Professional Documents
Culture Documents
FETOMATERNAL WARD REPORT 6 Feb 2 Pat
FETOMATERNAL WARD REPORT 6 Feb 2 Pat
Supervisor:
dr. Zanibar Aldy, MKed(OG), SpOG
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:
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
Therapy:
- IVFD RL 20 dpm
- Inj. Ceftriaxone 2 gr/IV skintest (profilaxis)
Plan:
- Immediate C-section
- Consult to Anestesiology Departement
- Consult to Perinatology Departement
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
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
Planning :
-Urine catheter removal
-Gradual mobilization
FOLLOW UP Monday, February 5th 2018
S Pain on the surgical site
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 -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
FOLLOW UP Monday, February 5th 2018
S Pain on the operative wound
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
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 :
Obstetrical state
Abdomen : Symmetrically enlarged
Fundal Height : 3 fingers above navel (26 cm)
Tension part : Right
Lowest part : Head
Contraction : (-)
Fetal heart : 165 bpm
Conclusion:
IUP (32-33) wga + head presentation + alive fetus + severe
olygohydramnios
LABORATORY FINDINGS on Friday February 2nd, 2018
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
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
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
Planning :
Evaluation vital sign, uterine contraction, vaginal bleeding, fluid balance and signs of post
partum eclampsia
Check CBC 2 hours post operation
LABORATORY FINDINGS on February 3rd, 2018 (post op)
Planning :
Evaluation vital sign, uterine contraction, vaginal bleeding, fluid balance and signs of post
partum eclampsia
Continue therapy
Gradual mobilization
FOLLOW UP Monday, February 4th 2018 at 18.45
S dyspnoe