CASE PRESENTATION

OBSTETRICS & GYNECOLOGY

DEPARTMENT
dr. Indra Utama Masyhur, Sp. OG
dr. Ismu Setyo Djatmiko, Sp. OG
dr. Hesty Duhita P, Sp. OG

Gunterus Evans
Jhonsen Indrawan
Dyana Suwandy
Sherly Oliviantin
Peter Mulyono Wijaya

R. Syamsudin, SH General District Hospital Sukabumi

Faculty of Medicine
Atma Jaya Catholic University of Indonesia
February 14, 2011 – March 12, 2011
 Identity
• Name : Mrs. Y
• Age : 29 years old
• Religion : Moslem
• Education : Elementary School
• Occupation : House wife
• Citizenship : Indonesia
• Tribe : Sundanese
• Address :Kp Warudoyong, Sukabumi
1st time marriage, 10 years
• Husband : Mr. S
• Age : 33 years
• Religion : Moslem
• Education : junior high school
• Occupation : employee
• Citizenship : Indonesia
• Tribe : Sundanese
• Address :Kp Warudoyong, Sukabumi city
 History taking
Chief Complaint : abdominal cramps 12 hours
before admission to hospital

12 hours before admission patient complained of

abdominal cramps, followed by bloody show
from vagina. 3 hours before admission
cramping became more often, occurred 2
times in 10 minutes and accompanied with
bloody show
• Other complaint :
 Palpitation –
 Dizziness -
 Epigastric pain –
 Vomiting -
 Dyspneu –
 Vision –
• Previous medical history :
 Previous hypertension –
 Previous abortion -
 History of infertility and medical treatment from doctor
(hormonal/IVF) -
 History of STD -
 History of Sterilization –
 Gynecologic History
• Period : 28 days, regular
• Duration : 5 days
• Volume : approx 60 cc/ day
• Menstrual Problem : dysmenorrhea -
• Menarche : 12 y. o
• Coitarche : 19 y.o (with her husband)
• Contraception : -
 Obstetrical History
• G3P2A0
• LMP : 15th February 2011
No. Husband Gestational Year Methods Attenda Complic Child Child
Age nt ation Sex Age

