II.

OBSTETRIC INPATIENT REPORT

Friday, May 31st 2019 - Wednesday, June 5th 2019
Chief on duty :
Dr. Mustika Dharma
Supervisor :
Dr. H. Nuswil Bernolian, SpOG(K) MARS

WEEKLY RECAPITULATION OF OBSTETRIC PROCEDURE

PROCEDURE AMOUNT %
Fullterm 3
No Induction
With Induction 2
Spontaneous Delivery
Preterm 3
Vaginal delivery Total extraction 0
Bracht maneuver 0
Vacuum extraction 1
Assissted Vaginal Delivery Forceps Extraction 0
Partial Extraction 1
LSCS 9
LSCS+ tubectomy pomeroy 2
Abdominal Delivery
LSCS+ IUD insertion 6
Hysterotomy
Conservative Management 5
Expectative Management 2
Brandt Andrew Maneuver 0
TOTAL 34 100%

RECAPITULATION OF OBSTETRIC PATIENTS

Physiological Patients : 5 Patients
Pathological patients : 129 Patients
Total : 34 Patients

Patient was discharged : 28 Patients

Patient was stable in ward : 6 Patients

Day/ Date New Discharged Total

patients patients Patients
Friday/ OBF 0 0 0
May 31st OBP 2 2 3
2019 GESTOSI 4 2 3
S
POST OP 3 5 3
Saturday/ OBF 0 2 0
June 1st 2019 OBP 1 1 2
 GESTOSI 0 1 2
S

POST OP 2 0 4
Sunday/ OBF 0 0 0
June 2nd OBP 1 1 2
2019 GESTOSI 0 0 2
S
POST OP 5 1 8
Monday/ OBF 1 0 1
June 3rd 2019 OBP 0 0 2
GESTOSI 0 2 0
S
POST OP 2 5 5
Tuesday/ OBF 0 1 0
June 4th 2019 OBP 2 2 2
GESTOSI 2 1 1
S
POST OP 1 2 4
Wednesday/ OBF 2 2 0
June 5th 2019 OBP 0 1 1
GESTOSI 0 1 0
S
POST OP 1 0 5
Total

Obstetrical Patients Friday, May 31st 2019

N Identity Diagnosis ICD Previous ICD Recent
O 10 Procedure 9 Diagnosis
1. Mrs. G1P0A0 40 O42.1 • Laborator 64.00 G1P0A0 40
SEL/25 weeks 0 y 73.01 weeks
yo /UA/ gestational age O41.0 examinati 65.0 gestational age
not inlabor with on not inlabor with
AF
PROM 3 days, • Antibiotic PROM 3 days,
SLF cephalic s SLF cephalic
presentation, • Induction presentation,
Oligohydramnio • P/ vaginal Oligohydramnio
us delivery us
2 Mrs. G1P0A0 38 O42.1 • Laborator 64.00 P1A0 post
VEL/19 weeks 0 y 73.01 spontaneous
yo /UA/ gestational age examinati 65.0 delivery with
not inlabor with on history of ROM
IS
PROM 2 days, • Antibiotic 2 days
SLF cephalic s
presentation • Induction
• P/ vaginal
delivery
3 Mrs. G2P1A0 26 O30.0 • Laborator 64.00 P2A0 post
ANI/24 weeks 41 y 65.0 preterm
yo /UA/ gestational age examinati spontaneus
inlabor 1st stage on delivery +
AA
active phase, • Vaginal gemelli
TLF cephalic Delivery
presentation-
cephalic
presentation

