FETOMATERNAL WARD REPORT 6 Feb 2 Pat

FETOMATERNAL WARD REPORT
Tuesday, February 6th 2018
Supervisor:
dr. Zanibar Aldy, MKed(OG), SpOG
Residents : 1. dr. Mega Sari Dewi

2. dr. Alyuhaz Nasution
3. dr. Effinia Kamila Hanum Siregar
Department of Obstetric and Gynecology

Medical Faculty – Universitas Sumatra Utara
Pirngadi General Hospital
2018
NEW PATIENT : 2 PATIENTS
NO Case Result
1. Mrs. D, 35 yo, P2A0 Therapy :
- Cefadroxyl 2 x 500 mg
Diagnosis: - Mefenamic acid 3 x 500 mg
Post C-section d/t fetal bradycardia + - B comp 2 x 1
Hepatitis B + PD3 - Other therapy based on interna
department
A male baby was born with
BW 3350 gr, BL 47 cm, AS 7/9, anal (+) Planning :
on Friday, February 2nd 2018 on 15.30 pm - Change verband
- Ambulatory today
NO Case Result
2. Mrs. E, 35 y.o, P3A0 Therapy
- IVFD RL 20 dpm
- Inj. Ceftriaxone 1 gr / 12 hours
- Drips Metronidazole 500 mg / 8
Diagnosis: hours
• Post C-section d/t fetal distress + PE with - Inj. Ketorolac 30 mg / 8 hours
severe feature + severe oligohydramnion + - Inj. Ranitidine 50 mg / 12 hours
PD3 - Nifedipine 4 x 10 mg
Plan:
- Waiting for thorax Ro result
- Evaluation vital sign, uterine
contraction, vaginal bleeding,
fluid balance and signs of post
partum eclampsia
- Patient move to FM ward
THANK YOU
Patient 1
Mrs. D, 31 y.o, G3P2A0, Bataknese, Christian, Junior High
School, Farmer, wife of Mr. M, 54 yo, Bataknese, Christian,
Junior High School, Farmer, came to Pirngadi General
Hospital at February 3rd 2018 with:
CC : Amniotic fluid leakage

This has been experienced by the patient since February 2nd
2018 at 8 am. History of labor contraction (-). Bloody slime
(-). Micturition and defecation was within normal limits. This
patient was refered from HKBP Balige Hospital with
diagnosis “MG + IUP (38-39) wga + head presentation + alive
fetus + HbsAg (+)”
• Prev Illness : (-)
• Prev Medication : (-)
LMP : 25/4/2017
EDD : 1/2/2018
ANC : Obstetrician 3 times, midwife 3 times
History of Pregnancy
1.Female, 3000 gr, aterm, SVD, midwife, clinic, 3 yo,
healthy
2.Female, 3000 gr, aterm, SVD, midwife, clinic, 2 yo,
healthy
3.Current pregnancy
Present state
Cons : Fully alert Anemic : -
BP : 100/60 mmHg Icteric : -
Pulse : 88 times/min Dyspnea : -
RR : 20 times/min Cyanosis: -
Temp : 36.8 °C Dyspnea : -
Localized state
• Head : Eye  Pale palpebra conjuctiva (-),
icteric (-)
• Neck : Lymph node enlargement (-)
• Cor : S1 > S2, additional sound : (-)
• Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-),
Rales (-)/(-)
• Genitalia : No abnormalities
• Superior Ext : No abnormalities
• Inferior Ext : Oedem : (-)/(-)
Obstetrical state
Abdomen : Asimetrically enlarged
Fundal height : 3 finger below umbilical (34 cm)
Tension part : Right
Lower Part : Head (Floating 5/5)
Fetal movement : (+)
Fetal Heart Rate : 110 bpm, regularity
Uterine contraction: (-)
EFW : (34-13) x 155 = 3255 gr
Gynecology state
VT: Cx sacral, dilated 1 cm, effacement 40%, hodge I-II,
amniotic membrane (-), minor fontanelle (?)
Gloves: amniotic fluid (+), blood slime (+)
LABORATORY FINDINGS on February 3rd, 2018
• Hb : 10,5 N: 12-14 gr/dl

