Clinical Report

Monday, December 4th 2022

Doctors in charge
1.
2. DWO
3.
4. DSI
5. BSE

Action Supervisor : dr. AAT, Sp.O.G.Subsp. K.Fm, M.Med.Ed

Operating Supervisor : LNI
Chief on Duty : AMU/MRE
General consultant : AJP
07.00 - 14.00 : dr. AAT, Sp.O.G.Subsp. K.Fm, M.Med.Ed
14.00 – 21.00 : dr. R. Detty Siti Nurdiati, MPH, PhD,SpOG Subsp. KFm

21.00 – 07.00 : dr. UCA, Ph.D, SpOG

II. OPERATING ROOM

A. MAJOR OBSTETRIC (1)
ER 1. Mrs. DS, 30 yo, G2P1A0, GA 36W0D
26/12/22 MR 02040186
03..
JKN NPBI LNI with permission dr.AAT, Sp.O.G.Subsp. K.Fm,
DPJP dr. MIA M.Med.Ed with assistant AMU and MRE had emergency
section cesarean with pomeroy sterilization e.c fetal
G2P1A0, 30 yo compromised, IUGR, P1A0, with the mother has AVSD
LMP 16/4/2022 incomplete with PH
EDD 21/01/2023
GA 36W2D At 10.10 baby delivered by section cesarean, female, BW
1566 gram, BH 39 cm, HC/CC 27/24 cm, AS 8/9/10.
BP 110/65 mmHg
HR 72 Bpm At 10.16 placenta was delivered, size 14x12x1,2 cm, weight
R 20 360 gr, CL 26 cm, paracentralis insertion, calcification (-).
T 36.0’C
SpO2: 98% RA

BW currently 73 kg
BW before
pregnancy 63 kg
weight gaib 10 kg
BH 161 cm
BMI 24.32 kg/m2

Chronology Lab Panti Rini

26/12/22 (01.30)
S: Referral patient from Panti Rini Hospital with fetal distress, Hgb 11.5
G2P1A0 36 weeks pregnant. The patient complained of RBC 3.74
bleeding from the birth canal since 00.30, contraction (+) more WBC 12.23
frequent, history of falling (-), leaking membranes (-), PCT 147
heartburn (-), headache (-), nausea, vomiting (-) , CHAPTER Net 80
and BAK dbn. The patient felt decreased fetal movement since Lim 12.8
around 03.00 while still at Panti Rini Hospital. Then the Lab 26/12/22
patient was referred because of fetal distress and arrived at the (06.30 )
RSS emergency room at 05.28. From the referrer, it was stated RBC 2.94
that since on the road DJJ had not been detected with fetal Hgb 9.5
doppler, then when he arrived at the RSS, a repeat of DJJ was Hct 27.9
also not found either by Fetal doppler or ultrasound and the MCV 95.0
fetus was declared dead (IUFD). From the time the referral MCH 32.4
hospital arrived at the RSS, the amount of bleeding was MCHC 34.1
around 750 ml. The patient came for referral from Panti Rini WBC 19.6
Hospital with fetal distress, G2P1A0 36 weeks pregnant. The Net# 17.50
patient complained of bleeding from the birth canal since Lim# 0.93
00.30, louder (+) more frequent, history of falling (-), leaking PCT 93
membranes (-), heartburn (-), headache (-), nausea, vomiting Na 137
(-) , CHAPTER and BAK dbn. The patient felt decreased fetal K 4.1
movement since around 03.00 while still at Panti Rini CL 106
Hospital. Then the patient was referred because of fetal HBsAg NR
distress and arrived at the RSS emergency room at 05.28. SARS COV2
From the referrer, it was stated that since on the road DJJ had negative
not been detected with fetal doppler, then when he arrived at IgM NR
the RSS, a repeat of DJJ was also not found either by Fetal NLR
doppler or ultrasound and the fetus was declared dead (IUFD).
From the time the referral hospital arrived at the RSS, the
amount of bleeding was around 750 ml.

Menstrual history: menarche aged 14 years, regular, duration 7

days, cycle 28 days, excessive menstrual pain (-), change pads
2-3x/day
Marriage history: 1x since 2016 (6 years)
ANC history: > 5x at PKM, >3x at SpOG
Obstetric history:
1. Female, 3300 gram birth weight, spontaneously at the
midwife, 5 years
2. This pregnant
Family planning history: denied
Operation history: denied
Medical history: DM (-), HT (-), Heart Disease (-), Thyroid
disease (-), Allergy (-)

O: General condition good conscious

Head: CA -/-, SI -/-
Thorax: Vesiculer +/+, retraction-/- Rhonki -/- whz -/
Abdomen: single fetus elongated, cephalic presentation, FHR
(-) motion (-) uterine conctraction2x/10’ /10”/Medium, FH 33
cm, EFW 3245 gram
Inspection: Normal stolsel vulva urethra (+), visible blood
flowing from the OUE (-)