N Identity Diagnosis ICD 10 Previous IC Recent

O Procedure D 9 Diagnosis
4. Mrs. G1P0A0 40 O42.10 • Laborator 64. P1A0 post LSCS
RIK/25 weeks 041.80 y 00 oi CPD + post
yo /UA/ gestational age examinati 669 IUD insertion
inlabor 1st stage on .7
FY
active phase with • Antibiotic 69.
history of ROM s 7
12 hours + susp • LSCS
CPD, SLF • IUD
cephalic insertion
presentation +
Anhydramnious
5 Mrs. G2P1A0 32 O15.2 • Stabilizati 64. G2P1A0 32
on
 • Espectativ
e
manageme
nt
weeks • Laborator weeks
gestational age y gestational age
YUL/ not inlabor with examinati 006 not inlabor with
on
34 yo/ severe 4.2 severe
• MgSO4
UA/ AA preeclampsia, 40% 1 preeclampsia,
SLF cephalic • Lung SLF cephalic
presentation maturation presentation
• Assessme
nt interna
departmen
t
6 Mrs. G4P3A0 38 O60.00 • Laborator 64. P4A0 post LSCS
LEL/29 weeks O32.2 y 00 oi prior CS 2x +
yo /RA/ gestational age examinati 69. HIV (+)
not inlabor with on 7
AF
prior CS 2x + • LSCS
HIV (+), SLF
cephalic
presentation

Obstetrical Patients Saturday, May 25th 2019

N Identity Diagnosis ICD Previous ICD Recent Diagnosis
O 10 Procedure 9
1
G1P0A0 39 weeks
Mrs.
gestational age in
NUR / O36. Spontaneous
labor first stage 656 P1A0 Post spontaneous
27 yo /
latent phase SDF 4 delivery .4 delivery with IUFD
UA /
cephalic
HD
presentation
2
G1P0A0 40 weeks
Mrs. 64.0
gestational age not -Laboratory
SEL / O42. 0
inlabor with examination
10 73.0 P1A0 post LSCS o.i
25 yo / PROM 3 days, SLF -Antibiotics
O41. 1 unripe cervix
UA / cephalic -Induction  Fail
0 65.0
AF presentation, LSCS
74.1
Oligohydramnious
3 Stabilization
Ekspectative
management
Laboratory
G2P1A0 32 weeks
examination
Mrs. gestational age not MgSO4 40% 64.0 P1A0 Post LSCS o.i
YUL / in labor with Lung maturation
O15. 06
34 yo / severe Assessment Impending Eclampsia +
2 4.21
UA / preeclampsia, SLF internal Post IUD insertion
74.1
AA cephalic department
presentation Ekspectative
management
(Failed)
LSCS
4
• Observati
G1P0A0 38 weeks
on Vital
Mrs. gestational age in 64.0
Sign and
AYU / labor first stage O42. 0
FHR
latent phase with 10 73.0 P1A0 post LSCS o.i
20 yo / • Laborator
PROM 12 hours O41. 1 anhydramnious
UA / y
SLF cephalic 8 65.0
HD examinati
presentation + 74.1
on
anhydramnious
• LSCS
5. P2A0 post LSCS 6 O14.
days (outside) o.i 13 P2A0 post LSCS 6 days
severe O30. (outside) o.i severe
Mrs. preeclampsia + 0 preeclampsia + gemeli
MEL / gemeli with late O72. Medicinalis with late postpartum
postpartum 2 General 99.2 hemorrhagic c.b
37 yo /
hemorrhagic c.b O14. improvement 99.0 subinvolution uterine +
RA / subinvolution PRC transfusion partial HELLP
22
HD uterine + partial E88. syndrome +
HELLP syndrome 09 hypoalbumine +
+ hypoalbumine + D64. moderate anemia
moderate anemia 9