• Ht : 33,7 N: 36-42 gr/dl
• RBC : 4,28 N: 4-5,4X106 uL
• WBC : 10.520 N:4000-11000/mm3
• Platelet : 331.000 N:150000-400000/mm3
• MCV : 78,7 N :80-97fL
• MCH : 24,5 N :27-33.7pg
• MCHC : 31,2 N :31.5-35g/dL
• PT : 15,8 C : 11,6-14,5 seconds
• APTT : 32,2 C : 28,6-42,2 seconds
• INR : 1,21 N : 1-1,3
• SGOT : 19 N : 0-40
• SGPT : 15 N : 0-40
LABORATORY FINDINGS on February 3rd, 2018
• Ureum : 10,0 N : 10-50 mg/dL

• Creatinin : 0,24 N : 0,60-1,20 mg/dL
• HbsAg : (+) N : (-)
• Anti HIV : (-) N : (-)
• Ad random glucose: 98 N : < 200 mg/dLs
• Natrium : 142 N : 136-155
• Potassium : 3,8 N : 3,5-5,5
• Chloride : 118 N : 95-103
Diagnosis:
Hepatitis B + MG + IUP (38-39) wga + head presentation + alive fetus + fetal
bradycardia
Therapy:
- IVFD RL 20 dpm
- Inj. Ceftriaxone 2 gr/IV  skintest (profilaxis)
Plan:
- Immediate C-section
- Consult to Anestesiology Departement
- Consult to Perinatology Departement
Reported to Supervisor on duty dr. Irliyan Saputra, MKed(OG), SpOG →

Approved
Decision Point
• Fetal bradycardia
• Hepatitis B
Post C-Section d/t Fetal bradycardia + Hepatitis B
A female baby was born with BW 3350 gr, BL 47 cm, AS 7/9, anal (+)
on February 3rd, 2018
Time
10.00 Decision
11.45 - The patient was positioned on the operating table in supine position under
spinal anesthesia with intravenous and catheter indwelled properly
-Aseptic and antiseptic protocol was performed using povidone iodine 10%
and 70% alcohol in the abdominal wall. The abdomen was then covered with
sterile cloth except the operating field
11.50 - Time out
11.55 - Pfanensteil incision was performed and deepened from cutis, subcutis to
fascia
By inserting the underlying anatomical tweezers, fascia was cut to right and
left.
Rectus abdomins muscle was separated to the upward and downward.
Peritoneum was clamped, and supended, and then cut cranially caudaly,
Uterus seems appropriate to the gestational age.
The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium was penetrated
bluntly and widened according to the incision.
Time
12.25 By grasping the head, a male baby with BW 3350 gr, BL 47 cm, AS 7/9, anal
(+) was born. The umbilical cord was clamped in two places and cut in-
between.
The placenta was born with an emphasis on the corpus posterior and
traction on the umbilical cord
Uterine cavity was cleaned with gauze and cleaned from residual amniotic
fluid and blood.
The end of the incision on the uterus were clamped by the oval clamp, Tip of
the uterine incision sutured,by simple interrupted suture.
Then the incision of the uterus was sutured by continuous interlocking
stitches, following overhecting, with Vicryl 2.0 and reperitonealization was
performed afterward.
Observation of uterine incision scar, suggesting that the bleeding was under
controlled
Identification both fallopian tubes and ovaries within normal limit
Abdominal cavity was cleaned from blood and Stoll cell.
Uterine was contracting well
Peritoneum sutured with plain catgut no.1.0 continuously, then do muscle
approximation, suturing the abdominal wall with Catgut plain no. 1.0 by
simple suture.
Both ends of the fascia is clamped with a Kocher clamp, then stitched
continuously with Vicryl no. 1.0
Time
- Subcutaneous were stitches by simple suture with Catgut plain no 0

- Cutis was sutured with vicryl 3.0 with subcuticular suture
13.30 - Surgical wound was closed with sufratulle, sterile gauze and hypafix
- Vagina was cleaned from the rest of blood and clean Stoll cell with a cotton
gauze to clean the blood
13.40 - Mother was stable after the operation

