DUTY REPORT

Tuesday, September 11th 2018

Supervisor
dr. Edwin Martin Asroel, M.Ked (OG), SpOG

Residents :
1. dr. Devi M. Syam
2. dr. Utari Purnama
3. dr. Putri Aini Daulay
4. dr. Mega Sari Dewi
5. dr. Jonathan Toman Lumbantobing
6. dr. Willy Kurnia Almon

Department of Obstetric and Gynecology

Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2018
NEW PATIENT : 1 PATIENT
New Patient
1. Mrs. S, 25 yo, G2P1001
Diagnose : SG + IUP (40-41) wga + Head Presentation + Alive Fetus + Active Phase Of Labor
Planning : - Observation Labor Progression through Partograph
- Spontaneous Vaginal Delivery
- In July 12th, at 8 am patient was handed over to Delivery ward team
Patient 1
Mrs. S. 25 y.o, G2P1001, Karonese, Moslem, Senior High School, Housewife, married to
Mr. A, 36 y.o, Bataknese, Moslem, Senior High School, Entrepreuner. The patient was
admitted to Adam Malik General Hospital on September 12th 2018, at 06.05 am with:

Cc : Labor contraction
E : This has been experienced by the patient since September 12th at 02.00 am.
History of Amniotic Fluid Leakage (-). History of bloody show (+) since September
12th at 03.00 am. Micturition and Defecation within Normal Limit.

History of previous illness : -

History of Medication : -
History of Surgery :-
LMP : 25/11/2017
EDD : 2/9/2018
ANC : Midwife 5 times, Obstetrician 2 times
History of pregnancy
1. Baby boy, 3500 gr, SVD, doctor, hospital, 5 yo, healthy
2. Current Pregnancy

Vital Signs
Cons : Alert Anemic : (-)
BP : 120/90 mmHg Icteric : (-)
Pulse : 88 bpm Cyanosis : (-)
RR : 20 rpm Dypsnoe: (-)
Temp : 36,5°C Edema : (-)

General state : Moderate

Illness State : Moderate
Generalized Status

Head : Inferior palpebra conj anemic (-), icteric (-)

Neck : No abnormality
Thorax : Respiratory sound : vesicular
Additional sound : wheezing(-)/(-), rales (-)/(-)
Abdomen : Simetrically enlarged, liver and spleen no abnormality
Sup. Extremities : Oedem (-)
Inf. Extremities : Oedem in lower extremities (-)
Obstetrical State
• Abdomen : Asimetrically enlarged
• Fundal Height : 3 fingers below proc xyphoideus (35 cm)
• Tension part : Right
• Lowest part : Head (4/5)
• Fetal movement : (+)
• Fetal Heart rate : (+), 154 bpm
• Uterine Contraction: 3 x 20”/10’
Gynecological State
Digital vaginal examination : Cervix axial, 4 cm dilated, effacement 60 %, head hodge I, Amniotic
membrane (+)
Hand Glove : Amniotic Fluid (-), blood slime (+)
TAS
 TAS
• Singleton Pregnancy, Head Presentation, Alive Fetus
• FM (+), FHR (+) 154 bpm
• BPD : 9.82 cm
• HC : 32,53 cm
• AC : 36,05 cm
• FL : 7,88 cm
• Placenta Posterior Grade III
• EFW : 4034 gr
• SD Ratio : 3,19
Conclusion : IUP (40-41) wga + Head Presentation + Alive Fetus
Laboratory Findings
September 12th 2018
Hb : 10,1 N: 12-14 gr/dL
Leukocyte : 11680 N: 4000-11000/uL
Hematocrite : 29 N: 36,0-42,0/%
Platelet : 243000 N:150.000 - 400.000/uL
Ureum : 11 N : 15 - 40 mg/dl
Creatinin : 0,54 N : 0,6-1,1 mg/dl
BUN :5 N : 7-19 mg/dl
Natrium : 132 N : 135-155 mEq/dl
Kalium : 4,0 N : 3.6 -5.5 mEq/dl
Chloride : 104 N : 96-106 mEq/dl
KGD adrandom : 78 N : < 200
HBsAg : Non Reactive N: Non reactive
HIV Ab : Non Reactive N: Non Reactive
Diagnosis :
SG + IUP (40-41) wga + Head Presentation + Alive Fetus + Active Phase Of Labor