A: IUFD, Lots of Antepartum Bleeding ec PPT, G2P1A0 GA

36W2D

P:
Proposal: Emergency caesarean
report to dr. Lutfi, SPOG(K) is not yet connected
report to dr. Shinta SpOG(K) acc dx tx, advice keep reporting
back to dr. Lutfi SpOG(K)
CTG (12/04/22)

FHR baseline 130

bpm
Variability >5
Acceleration -
Deceleration –
Movement (+)
His –
Category 3

Ultrasound 26/12/22
Single fetus looks
elongated, cephalic
presentation, motion
(-), FHR(-),
Amniotic fluid
sufficient
impression, SDP
2.03 cm, placenta
covering the corpus
anterior extends
inferiorly covering
the OUI
BPD 8.63 cm-34w5d
HC 31.9cm-35w6d
AC 30.6cm-34w1d
FL 5.66 cm-29w5d
EFW 2178 grams

Chest X-Ray

-Pulmonal
Hypertension
- Bilateral
Pneumonia
- Cardiomegaly,
LAE, LVH
Levoskoliosis
thoracales
Documentation
ACC Anest Anest Perina Patient Perina Anest Surgery Surgery
DPJP Consult ACC consult came came started started finished

Condition this morning

BP 140/70 mmgHg CM Hb post op
HR 87 bpm CK
R 26 bpm BC g/dl
T 36,5 c UO
SpO2 90% with NRM 15lpm

ACC Anest Anest Perina Patient Perina Anest Surgery Surgery

DPJP Consult ACC consult came came started started finished

Condition this morning

BP CM Hb post op
HR CK
R BC g/dl
T UO

ACC Anest Anest Perina Patient Perina Anest Surgery Surgery

DPJP Consult ACC consult came came started started finished

Condition this morning

BP CM Hb post op
HR CK
R BC g/dl
T UO

B. MAJOR GINECOLOGYC (1)

 Condition this morning
BP IF Hb Post op
HR OF
RR BC
T UO

C. MINOR GINECOLOGYC (0)

NIHIL
D. STERILIZATION (0)
NIHIL
III. OPERATION PLAN
A. MAJOR OBSTETRIC (0)
NIHIL
B. MAJOR GINECOLOGYC (0)
NIHIL
C. MINOR GINECOLOGYC (0)
NIHIL
D. STERILIZATION (0)
NIHIL
IV. HOSPITALIZED PATIENT (3)
1. Mrs. Lab
LMP RM
EDD WBC
GA Dx: RBC
Hb
BP mmHg Tx: Plt
HR Neut#
R Limf#
T °C NLR

BW kg
BH cm
↑ BW kg
BMI kg/m²
USG

2. Mrs. Lab
MR
BP WBC
HR Dx: RBC
RR Hb
T Hmt
Plt
BH cm Net#
BW kg Limf#
BMI HBsAg NR
SARS COV2 IgM
NR
USG

3. Mrs Lab
G1P0A0, 31 yo MR
LMP WBC
EDD Dx: RBC
GA
Hb
Tx: proposed:
BP Hmt
HR Plt
RR Net#
T Limf#
APTT
BH cm Alb
BW kg SGOT
↑ BW kg
SGPT
BMI
BUN
Cre
BG
Na
K
Cl
Mg
K
USG
 V. WARD SITUATION
1. Bougenvill 1 2. Bougenvill
ONKO: - Obs:
Gin : - Gin: -
ER: - MFM:
ER: -
Onko:
3. IMP 4. Other Wrds
MFM: Onko:
Obs: - ER: -
Obs:
Gin: -
MFM:
VI. PATIENT IN OTHER WARDS (4)
1. Mrs. Lab 2
P1A0, yo MR
Menopouse 1 year WBC
Dx: RBC
BP Hb
HR Tx: Hmt
RR
Plt
T
Net#
Limf#
APTT
Alb
SGOT
SGPT
BUN
Cre
BG
Na
K
Cl
Mg
K
2. Ms. Lab
MR
WBC
Dx: RBC
Hb
Tx: Hmt
Plt
Net#
Limf#
APTT
Alb
SGOT
SGPT
BUN
Cre
 BG
Na
K
Cl
Mg
K
VII. PHC RECAPITULATION
1. Tegalrejo 2. Jetis
Physiologic : 0 Physiologic : 0
Pathologic : 0 Pathologic : 0
IUD 0 IUD 0
VIII. DELIVERY ROOM (2)
IMP E2 1. Mrs. BE
25/05/20 MR
17.00 Not examined
JKN PBI Dx:
DPJP DR
Tx:
GPA, yo
LMP
EDD
GA

BP
HR
R
T

CM
CK
BC
UO

His (-)
FHR bpm
IX. OBSTETRIC HEMORRHAGE PPH Death
RS BANJARNEGARA 0 0
RS WONOSOBO 0 0
RS WATES 0 0
RS PATI 0 0
RS CILACAP 0 0
RS KLATEN 0 0
RS MUNTILAN 0 0
RS BANTUL 0 0
RS WONOSARI 0 0
RS SLEMAN 0 0
RS PURWOREJO 0 0
RS BANYUMAS 0 0

Corrector Jaga Tua

HBA
UTA/RPA
Chief on Duty

HRD