- Blood loss : approx 800 cc
Therapy:
• IVFD RL + Oxytocin 10-10-5-5 IU  20 dpm
• Inj Ceftriaxone 1 gram / 12 hours
• Inj Ketorolac 30 mg / 8 hours
• Inj Ranitidine 50 mg / 12 hours
Plan :
• Check CBC 2 hours after operation
• Monitoring vital sign, uterine contraction, vaginal bleeding
LABORATORY FINDINGS on February 3rd, 2018 (post-op)
• Hb : 10,8 N: 12-14 gr/dl

• Ht : 35 N: 36-42 gr/dl
• RBC : 4,4 N: 4-5,4X106 uL
• WBC : 18420 N:4000-11000/mm3
• Platelet : 320.000 N:150000-400000/mm3
• MCV : 79,5 N :80-97fL
• MCH : 34,5 N :27-33.7pg
• MCHC : 30,9 N :31.5-35g/dL
FOLLOW UP Sunday, February 4th 2018
S Pain on the surgical site
O Presens state Obstetrical state

Sens : CM Abdomen : lax, normoperistaltic
BP : 100/60 mmHg Fundal height : 2 finger below umbilical, adequate
P : 74 x/min
contraction
RR : 20 x/min
Vaginal bleeding : (-), lochia (+) rubra
T : 36,50C
Surgical wound : covered by gauze, dry
Micturion : (+) via urine catheter, UOP 50
cc/hr
Defecation : (-), flatus (+)
A Post C-section d/t Hepatitis B + fetal bradycardia + PD1
P -IVFD RL + Oxytocine 10-10-5-5 IU  20 dpm

-Inj. Ceftriaxone 1 gr/12hr
-Inj. Ketorolac 30 mg/8hr
-Inj. Ranitidine 50 mg/12hr
Planning :
-Urine catheter removal
-Gradual mobilization
FOLLOW UP Monday, February 5th 2018
S Pain on the surgical site

P : 88 x/min
contraction
RR : 20 x/min
T : 36,50C
cc/hr
P -Cefadroxyl 2 x 500 mg
-Mefenamic acid 3 x 500 mg
-B comp 2 x 1
Planning :
-IV line removal
-Oral therapy
-Consult to interna medicine department
Internal Medicine Result on February th
5 , 2018
Assesement:
Hepatitis B
Therapy:
Curcuma tab 3 x 1
B comp 3 x 1
Plan:
Check LFT/3 days
FOLLOW UP Tuesday, February 6th 2018
S Pain oh the surgical site

P : 84 x/min
contraction
RR : 20 x/min
T : 36,50C
cc/hr
P -Cefadroxyl 2 x 500 mg
-Mefenamic acid 3 x 500 mg
-B comp 2 x 1
-Other therapy based on interna department
Planning :
Change verband
Ambulatory today
THANK YOU
Patient 2
S Pain on the operative wound

Sens : CM Abdomen : Soepel, peristaltic (+) normal
BP : 140/90 Fundal height : 1 finger below navel, adequate
mmHg
contraction
P : 94 x/min
RR : 22 x/min
T : 36,50C Surgical wound : covered by gauze, dry
Micturition : (+) via urine catheter, UOP 50 cc/hr,
yellowish, fluid balance -1300cc
Breathing sound: vesicular

Additional sound: rales(+) on the upper left side of lung
A Post C-section d/t fetal distress + PE with severe feature + severe oligohydramnion + PD2
P - IVFD RL 20 dpm
- Inj. Ceftriaxone 1 gr / 12 hours
- Drips Metronidazole 500 mg / 8 hours
- Inj. Ketorolac 30 mg / 8 hours
- Inj. Ranitidine 50 mg / 12 hours
- Nifedipine 4 x 10 mg
Planning :
Continue therapy
Gradual mobilization
Thorax rontgen
Consult to pulmonology department
Evaluation vital sign, uterine contraction, vaginal bleeding, fluid balance and signs of post
partum eclampsia
FOLLOW UP Tuesday, February 6th 2018
S Pain on the operative wound

Sens : CM Abdomen : soepel, peristaltic (+) normal
mmHg
contraction
P : 90 x/min
RR : 23 x/min
yellowish, fluid balance -1200cc

