above navel,
perform evacuation
multiple pocket abcess
and omentectomy
 Cranial

Cranial

On exploration there was severe Uterine wound dehiscence from previous

adhesion at LUS and bladder, and Section and found suture material
found left tube ovarian abcess (chromic). Found necrotic area and
inflammate tissue.
Decided to performed Total
Hysterectomy, Left
Salpingoophorectomy, and Right
Salpingectomy
No Patient Today’s Problems

ICU ER 2nd floor

Mrs. TWA, 26 yo
MR 4209244
1.
Post Laparotomy Exploration
Adhesiolysis, Evacuation Multiple
Pocket Abcess, Omentectomy, Total
Hysterectomy, Left
Salpingoophorectomy, and Right
Salpingectomy
1. Sepsis due to Deep Surgical Site
Infection, Multiple pocket abscess,
tubo ovarian abscess, Uterine wound
dehiscence (SOFA Score 1)
2. Hypoalbuminemia (1.81)
3. Hypokalemia (2.9)
 Today Condition
April 5th, 2017, 06.00

Fluid Balance
ICU 2nd floor
Adequate contact
S: operation site pain VAS 2-3 4/4/17 – 5/4/17
GCS E4M5VX BP : 124/80(99) mmHg , HR 106 x/min, temp 36.80C, 06.00 – 06.00
RR 21x/min, O2 Sat 100% on simple mask Input 5208 cc

Output 3697 cc
General status:
Balance +1511 cc
Eye: CA (-/-), SI (-/-)
Heart: S I-II N , murmur (-) gallop(-) Diuresis 1,1 cc/kgBW/hour
Lung: Vesicular +/+, rhales -/-, wheezing -/-
Abdomen: no distention, bowel movement (+)
Extremity: warm, CRT<2”, edema (-/-)

Gynecological state :
I: V/U wnl, no active bleeding
Surgical site : no bleeding and pus
 Transfusion
Vital Chart PRC 607 cc
FFP 190 cc
4/4/2017 – 5/4/2017
160 Operating Theatre
Bleeding 600 cc
Urine 500 cc

140

120

100

80

60

40

20

0
6 8 10 12 14 16 18 20 22 24 2 4 6

Systolic Diastolic HR RR SaO2

Lab 2/4/2017 3/4/2017 4/4/2017 4/4/2017 5/4/2017 Normal Value
17.20 17.58 05:30 23:30
CBC 9,68/31.1/19.000/ 10.8/34.4/19000/3090 12,7/39,8/31.600/2 12,3/38,8/30.900/285.000 12.0-15.0/36.0-
292.000 00 98.000//82,9/26,4/ //82,5/26,2/ 46.0/5.0-
31,8 10.0/150.0-400.0
Transfusion 250 cc
MCV / 81.1/25.3/31.1 80,6/25,7/31.8 80.0-95.0/27.0-
MCH / 31.0/32.0-36.0
MCHC

Diff 0/0/1/83/15/1 0.5-1.0/1-4/1-3/55-

(Bas/Eo 70/20-40/2-8
s/N.Bat
/N.Seg/
Lim/Mo
n
Ur/Cr 19,4/0.702 11,8/0,3 13,5/0,627 0-49/ 0.6-1,2
RBG 113 122 122 <200

SGOT/ 37/54 47/34 32/17 0-26/0-33 u/L

SGPT

PT/APT 1,07x/1,1x 9,8-12.6/31.0-47.0

T 150-400/0-0.3
Fib/D-
Dimer/I
NR
Uric 0-5.6
acid
LDH 0-599

Lactate 0.9 1,2 0,9 1,2 0,55-2,2

Procalci 0,51 N<0.05, <0.5

tonin Susp.Infection,
Lab 2/4/2017 3/4/17 4/4/2017 4/4/2017 5/4/2017 Normal Value
17.20 05:30 23:30
Albumin 2,87 2,42 2,99 1,81 3,4-4,8

Na/K/Cl 139/2,9/97 139/3,2/99 135/2,9/97 137/3,0/102 140/2,9/100 132-147/3,3-5,4/94-

111
Mg/Ca 0,7/- -/5,9 2,01/5,4 1,05/5,2 1.7-2.55/8.4 - 10.2

PCT <0.5

Bilirubin indirect 0,49 0.46 0,54 0.10-0.70

Bilirubin direct 0,54 0.54 0,72 0.00-0.29

Bilirubin Total 1,03 1 1,36 0.00-0.99

 Blood Gas Analysis

5/4/17
Lab 4/4/17 5/4/17
examinati Normal Range
on
Artery Artery Vein

pH 7,486 7,491 7,431 7.35-7.45

pCO2 24,7 35,6 40,1 35-45
pO2 99 165,1 49,0 75-100
SaO2 92,3 98,6 83,6 95-98
BE -5,8 4,7 3,1 -2.5-2.5
HCO3 18,1 27,4 26,9 21-25
 Management Plan
Problem Diagnostic Plan Management plan Target
Sepsis due to Deep Surgical Site
• Fluid intake (30cc/kg/bb) 1500
Infection, Multiple pocket
Pus culture cc/24 hrs Improvement of SOFA
abscess, tubo ovarian abscess,
(waiting for result) • Meropenem 3 x 1 gr score
Uterine wound dehiscence (SOFA
• Levofloxacin 1 x 750mg
Score 1)
Hypoalbuminemia (1,81) - Albumin 25% / day Albumin > 3
Diet protein 50 gram/day

Hypokalemia (2.9) - KCL 25 meq + 500 NaCl/8 hr Kalium >3,3 mmol/L

THANK YOU