1. I 9 months 2002 SVD Midwife (-) Boy 8 yrs

2. I 9 months 2007 SVD Midwife (-) Girl 3 yrs

3. This one
 Present State
15th FEBRUARY 2011
• General condition : in pain
• Conciousness : compos mentis
• Height : 155 cm
• Weight : 60 kg
• BP : 110/80 mmHg
• HR : 82 beats/ mnt
• RR : 20 times/mnt
• Temperature : 37,0°C
 Physical Examination
• Head : normocephaly, deformity –
• Face : chloasma gravidarum +
• Eyes : ananemic conjunctiva, anicteri c sclera
• Neck : thyroid gland enlargement -, lymph
nodes enlargement -, mass –
• Heart and Lung wNL
• Mammae : symmetrical, hyperpigmented
areola +/+
• Abdomen:
– I : Striae gravidarum (+); striae nigra (-)
– P: fundal height : 30 cm
Uterine contraction : (+)
1st Leoplod : buttock
2nd Leopold : right spine
3rd Leopold : head
4th Leopold : 2/5
• Extremity
– Pitting edema -/-
– Physiologic reflex +/+
– Pathologic reflex -/-
– Warm, capillary refill time< 2 sec, cyanosis -/-
• Vaginal Toucher :
– v/v normal, thick and stiff portio
– 10 cm dilatation, 100% effacement, amniotic sac (-)
– Cephalic presentation; Hodge 3+; denominator : right anterior
minor fontanelle
• Additional examination
Hg = 10.8 gr/dL
Ht = 30.2%
WBCs = 10.800/μL
Platelets = 257.000/ μL
Bleeding time = 2’
Clotting time = 4’
RBG = 83 mg/dL
Blood type = B/ Rh +
• Estimated fetal weight = 3300 grams
• Fetal heart rate : 140 bpm
 Resume
• Patient - G3P2A0, 32 years old, in labor, GA 40
weeks (LMP), first stage latent phase with
severe preeclampsia
• chief complaint : abdominal cramping 12
hours before the admission
• Bloody show +
PE :
• General condition : in pain
• Conciousness : compos mentis
• Height : 155 cm
• Weight : 60 kg
• BP : 110/80 mmHg
• HR : 82 beats/ mnt
• RR : 20 times/mnt
• Temperature : 37,0°C
• Abdominal :
• I : Striae gravidarum (+); striae nigra (-)
• P: fundal height : 30 cm
Uterine contraction : (+)
Leoplod I : buttock
Leopold II: spine at right
Leopold III: head
Leopold IV: 2/5
• Vaginal Toucher :
– v/v normal, thick and soft portio
– 10 cm dilatation, 100% effacement, amniotic sac (-)
– Cephalic presentation; Hodge 3+; denominator : right anterior
minor fontanelle
 Hg = 10.8 gr/dL
 Ht = 30.2%
 WBCs = 10.800/μL
 Platelets = 257.000/ μL
 Bleeding time = 2’
 Clotting time = 4’
 RBG = 83 mg/dL
 Blood type = B/ Rh +
 Working Diagnosis
Maternal Diagnosis
- G3P2A0, 29 years old, in labor, GA 40 weeks
Second Stage
Fetal Diagnosis : single, live, intrauterine fetus
with cephalic presentation
 Therapy
• Immediate delivery
DISCUSSION
 Delay for Women Who Die in
Childbirth Experienced
• 1st Delay : deciding to seek care for an obs
complication (recognition, fear, cost)
• 2nd delay : actually reaching the Care Facilty
Transport
• 3rd Delay : obtaining care in facility (poor staff,
repayment, difficulity of blood supply,
equipment, op. theatre
 Client Flow Analysis for EmOc
• Purpose :
– Gather info about care pregnant client w/
complication
– Eliminate /reduce delays in receiving care
– Aim quickly evaluate client
 Critical Steps in Caring
• Arrival (T1)
• eValuation (T2)
• Initial treatment T30
• Definitive (T4)
• Monitoring and recovery
• Info and conselling and discharge
 The Times
• T1 and T2 < 15 min
• T2 and T3 +- 30 min
• T2 and T4 +- 2 h
 Initial treatment (T3)
• Asking and shouting for help
• IV fluid
• CPR
• Administrating drug
• Sending lab test
• Alerting provider in labor and delivery
• Preparing for definitive treatment
 Definitive Treatment (T4)
• SC
• Ev / EF
• Hysterectomy
• Laparoscopy
• Uterine evacuation
• Manual placenta removal
• AB, oxy, methergin
• Blood transfusion
• IV fluid
• Repair laceration
• Observ
Time Planning on OB/GYN

Initial
Diagnosis –
Admission - Treatment -
Initial
Diagnosis Definitive
Treatment
therapy
 ER Management
• Patient having labor and come to ER
• Triage
• 1 person  taking history, ask about her
finance planning, and tell admission
procedure to her family immediately
• 1 person  do examination and observation
• Call Delivery Room to transfer the patient
 ER Time Management
• Patient come on 02:42:17
• history taking, physical examination, tell her
family simultaneously finish on 02:43 o’clock
– Patient do pay on her own money
– Cervix dilatation reach 10 cm (immediately
transfer)
• Administration finished on 02:44:07
• Arrived at Delivery room on 02:55 o’clock
• Time ± 13 minutes
 DR Time Management
02.45  Prepare room and Labor set
02.55  Patient come to VK Room
02.55 – 03.00  Taking history, Examination
mother-child and Vaginal Toucher
03.00 – 03.15  Patient was led to strained
simultaneously with uterine contraction
Oxytocin in RL 500 ml, 8 gtt per minutes
 DR Time Management
03.15  Child’s Labor
Immediately check the baby and do early
breastfeeding
03.18  Placental Delivery
Ergonometrin 0.2 mg
Examine the placenta
03.20-03.25  Placental, vulva, vagina, cervix,
uterine and haemmorhage examination
 DR Time Management
03.25-03.40  suture
Lidocaine
03.40 – 05.40  Observation in Delivery room
before transfer to MM Ward
- Antibiotics and pain management after labor 
amoxicilline and mefenamic acid
- Clean Equipment and Room
- Check used items
- Management medical waste (yellow bag)
 Ward Management
05.30  prepare room
05.40  Cross checking in ward
06.00  SOAP by trainee
09.00  Visite
Recheck planning for today
 Ward Management
16/02/2011
06.00  SOAP by Co Ass
09.00  Visite
No pathologic problem occur
Patient can be released
09.00-09.30  administration finished the
calculation, patient’s family get the bill and
pay on cashier, after that, patient get released
 Ward’s Management
11.00  Resume was finished
Medical Record can be transfer to Medical
Record Central
THANK YOU