Therapy :
-

Plan :
- Check Complete Blood Count, HST, Random Glucose , RFT, HBsAg, HIV
-Observation of Labor Progression through Partograph
- Spontaneous Vaginal Delivery
- Patient was handed over to Delivery Room team

Report to supervisor on duty dr. Edwin Martin Asroel , M.Ked (OG). Sp. OG approved
Delivery Team Follow-up
Partograph
Wednesday , September 12th 2018 at 08.00

S Labor contraction (+), amniotic fluid leakage (+)

O Presens state
Sens : CM
BP : 120/80 mmHg
P : 82 x/min
RR : 18 x/min
T  : 36,50C
Obstetrical state
Abdomen : Asymmetrically enlarged
Fundal Height : 3 Fingers below xyphoid processus, 35 cm
Uterine Contraction : (+) 3 x 30”/ 10’
Fetal movement : (+)
FHR : (+) 136 bpm
VT : Cervical axial, dilated 5 cm, effacement 80%, Head Hodge I, amniotic membrane (-)
Gloves : Blood slime (+), amniotic fluid (+) clear

A SG + IUP (40-41) wga + Head Presentation + Alive Fetus + Active Phase Of Labor

P Observe labor progression through Partograph

Wednesday , September 12th 2018 at 12.00

S Labor contraction (+)

O Presens state
Sens : CM
BP : 110/80 mmHg
P : 86 x/min
RR : 18 x/min
T  : 36,50C
Obstetrical state
Abdomen : Asymmetrically enlarged
Fundal Height : 3 Fingers below xyphoid processus, 35 cm
Uterine Contraction : (+) 3 x 30”/ 10’
Fetal movement : (+)
FHR : (+) 144 bpm
VT : Cervical axial, dilated 7 cm, effacement 100%, Head Hodge II, amniotic membrane (-)
Gloves : Blood slime (+), amniotic fluid (+) clear

A SG + IUP (40-41) wga + Head Presentation + Alive Fetus + Active Phase Of Labor

P Observe labor progression through Partograph

Wednesday , September 12th 2018 at 16.00

S Labor contraction (+)

O Presens state
Sens : CM
BP : 120/70 mmHg
P : 90 x/min
RR : 18 x/min
T  : 36,50C
Obstetrical state
Abdomen : Asymmetrically enlarged
Fundal Height : 3 Fingers below xyphoid processus, 35 cm
Uterine Contraction : (+) 4 x 40”/ 10’
Fetal movement : (+)
FHR : (+) 130 bpm
VT : Cervical axial, dilated 7 cm, effacement 100%, Head Hodge II, amniotic membrane (-)
Gloves : Blood slime (+), amniotic fluid (+) clear

A Protracted Active Phase + SG + IUP (40-41) wga + Head Presentation + Alive Fetus

P Action line was crossed, no additional cervical dilation  Emergency C-Section

Report of C-section d/t Protracted Active Phase
born baby boy ,BW 3760 gr, BL 52 cm, A/S 8/9, Anus (+), NBS 38
weeks
• The patient was laid on the operating table, with IV line and urinary
catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine
on the abdomen, and then draped leaving the surgical field exposed.
• Under regional anesthesia, a pfanennsteil incision was made, through to
the underlying layer of fascia. The fascia was incised and extended laterally
using scissor. Superior aspect of the fascia was elevated using Kocher, and
the underlying rectus muscles were dissected.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the bladder.
• The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium penetrated
and widened bluntly.
• By luxating the head born baby boy, BW 3760 gr, BL 52 cm, A/S 8/9,
anus (+). The umbilical cord was clamped in two places and cut in
between. The placenta was born with fundal pressure and traction on
the umbilical cord.
• Uterine cavity was cleaned with gauze.
• Uterus was sutured by continuous interlocking stitches in two layer.
• Abdominal cavity was cleaned from blood and stoll cell.
• Identification both tuba and ovarium shows no abnormality.
• Peritoneum sutured continuously, muscle approximation using simple
suture and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was
sutured with subcuticuler suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Mother was stable the after the operation.
• Estimated blood loss ± 300 cc.
Therapy:
• IVFD RL+ oxytocin 10 IU  20 dpm
• Ceftriaxone inj 1 gr/12 hours
• Ketorolac inj 30 mg/8 hours

Plan :
• Check CBC 2 hours post operation.
• Monitoring vital sign, uterine contraction, vaginal bleeding
CTG