Additional sound: rales(+) on the upper left side of lung
A Post C-section d/t fetal distress + PE with severe feature + severe oligohydramnion + PD3
P - IVFR RL + oxytocin 10-10-5-5  20 gtt/I

- IVFD RL + MgSO4 40% 12 gr  14 dpm
- Inj. Ceftriaxone 1 gr/ 12 hours
- Drips Metronidazole 500 mg/ 8 hours
- Inj. Ketorolac 30 mg/ 8 hours
- Inj. Ranitidine 50 mg/ 12 hours
Planning :
- Waiting for thorax Ro result
- Evaluation vital sign, uterine contraction, vaginal bleeding, fluid balance and
signs of post partum eclampsia
- Patient move to FM ward
- Still waiting for consult pulmonology department result
THANK YOU
Mrs. E, 35 yo, G3P2A0, Javanese, Moslem, Senior High School, Worker, wife of Mr. B,
36 yo, Javanese, Moslem, Senior High School, Worker. This patient was admitted to
Pirngadi General Hospital on February, 2nd 2018 with
CC : Shortness of breath
This has been experienced since 1 week prior to admission, and worsen within today.
This complaint was not associated with weather and activity. High blood pressure was
experienced by patient since 1 week prior admission. High blood pressure in prior
pregnancy was denied by patient. Headache, blurred vision, epigastric pain was denied
by patient. Labor contraction, bloody show, and watery discharge was not found.
Patient was referred by obstetrician with diagnosis Preeclampsia + MG+ IUP (33-34)
wga + Head presentation+ alive fetus+ fetal bradicardia
Micturition and Defecation within normal limit.
Previous illness : Tuberculosis

Previous medical : Anti tuberculosis agents
History of Surgery :-
LMP : ?/06/2017
EDD : ?/03/2018
ANC : midwife 2 x, Obstetrician 1 x
Obstetric History :
1. Boy, aterm, 3500gr, SVD, midwife, Clinic, 12yo, healthy
2. Boy, aterm, 2600gr, SVD, midwife, Clinic, 9yo, healthy
3. Current Pregnancy
Present State :
Cons : Fully Alert Anemic : ( -)
BP : 160/110 mmHg Icteric :(-)
Pulse : 100 x/i Cyanosis :(-)
Respiration : 25 x/i Dypsnoe : (+ )
Temp : 36,7°C Edema :(+)
Localized St :
Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)
Neck : In normal limit
Thorax : Respiratory sound : Vesiculer
Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)
Obstetrical state
Abdomen : Symmetrically enlarged
Fundal Height : 3 fingers above navel (26 cm)
Tension part : Right
Lowest part : Head
Contraction : (-)
Fetal heart : 165 bpm
Inspeculo : Not performed
Vaginal Examination : Not performed

TAS
TAS
TAS
TAS
USG TAS
Singleton fetus, head presentation, alive fetus
FM (+), FHR (+)
BPD : 83 mm
AC : 280 mm
HC : 303 mm
FL : 65,1 mm
Placenta fundal anterior grade II
EFW : 2011 gr
MVP : 1,16 cm
Conclusion:
IUP (32-33) wga + head presentation + alive fetus + severe
olygohydramnios
LABORATORY FINDINGS on Friday February 2nd, 2018
• Hb : 11,2 N: 12-14 gr/dl

• Leukocyte : 20.470 N:4000-11000/mm3
• Hematocryte : 33,8 N: 36,0-42,0/%
• Platelet : 440000 N:150000-450000/mm3
• HbsAg : Non Reactive
• Rapid Test : Non Reactive
• SGOT : 39 N : 0 - 40 U/L
• SGPT : 19 N : 0 - 40 U/L
• Bilirubin direct : 0,47 N : 0,05 - 0,5 mg/dL
• Ureum : 48 N: 10 - 50 mg/ dL
• Creatinine : 1,4 N : 0,6 - 1,2 mg/ dL
• LDH : 477 N : 240 - 480 U/L
• KGD ad R : 172 N : < 200 md/ dL
• Na/ K/ Cl : 138/ 4,5/ 108
• D- dimer : 2000 N : < 500 ng/ dL
• Fibrinogen : 374 N : 240 - 340 mg/ dL
• Proteinuria : +1
Diagnosis :
PE with severe Features + MG + IUP (32-33) wga + Head
Presentation + Live Fetus + Severe Oligohidramnion
Th/ :
- Oxygen 2-3 L/ min nasal
- MgSO4 loading 4g bolus IV
- IVFD RL + MgSO4 12gr → 14 dpm
- Nifedipine 3x10mg
- Dexamethasone 6mg/ 12hours (48 hours) for lung maturation
Report to supervisor on duty dr. Sanusi Piliang, Sp.OG → Advise for