Obstetrical Patients Sunday, June 2nd 2019

No Identity Diagnosis ICD Management ICD Recent Diagnosis
10 9
1. G P A 39 weeks Observation Vital
2 1 0
Sign P2A0 Post LSCS o.i Prior
gestational age in labor
Mrs. POP / O34.21 Laboratory
st 669 cs 1x +
34 yo / UA 1 stage latent phase Examination
O09.01 .7 H/laparotomy 2x + post
/ AF with prior sc 1x + H/ LSCS
laparotomy 2x SLF Tubectomy tubectomy pomeroy
cephalic presentation pomeroy
2. Mrs. NIA/ G1P0A0 35 weeks O14.12 Stabilization 669 G1P0A0 35 weeks
21 yo / RA gestational inlabor first Observation Vital .7 gestational inlabor first stage
/ FU Sign
 MgS04 ~ protocol
Anti Hypertension
Laboratory
stage latent phase with Examination
Assessment latent phase with severe
severe preeclampsia
Internist and preeclampsia SLF cephalic
SLF cephalic
Ophthalmology presentation
presentation
Evaluation
Gestosis Task
P/ Vaginal
Delivery
3. Mrs. G1P0A0 31 weeks O42.0 Conservative G1P0A0 31 weeks of
SEP/ 28 of gestational age O32.1 management gestational age not in
yo/ UA not in labor with Obs. VS, labor with PPROM 12
HI PPROM 12 hours IVFD RL hours SLF Breech
SLF Breech Lab exam presentation
presentation Ampicillin 1
gr/ 6 hr
Dexamethason
12 mg/day
US
confirmation

Obstetrical Patients Monday June 3rd 2019

N Identity Diagnosis ICD 10 Previous ICD Recent
O Procedure 9 Diagnosis
G1P0A0 38 weeks
gestational age
st P1A0 post
Mrs. inlabor 1 stage
vaccum
YUN active phase with O98.3
1. Vaccum Extraction 66.9 extraction
/30 yo/ severe O14.1
with severe
RA/ FU
preeclampsia SLF preeclampsia
cephalic
presentation
• Conservati
ve
Managame
nt
G3P2A0 34
• Observatio
weeks
G3P2A0 34 weeks n of vital
Mrs. gestational
gestational age with signs,
ANI / age with
threatened preterm O30.0 FHR, 69.0
2. threatened
23 yo/ labor + prior CS 2x O61.0 contraction 99.8 preterm labor
RA/ FB SLF cephalic • Antibiotic
+ prior CS 2x
presentation • Lung
SLF cephalic
maturation
presentation
• Tocolytic
• P/ US
confirmati
on
Obstetrical Patients Monday June 3rd 2019
Identity Diagnosis ICD 10 Previous Procedure ICD Recent Diagnosis
N 9
O
3. G3P2A0 32 • Conservative G3P2A0 32
weeks Managament weeks
gestational age • Observation of gestational age
Mrs. not inlabor with vital signs, not inlabor with
WIN /27 antepartum O46.9 FHR, 69.0 antepartum
yo/ RA/ haemorrhage cb O32.1 contraction 99.8 haemorrhage cb
FB totalis placentae • Antibiotic totalis placentae
previa SLF • Tocolytic previa SLF
cephalic • P/ US cephalic
presentation confirmation presentation
4. G5P1A3 33
Stabilization
weeks
Observation Vital Sign
gestational age
MgS04 ~ protocol
not inlabor with
Anti Hypertension P3A0 Post
Mrs. prior cs 1x(a.i
Laboratory LSCS o.i
YOS/ 34 fetal distress) O14.12
Examination 74.1 impending
yo / RA / with impending E115.2
Assessment Internist eclampsia + IUD
AB eclampsia + DM
and Ophthalmology insertion
type II SLF
Evaluation Gestosis
cephalic
Task
presentation +
Plan for LSCS
AEDV
5. • Conservative
G3P2A0 34 Managament G3P2A0 34
weeks • Observation of weeks
gestational age vital signs, gestational age
with threatened FHR, with threatened
Mrs. IIS preterm labor + O30.0 contraction 69.0 preterm labor +
/ 35 yo/ herpes infection B00.9 • Antibiotic herpes infection
88.7
RA/ PB + ferritin E61.2 • Lung + ferritin
deficiency SLF maturation deficiency SLF
cephalic • Tocolytic cephalic
presentation • P/ evaluation presentation
polyhidramnions HSV 1-2 test (2 polyhidramnions
days later)
6. Mrs. G4P1A2 38 O14.12 Stabilization 74.1 P2A2 Post
LIS/ 39 weeks O98.30 Observation Vital Sign LSCS o.i
yo/ RA/ gestational age MgS04 ~ protocol transverse lie
FB inlabor 1st stage Anti Hypertension
laten phase with Laboratory
severe Examination
preeclampsia + Assessment Internist
prior cs 1x (a.i and Ophthalmology
severe Evaluation Gestosis
preeclampsia) Task
Plan for LSCS
 SLF transverse
lie presentation

