CONTRACEPTIVE CLINIC,

LACTATION-PUERPERAL
OUTPATIENT and OPERATIVE
REPORT
Monday, February 6th 2017
Doctor incharge:
Dr. H. Asrol Byrin, OBGYN(C)

Supervisor:
Dr. H. Azhari, OBGYN(C)
Dr. H. Firmansyah Basir, OBGYN(C)

Residents on Duty:
Dr. Rakhmad Hidayat
Dr. Almuhir Yuliansyah 1
 Total
Identity
Patient on
Total
2017
6 Feb Tota
1 jan 3 Feb
2017 2017 l
Counselling contraception:
Another contraception - - -
Interval contraception 14 - 14
Control post contraception - - -
IUD insertion 8 1 9
Removal of IUD 1 - 1
IUD insertion after
1 - 1
curretage
Implant insertion
8 - 8
Batch number: 3E03B140
Removal of Implant 2 - 2
Tubal ligation 5 - 5
LSCS + Tubal ligation 5 - 5
DMPA 8 2 10
Total patient consult
52 3 55 2
to Contraceptive Outpatient
 Family Planning
No. Identity Diagnosis ICD-10 Manageme ICD-9
nt
Mrs. P3A0 post LSCS due
DMPA
1. MAR/35 to total plasenta O65.5 Z30.013
Injection
yo/UA preve (4th day)
Mrs. P1A0 post
IUD
2. WEN/28 spontaneous delivery O36.4 V25.42
Insertion
yo/UA (3rd day)
Mrs. P1A0 post
DMPA
3. ROM/20 spontaneous delivery O36.4 Z30.013
Injection
yo/UA (3rd day)

3
 Lactation and Puerpural
No. Identity Diagnosis ICD-10 Manageme ICD-9
nt
Mrs. OKT/29 P2A0 post spontaneus
1. O36.4 Counseling V65.40
yo/UA delivery (8th day)
P1A1 post LSCS due to
Mrs. PUJ/26
2. anhydramnios (11th O65.5 Wound care V58.30
yo/UA
day)
P1A2 post LSCS due to
Mrs. FIT/27
3. severe preeclampsia O65.5 Wound care V58.30
yo/UA
+ BOH (11th day)

4
5
 Family
Planning

6
Identity 1. Mrs. MAR/35 yo/UA
Chief Contraception counseling
complaint
History Patient has performed LSCS due to total plasenta
preve on February 2nd 2017. Male dead baby was
born, BW 3200 g, BL 52 cm, maseration grade II
Marital status 1x, 9 years
Reproduction Menarche since 14 yo, regular cycle 28 days, 7 days,
status LMP: 05/05/2016
Obstetric 1. 2008, female, 3200 g, aterm, spontaneous,
history midwife, health
2. 2011, female, 3200 g, aterm, spontaneous,
midwife, health
3. 2017, male, 3200 g, aterm, CS due to total plasenta
preve, M. Hoesin Hospital, dead
Obstetrical Palpation: fundal height was in 2 fingers below
examination umbilical, good contraction, no active bleeding
Diagnosis P3A0 post LSCS due to total plasenta preve (4th day)
Management DMPA injection
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Identity 2. Mrs. WEN/28 yo/UA
Chief Contraception counseling
complaint
History Patient has performed spontaneous delivery on
February 3rd 2017. Male life baby was born, BW 3400
g, BL 47 cm, A/S 8/9 FTAGA
Marital status 1x, 1 years
Reproduction Menarche since 13 yo, regular cycle 28 days, 5 days,
status LMP: May 2016
Obstetric 1. 2017, male, 3400 g, aterm, spontaneous, M. Hoesin
history Hospital, healthy
Obstetrical Palpation: fundal height was in 2 fingers below
examination umbilical, good contraction, no active bleeding
Diagnosis P1A0 post spontaneous delivery (3rd day)
Management IUD insertion

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Identity 2. Mrs. ROM/20 yo/UA
Chief Contraception counseling
complaint
History Patient has performed spontaneous delivery on
February 3rd 2017. Female life baby was born, BW
2500 g, BL 46 cm, A/S 8/9 FTAGA
Marital status 1x, 2 years
Reproduction Menarche since 13 yo, regular cycle 28 days, 5 days
status
Obstetric 1. 2017, male, 2500 g, aterm, spontaneous, M. Hoesin
history Hospital, healthy
Obstetrical Palpation: fundal height was in 2 fingers below
examination umbilical, good contraction, no active bleeding
Diagnosis P1A0 post spontaneous delivery (3rd day)
Management DMPA injection

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Lactation and
Puerpural

10
Identity 1. Mrs. OKT/29 yo/UA
Chief Control post spontaneous delivery
complaint
History Patient have performed spontaneous delivery at
January 29th, 2017. Female life baby was born, BW
3000 g, BL 46 cm, AS 8/9 FTAGA
Marital status 1x, 5 years
Reproduction Menarche since 15 yo, regular cycle 28 days, 7 days,
status LMP: 15-05-2016
Obstetric 1. 2013, male, 2900 g, aterm, spontaneous delivery,
history Bhayangkara Hospital, health
2. January 29th, 2017, female, 3000 g, aterm,
spontaneous delivery, Mohammad Hoesin Hospital,
health
Obstetrical Palpation: fundal height was in 1 finger below
examination umbilical, good contraction, no active bleeding
Diagnosis P2A0 post spontaneous delivery (8th day)
Management Counseling
Identity 2. Mrs. PUJ/26 yo/UA
Chief Control post operation C-Section
complaint
History Patient have performed C-section operation at January
26th, 2017 due to anhydramnios. Male life baby was
born, BW 2400 g, BL 46 cm, the Baby was dead in
NICU
Marital status 1x, 1 year
Reproduction Menarche since 12 yo, regular cycle 28 days, 7 days,
status LMP: 22-04-2016
Obstetric 1. 2016, 7 weeks, abortion, no curretage
history 2. January 26th, 2017, male, 2400 g, aterm, CS due to
anhydramnios, Mohammad Hoesin Hospital, dead
Obstetrical Inspection: abdominal flat, simetry, no active
examination bleeding, fundal height unpalpable, incision
pfannensteil wound was good.
Diagnosis P1A1 post LSCS due to anhydramnios (11th day)
Management Wound care
Identity 3. Mrs. FIT/27 yo/UA
Chief Control post operation C-Section
complaint
History Patient have performed C-section operation at January
26th, 2017 due to prior severe preeclampsia + BOH.
Male life baby was born, BW 2900 g, BL 46 cm, AS 8/9
FTAGA
Marital status 1x, 5 years
Reproduction Menarche since 12 yo, regular cycle 28 days, 7 days,
status LMP: 18-04-2016
Obstetric 1. 2013, 3 months, abortion, curretage, Bari Hospital
history 2. 2015, 10 weeks, abortion, no curretage
3. January 26th, 2017, male, 2900 g, aterm, CS due to
severe preeclampsia + BOH, Mohammad Hoesin
Hospital, health
Obstetrical Inspection: abdominal flat, simetry, no active
examination bleeding, fundal height unpalpable, pfannensteil
incision wound was good.
Diagnosis P1A2 post LSCS due to severe preeclampsia + BOH
(11th day)