Duty Report

August 11-17, 2014
Consultants :
dr. St. Finekri Abidin, OBGYN (C)
dr. Bintari Puspasari, OBGYN
dr. T. Indang Dewi, OBGYN (C)

RSGS Team August 2014

Reporting • 4 Caesarean sections .

CAESAREAN SECTION #1 .

closed. state: preeclampsia.15 Mrs.00 Blood pressure elevated since 2 months Vt: portio firm.9/31/9200/182000 Placenta born dysmenorrhea (-) SGOT 35 SGPT 20 Alb 3. previous contractions. H I adhesion Frontal headache (-). boy 3800 g. 54 cm AS Active fetal movement Lab: 8/9 CBC (11/8/14) Clear amniotic fluid Menarche 12 yo.00 – 03. miscarriage.6 RBG 115 Married 1x Na 138 K 3. ANC regularly at OBGYN (Bogor). GP 3x/day.6 completely Ur 19 Cr 0. bloody show I: V/U wnl Vit C 2 x 400 mg IV (-) Io: smooth portio. presentation. TB 169 cm: BMI 31. baby in good condition. Born baby boy. curettage at RS Bogor Singleton live head presentation.1999. miscarriage. reguler. MR. MgSO4 LMP 4/12/13 (unsured) EDD 11/9/14~ 35-36 not in labor Nifedipine 4 x 10 wga. Observe worsening CC: Referred from RS Bersalin Pasutri with kg/m2 superimposed of preeclampsia suspected severe preeclampsia. posterior. t 3cm. 9. Gen. not given drugs.2009. BP : 170/100 Pregnancy. SC at RSPAD due to cord placenta implanted at fundus. water broke (-).Day S O A P 11/8/14 SCTPP Physical examination G5P2A2 Term P: DAY I Compos mentis.4/HC 36 / AC 37/ FL 7. 02. 41 yo mmHg. spontaneous delivery at RSPAD US exam (7/7/14) Hb Post op: 9. FHR 152 NAC 3 x 600 mg PO Contraction (-). head mg at every visit. 3. 129632 36OC fetus.5 C-section 1x. FHR BB: 90 kg. blurred vision (-) CTG: Category 1 4050 gr.6 Cl 108 FP : Tubectomy Obs history: G5P2A2 Ul protein +2 Pomeroy 1. head 4/5.2011. LUS free of (140/90 mmHg). Pale conjungtive -/-. girl 3000 g. Observe 22. curettage at RS Bogor BPD 9. T : singleton live hemodynamics.2007.4/ AFI Now patient 5. nausea / vomiting (-). susp Emergency CS Patient admitted 9 month pregnancy.8 g/dl 2. flx (-). FR 20x/m. Her abd ~ pregnancy macrosomia. entanglement normal implantation Outcome: 4. P: 86x/m. closed ostium.This pregnancy normal/ EFW 4075 (130/90 mmHg) and baby are in good . flr (-). Ella Sofhia. USG Obstetrical Status: FH 36 cm.

CAESAREAN SECTION #2 .

Anterior part of uterus closed. ready presentation.8/HC 314/ AC 330/ FL 76/ mmHg) and baby are in 1. Obstetrical Status : FH 30 cm. head 4/5. H I was adhered to Blood pressure elevated since previous omentum  pregnancy.30 fetal movement Vt: portio firm. blurred vision (-) Ul protein +2 FP: IUD TC Menarche 12 yo.00 Mrs.6 RBG 83 completely Frontal headache (-). for rooming in . Io: smooth portio. 14. FHR MR. normal implantation Now patient (BP 130/90 Obs history: G2P1 BPD 8. 12/8/14 Contraction (-). placenta implanted at right Outcome: Married 1x corpus. P: 84x/m.8 g/dl dysmenorrhea (-) Singleton live head presentation. FHR NAC 3 x 600 mg PO 19/8/14~ 39 wga. consulted to internal medicine dept.2005. flx (-).5 SP / EFW 3000 good condition. Nifedipine 4 x 10 mg Her LMP 12/11/13 (unsure) EDD head presentation.9 Cl 106 (-). In RSGS policlinic patient got CTG: Category 1 Adhesiolysis Methyldopa 3x500 mg and was already Lab: Born baby girl.9 Placenta born Ur 19 Cr 0. state: previous CS 1x preeclampsia CC: irreguler contraction since 5 hours Pale conjungtive -/-. FR 18x/m. reguler. water broke (-). SC at RSPAD due to breech AFI 3. closed ostium. 2780 gr. baby in good condition. CBC (11/8/14) 49 cm AS 8/9 already plan for elective c-section at 10. severe contractions. BP : 160/110 singleton live Observe hemodynamics. girl 2500 g. before admission abd ~ pregnancy Emergency CS MgSO4 Patient admitted 9 months pregnancy. USG 4x. T : fetus. US exam (7/7/14) Hb Post op: 11. 242324 36OC preeclampsia.7/32/14000/395000 Clear amniotic fluid 18/8/2014 SGOT 16 SGPT 19 Alb 3. Dwi Novianti. Observe worsening of Gen.30 – 15. posterior.Day S O A P 11/8/14 SCTPP Physical examination G2P1 38 wga. 33 yo mmHg. P: DAY I Compos mentis. t 3cm. nausea / vomiting Na 140 K 3. GP 3x/day. ANC regularly at 146 Vit C 2 x 400 mg IV KesDip Tangerang then referred to I: V/U wnl RSGS. active flr (-). 14.