- Termination after lung maturation
- USG Confirmation (Doppler)
- Follow up for mothers condition and FHR
Thank You
Time Blood Pressure Fetal Heart Rate
04.30 170/100 168x/i
04.45 160/100 164x/i
05.00 170/100 160x/i
05.15 160/100 160x/i
05.30 160/100 160x/i
05.45 160/100 164x/i
06.00 170/100 158x/i
06.15 160/100 168x/i
06.30 160/100 164x/i
06.45 160/100 160x/i
07.00 170/100 164x/i
07.15 160/100 158x/i
07.30 160/100 160x/i
07.45 160/100 164x/i
08.00 160/100 156x/i

THANK YOU
Post C-Section d/t Fetal distress + severe oligohydramnion +
PE with severe feature
A Male baby was born with BW 2065 gr, BL 42 cm, AS 8/9, anal (+)
On February 3rd, 2018
Time
13.00 Decision
15.00 - The patient was positioned on the operating table in supine position under
spinal anesthesia with intravenous and catheter indwelled properly
-Aseptic and antiseptic protocol was performed using povidone iodine 10%
and 70% alcohol in the abdominal wall. The abdomen was then covered with
sterile cloth except the operating field
15.05 - Time out
15.10 - Pfanensteil insicion was performed and deepened from cutis, subcutis to
fascia
By inserting the underlying anatomical tweezers, fascia was cut to right and
left.
Rectus abdomins muscle was separated to the upward and downward.
Peritoneum was clamped, and supended, and then cut cranially caudaly,
Uterus seems appropriate to the gestational age.
The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium was penetrated
bluntly and widened according to the incision.
Time
15.30 By grasping the head, a male baby with BW 2065 gr, BL 42 cm, AS 8/9, anal
(+) was born. The umbilical cord was clamped in two places and cut in-
between.
The placenta was born with an emphasis on the corpus posterior and
traction on the umbilical cord
Uterine cavity was cleaned with gauze and cleaned from residual amniotic
fluid and blood.
The ends of the incision on the uterus were clamped by the oval clamp ,Tip
of the uterine incision sutured,by simple interrupted suture.
Then the incision of the uterus was sutured by continuous interlocking
stitches, following overhecting, with Vicryl 2.0 and reperitonealization was
performed afterward.
Observation of uterine incision scar, suggesting that the bleeding was under
controlled
Identification both fallopian tubes and ovaries within normal limit
Abdominal cavity was cleaned from blood and Stoll cell.
Uterine was contracting well
Peritoneum sutured with plain catgut no.1.0 continuously, then do muscle
approximation , suturing the abdominal wall with Catgut plain no. 1.0 by
simple suture.
Both ends of the fascia is clamped with a Kocher clamp, then stitched
continuously with Vicryl no. 1.0
Time
- Subcutaneous were stitches by simple suture with Catgut plain no 0

-Cutis was sutured with vicryl 3.0 with subcuticular suture
16.00 - Surgical wound was closed with sufratulle, sterile gauze and hypafix
-Vagina was cleaned from the rest of blood and clean Stoll cell with a cotton
gauze to clean the blood
16.10 - Mother was stable the after the operation

