LAPORAN DOKTER JAGA

RSUP Prof. Dr. R. D. Kandou Manado

Tgl 17 Februari 2018 jam 08.00 WITA s/d 18 Februari 2018 jam 08.00 WITA
Tim Jaga : dr. Angga, dr. Helena, dr. Christy, dr. Astrina, dr. Bowo,
dr. Fandy, dr. Tiffany, dr. Ando, dr. Winata, dr. Tesa
Konsulen Jaga : dr. Joice Sondakh, SpOG-K

OBSTETRI : 6 orang
FISIOLOGI : 1 orang ( 1 laporan singkat)
1. G3P2A0 34 thn hamil 37-38 minggu dengan inpartu kala I  Lahir
bayi , spt lbk, gr, cm, AS
PATOLOGI : 5 orang ( 2 laporan singkat, 3 laporan lengkap)
1. G3P2A0 41 tahun hamil 22 – 23 minggu + Ancaman Partus prematurus +
KPD 6 hari + oligohidramnion berat + HRP  terminasi kehamilan  lahir
bayi laki-laki, spt bokong, 450 gr, 27 cm, AS 1-0 lahir plasenta kesan
tidak lengkap kuretase + IUD post plasenta
2. P0A2 27 tahun dengan Abortus inkomplit Kuretase
GINEKOLOGI : 1 orang ( 1 laporan singkat)
1. P3A0 30 tahun dengan Kista Ovarium suspek ganas + Anemia  Perbaiki
KU dan Lap VC tgl 9/2-2018
KB : 2 orang (2 IUD post plasenta)

LAPORAN OBSTETRI PATOLOGI

1. G2P1A0 24 years old 38-39 weeks of gestation inertia uterine first stage of labor + Breech
presentation  Cesarean Section + IUD Post Plasenta (Mrs. Vivid Virginia Tuna MR 52.55.48)
G2P1A0 24 years old admitted on Februari 16st , 2018 at 22.00 am reffered from Obstetrician with diagnose
G2P1A0 24 years old term of gestation + observation of inpartu. Intrauterine fetal singleton alive breech
presentation

Anamnesis :
 The mother felt labor pain since Februari 16th 2018 at 22.00
 There was bloody show
 There was no amniotic discharge
 She felt the baby’s movement
 There weren’t history of hypertension, cardiac, pulmonary, liver, renal, and diabetic disease
 ANC : 8 times at Obstetrician
 LMP : May 21 th, 2017 EDC : Februari 28th, 2018
 Marriage : once for 19 years Contraception : Pils contraception, last taken 2016
- P1 : 1998, Male, aterm, spontaneous vertex delivery, at home, by midwife ,
3600 , alive

General examinations :
General Condition : Moderate, concious
Blood pressure : 120/70 mmHg Pulse rate : 88 x/minute
Respiration rate : 18 x/minute Temperature : 36,6° C
Conjunctive : anemic -/- Sclera : icteric -/-
Heart and lung : within normal limit Extremities : oedema -/-
Body height : 158 cm Body weight : 60 kgs
Obstetrics examination:
Fundal height : 32 cm Fetal presentation : cephalic presentation W back on
FHS : 140-145 dpm the left
EFW : grams (JT) Uterine contraction : 8’-9’ // 10’’ - 15’’

Vaginal Toucher :
Eff 75%, 1 - 2 cm cervical dilated, amniotic membrane intac, breech, presentation H I

USG : Intrauterine fetal singleton, breech presentation

FM(+), FHM(+),
BPD : 8.94 cm, AC : 34,09 cm, FL : 7,43 cm
EFW : 3300 – 3400 grams
Placental implantation at fundus grade II-III
AFL > 2 cm
Result : fullterm pregnancy + breech presentation

ECG : within normal limit

Laboratorium :
Hb 14,1 gr/dl, WBC : 10.500/mm3, Platelet: 333.000/mm3

Diagnosis :
G2P1A0 24 years old term of gestation + observation of inpartu.
Intrauterine fetal singleton alive breech presentation

Management :
- Observation of inpartu
- Laboratory :
- Observation of Vital Sign, UC, FHS
- Consulted to supervisor → Advice :

Observations
At 11.00 pm – 11.30 pm
At 11.30 pm – 00.00 am
At 00.00 am – 00.30 am
At 00.30 am – 01.00 am
At 01.00 am – 01.30 am
At 01.30 am – 02.00 am
At 02.00 am – 02.30 am
At 02.30 am – 03.00 am
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 145-150 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm
UC : 8’-9’ // 10’’-15’’ FHS : 140-145 dpm

Vaginal Toucher :
Eff 75%, 2 - 3 cm cervical dilated, amniotic membrane intac, breech, presentation H I

At 03.00 am – 03.30 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm

At 03.30 am – 04.00 am
At 04.00 am – 04.30 am
At 04.30 am – 05.00 am
At 05.00 am – 05.30 am
At 05.30 am – 06.00 am
UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
UC : 7’-8’ // 15’’-20’’ FHS : 145-150 dpm
UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
At 06.00 am – 06.30 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
At 06.30 am – 07.00 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm

Vaginal Toucher :
Eff 75%, 2 - 3 cm cervical dilated, spontaneous amniotic leakage with slight meconium expelled, breech,
presentation H I

At 07.00 am – 07.30 am UC : 7’-8’ // 15’’-20’’ FHS : 145-150 dpm

At 07.30 am – 08.00 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
At 08.00 am – 08.30 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm
At 08.30 am – 09.00 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm

Vaginal Toucher :
Eff 75%, 2 - 3 cm cervical dilated, spontaneous amniotic leakage with slight meconium expelled, breech,
presentation H I

At 09.00 am – 09.30 am UC : 7’-8’ // 15’’-20’’ FHS : 140-145 dpm

At 09.30 am – 10.00 am UC : 6’-7’ // 20’’-25’’ FHS : 145-150 dpm
At 10.00 am – 10.30 am UC : 6’-7’ // 20’’-25’’ FHS : 140-145 dpm

At 10.30 AM : The mother was brought to the operation theatre

At 11.27 AM : Operation was begun, low segment cesarean section was performed
At 11.32 AM : Male baby was born, BW 3100 grams, BL 48 cm, AS 7-9
Less meconium expelled, there was strangulated umbilical cord at neck.
At 00.30 PM : Operation finished
Up to now the mother is in good condition.(Hb : g/dL) and the baby is in transition room