Obstetrical Patients Tuesday, June 4th 2019

N Identity Diagnosis ICD 10 Previous ICD Recent

O Procedure 9 Diagnosis
1 G1P0A0 39
weeks
gestational age P1A0 post LSCS
Mrs.
in labor first O32.9 74 oi breech
ADE / LSCS + IUD
stage latent V25 presentation +
15 yo / Q00.0 insertion
phase SLF .11 post IUD
UA / FY
breech insertion
presentation +
anencephaly

Obstetrical Patients Wednesday June 4th 2019

Identity Diagnosis ICD 10 Previous Procedure ICD Recent Diagnosis

N 9
O
1. G3P2A0 33
weeks • Laboratory P3A0 Post
Mrs. gestational age
O34.21 Examination LSCS o.i prior
YEN / inlabor first stage 74.1
• LSCS CS 2x + post
31 yo / latent phase with O47.0 66.3
• Tubectomy tubectomy
UA / AF prior CS 2x SLF Pomeroy pomeroy
Cephalic
presentation
2. G3P1A1 34 G3P1A1 34
weeks • Conservative weeks
gestational age management gestational age
Mrs.
with threatened • Laboratory with threatened
ANI / 26 O34.21
preterm labor + examination 99.1 preterm labor +
yo/ UA / O47.0
prior CS 1x (oi • Tocolitic prior CS 1x (oi
NS
anhydramnios) • Lung anhydramnios)
SLF Cephalic maturation SLF Cephalic
presentation presentation
3. G7P6A0 37
weeks • Laboratory
Mrs. gestational age Examination P7A0 post
RUS/ 39 inlabor first stage O60.1 • Plan for 72.5 partial extraction
yo/ UA/ active phase D64.9 vaginal 69.7 + post IUD
AF +moderate delivery insertion
anemia SLF • IUD insertion
breech
presentation
4. G1P0A0 38
weeks
Mrs. gestational age • Laboratory P1A0 Post
RIA / 22 inlabor first stage O60.1 Examination spontaneous
72.5
yo / UA / latent phase with B19.1 • Vaginal delivery with
AF Hepatitis B SLF delivery Hepatitis B
Cephalic
presentation
5. G1P0A0 39
weeks
IND/ 29 gestational age • Plan for P1A0 Post
O60.1
yo/ UA/ with history of vaginal 72.5 Spontaneous
AF O42 delivery
PROM 6 hours delivery
SLF Cephalic
presentation
6. G1P0A0 31
weeks
SEP/ 28 gestational age P1A0 Post
O34.21
yo/ UA/ with history of • LSCS 74.1 LSCS oi
HI O42
PROM 8 days anhydramnios
SLF Cephalic
presentation
7. G3P2A0 39
weeks
gestational age P3A0 Post
Mrs. inlabor first stage • Stabilization
SAN / 33 latent phase with O60.1 • Antihypertensi LSCS oi
72.5 macrosomia +
yo / UA / severe O14.1 on
AF • LSCS severe
preeclampsia +
preeclampsia
PROM 3 hours
SLF Cephalic
presentation
8. G3P2A0 34 G3P2A0 34
weeks • Expectative weeks
Mrs. SIT gestational age O34.21 management gestational age
/ 37 yo/ with APH cb • Lung 99.1 with APH cb
UA/ AF O44.1 maturation
PPT SLF PPT SLF
Cephalic • Tocolitic Cephalic
presentation presentation