-Blood loss: 800 cc
Therapy:
•IVFD RL + Oxytocin 10-10-5-5 IU  20 dpm
•Inj Ceftriaxone 1 gram / 12 hours
•Inj Ketorolac 30 mg / 8 hours
•Inj Ranitidine 50 mg/ 12 hours
Plan :
• Check CBC 2 hour post operation
- Evaluation vital sign, uterine contraction, vaginal bleeding, fluid balance
and signs of post partum eclampsia
FOLLOW UP Saturday, February 3rd 2018
S Pain on the wound operation

mmHg
contraction
P : 80 x/min
RR : 24 x/min
Micturition : (+) via urine catheter, UOP 40 cc/hr
Defecation : (-), flatus (-)
A Post C-section d/t fetal distress + PE with severe feature + severe oligohydramnios + PD0

Planning :
partum eclampsia
Check CBC 2 hours post operation
LABORATORY FINDINGS on February 3rd, 2018 (post op)
• Hb : 11,1 N: 12-14 gr/dl

• Ht : 34,5 N: 36-42 gr/dl
• RBC : 5,75 N: 4-5,4X106 uL
• WBC : 32.640 N:4000-11000/mm3
• Platelet : 478.000 N:150000-400000/mm3
• MCV : 60 N :80-97fL
• MCH : 19,3 N :27-33.7pg
• MCHC : 32,2 N :31.5-35g/dL
S Pain on the wound operation

mmHg
contraction
P : 80 x/min
RR : 24 x/min
yellowish
Defecation : (-), flatus (-)

Planning :
partum eclampsia
Continue therapy
FOLLOW UP Monday, February 4th 2018 at 18.45
S dyspnoe

mmHg
contraction
P : 80 x/min
RR : 28 x/min
yellowish

Additional sound: rales(+)

-Inj. Fiurosemide 40 mg extra
Planning :
partum eclampsia
Continue the therapy
Thorax rontgen
Consult to pulmonology department
THANK YOU

FETOMATERNAL WARD REPORT 6 Feb 2 Pat

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FETOMATERNAL WARD REPORT

Tuesday, February 6th 2018

Residents : 1. dr. Mega Sari Dewi

Department of Obstetric and Gynecology

CC : Amniotic fluid leakage

• Hb : 10,5 N: 12-14 gr/dl

• Ureum : 10,0 N : 10-50 mg/dL

Reported to Supervisor on duty dr. Irliyan Saputra, MKed(OG), SpOG →

- Subcutaneous were stitches by simple suture with Catgut plain no 0

13.40 - Mother was stable after the operation

• Hb : 10,8 N: 12-14 gr/dl

O Presens state Obstetrical state

P -IVFD RL + Oxytocine 10-10-5-5 IU  20 dpm

O Presens state Obstetrical state

O Presens state Obstetrical state

O Presens state Obstetrical state

Breathing sound: vesicular

O Presens state Obstetrical state

Breathing sound: vesicular

P - IVFR RL + oxytocin 10-10-5-5  20 gtt/I

Previous illness : Tuberculosis

Head : Conj Palpebra inferior pale (-)/(-), icteric (-)/(-)

Neck : In normal limit

Thorax : Respiratory sound : Vesiculer

Additional sound : Wheezing(-)/(-), Rhonki (-)/(-)

Inspeculo : Not performed

Vaginal Examination : Not performed

• Hb : 11,2 N: 12-14 gr/dl

Report to supervisor on duty dr. Sanusi Piliang, Sp.OG → Advise for

04.30 170/100 168x/i

04.45 160/100 164x/i

05.00 170/100 160x/i

05.15 160/100 160x/i

05.30 160/100 160x/i

05.45 160/100 164x/i

06.00 170/100 158x/i

06.15 160/100 168x/i

06.30 160/100 164x/i

06.45 160/100 160x/i

07.00 170/100 164x/i

07.15 160/100 158x/i

07.30 160/100 160x/i

07.45 160/100 164x/i

08.00 160/100 156x/i

- Subcutaneous were stitches by simple suture with Catgut plain no 0

16.10 - Mother was stable the after the operation

O Presens state Obstetrical state

P - IVFR RL + oxytocin 10-10-5-5  20 gtt/I

• Hb : 11,1 N: 12-14 gr/dl

O Presens state Obstetrical state

P - IVFR RL + oxytocin 10-10-5-5  20 gtt/I

O Presens state Obstetrical state

Breathing sound: vesicular

P - IVFR RL + oxytocin 10-10-5-5  20 gtt/I

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