CAESAREAN SECTION #3 .

axial. Obstetrical Status : FH 32 cm.This pregnancy US exam (7/7/14) Singleton live head presentation. FR 18x/m.2011. head H I-II Menarche 13 yo. closed ostium. normal implantation BPD 90/HC 311/ AC 344/ FL 71/ AFI 12 / EFW 3159 .4 g/dl dysmenorrhea (-) Lab: CBC (7/8/14) Outcome: Married 1x 10. active fetal movement Vt: portio firm.6 RBG 79 already discharged 2. 1. 146. girl 2600 g. 3100 gr. 12/8/14 Her LMP 10/11/13 EDD 17/8/14~ 39 head presentation. USG 3x. reactive Consult to perinatology show since 1 day before admission abd ~ pregnancy for HepB Ig Patient admitted 9 months pregnancy. placenta implanted at leftcorpus. GP 2-3x/day. t 2 cm. 3. CTG: Category 1 Hb Post op: 10. Planned for I: V/U wnl 50 cm AS 8/9 elective CS on 19/8/2014 due to Io: smooth portio. P: 92x/m. reguler.00 – 21. head 4/5. baby in good condition.00 Mrs. 419713 36OC singleton live Gen. 31 yo mmHg. spontaneous Ul wnl delivery at RSAL. miscarriage Ur 14 Cr 0. Arum A.00 wga. Placenta born Water broke (-). contractions. 2 cm completely dilatation.Day S O A P 13/8/14 SCTPP Physical examination Latent phase of P: DAY I Compos mentis. FHR MR.2008. Clear amniotic fluid HbsAg(+) flr (-). 15. FHR 20. HbsAg Emergency CS CC: irreguler contractions and bloody Pale conjungtive -/-. BP : 100/70 labor in G3P1A1 Observe hemodynamics. flx (+). ANC regularly at RSGS. state: fetus.6/31/11830/221000 Now patient and baby Obs history: G3P1A1 SGOT 20 SGPT 19 are in good condition. his 1-2 x/10’/40’’ Born baby boy. T : 38 wga.

CAESAREAN SECTION #4 .

P: 90x/m. FR 18x/m. head 2/5. water I: V/U wnl start at 8 tpm. BP : 110/50 phase of labor in Observe hemodynamics. placenta implanted at anterior corpus. FHR Acceleration with wga. normal implantation BPD 91/HC 314/ AC 310/ FL 79/ AFI 4. Grace A.6/36/24000/226000 Menarche 12 yo. adequate contractions transverse or max 40 tpm.This pregnancy Singleton live head presentation. his 1-2x/10’/45’’ Oxytocin 5 IU/500 cc RL. T : G1 40-41 wga. delivery Her LMP 29/10/13 EDD 5/8/14~ 41 head presentation. 4 tpm/30 mins until movement head H II-III. 26 yo mmHg. 7 cm dilatation.30 Mrs. Contraction (+) since 10 hours. reguler.6 RBG 108 Ul protein wnl Married 1x Obs history: G1 US exam (7/7/14) 1. escalated broke (+) 18 hours. contractions. 20. Patient was given oxytocin drip 24 drip/minute for 12 hours at PHC. Active fetal Vt: portio thin. 440720 36. 156. GP 3x/day. Obstetrical Status : FH 33 cm. SGOT 3 SGPT 20 dysmenorrhea (-) Ur 15 Cr 0. CTG: Category 1 Ceftriaxone 1 x 2 g IV Dilatation 4 cm  6 cm  7 cm  7 cm Lab: (every 4 hours) CBC (13/8/14) 12. state: fetus intrauterine infection CC: Referred from Tebet PHC due to Pale conjungtive -/-. ANC regularly at PHC.5OC singleton live Observe signs of Gen.1 / EFW 3100 .Day S O A P 13/8/14 SCTPP Physical examination Inertia of active P: DAY I Compos mentis. FHR MR. and cord compression prolonged active phase of labor abd ~ pregnancy Initial plan: vaginal Patient admitted 9 months pregnancy. small fontanel left.

singleton live fetus FR 18x/m.00 in G1 40-41 wga. caput H III+.00 13/8/14 Frequent contractions. live fetus FR 18x/m.00 110/70 mmHg. 3150 gr. Obstetrical Status : FHR 50 cm AS 8/9 150.5OC Management of second Gen. active fetal Physical examination Second stage of labor in Observe hemodynamics. singleton live fetus 13/8/14 Frequent contractions. BP : of labor in G1 40-41 120/80 mmHg. his 4x/10’/45’’ Nil amniotic fluid I: V/U wnl Placenta born Vt: complete cm completely dilatation. DAY I movement FHR 142 dpm on active phase of labor evaluate after 3 hours 22. state: wnl Born baby girl. small fontanel left-transverse 14/8/14 Frequent contractions. wga.5OC 03:00 Gen. his 4x/10’/45’’ I: V/U wnl Vt: complete cm dilatation. active fetal Physical examination Distosia of second stage Emergency CS 02.Day S O A P 13/8/14 Oxytocin drip is administered (8 tpm) DAY I 21. singleton contractions. BP : G1 40-41 wga. T : 36. small fontanel Now patient and baby posterior are in good condition already discharged . DAY I movement Compos mentis. state: wnl stage Obstetrical Status : FHR 150. FHR 24. active fetal His 3-4 x /10’ / 45’’ Adequate contractions Sustain oxytocin drip. P: 90x/m.00 movement Compos mentis. P: 86x/m. head H III. T : 36. head H III.

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