DUTY REPORT

Monday, September 10th 2018

Supervisor :
dr. Yostoto B Kaban, Sp.OG(K)

Residents :
1. dr. M. Iman Syahputra
2. dr. Cherry Kumalasari
3. dr. Dedet Steavano
4. dr. Chairul Adilla Ardy
5. dr. Sofyan Andri
6. dr. Hayatun Nufus Namira

Department of Obstetrics and Gynecology

Medical Faculty of Universitas Sumatera Utara
H. Adam Malik General Hospital
2018
NEW PATIENT : 1 PATIENT
PRIOR PATIENT : - PATIENT
1. Mrs. A, 25 y.o, G2P1001
Diagnosis : Susp. Abdominal Birth Defect (Gastroschisis dd
Omphalocele) + MG + IUP (37-38) wga + Head
Presentation + Alive Fetus + 2nd stage of labor

Plan : Vaginal Delivery Assistance

On Sept 10th 2018 at 06.45 am born a baby boy, BW 2550 gr, BL 45

cm, Apgar Score 7/8, Anal (+), NBS appopriate with 36-38 wga
PATIENT 1
Mrs. A, 25 y.o, G2P1001, Melayunese, Moslem, Senior high
school, Housewife, married to Mr. T, 28 y.o Melayunese,
Moslem, Senior High School, Entrepreneur was admitted to
Adam Malik General Hospital on September, 10th 2018, at 06.30
pm with:

Chief complain: Urge to push

Review: This has been experienced by the patient since 1 hour
before arrival in Adam Malik General Hospital. Labor
Contraction has been experienced since September, 10th 2018
at 06.30 a.m. History of bloody show (+) since September, 10th
2018 at 10.00 am. History of amniotic fluid leakage (+) since
September, 10th 2018, 05.30 pm. Micturition and defecation
were normal. The patient underwent antenatal care in OB/GYN
about 1 month ago, and diagnosed with abdominal birth defect
– Gastroschicis dd/ Omphalochele.
History of previous illness : -
History of Medication :-
History of Surgery :-
LMP : 20/12/2017
EDD : 27/09/2018
ANC : OB/GYN 1x midwife 3x

History of pregnancy :

1. Female, 3000 gr, Aterm, SVD, Clinic, Midwife, 3 y.o, healthy

2. Current pregnancy
Vital Signs
Cons : CM E4V5M6 Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
Pulse : 108 x/i Cyanosis : (-)
RR : 22 x/i Dypsnoe : (-)
Temp : 36,7°C Edema : (-/-)
Turgor : Good

General state : Normal

Nutritional state : Normoweight (BW : 60, BH : 155 ; BMI : 25)
Upper arm circumference : 24 cm
Illness State : Normal
Generalized State :
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : No abnormality
• Thorax : Respiratory sound : vesicular
Additional sound : wheezing(-)/(-), rales (-)/(-)
• Abdomen : Asymetrically enlarged, liver and spleen
difficult to assess
• Sup. Extremities : Edema (-)
• Inf. Extremities : Edema (-)
Localized State
• Abdomen : Asymmetrically enlarged
• Fundal Height : 4 finger below xyphoid process (29 cm)
• Tension part : Left
• Lower part : Head, 0/5
• Contraction : 4x40”/10’
• FHR : 164 bpm, regular
• EFW : 2790 gr

Gynecology State
Vaginal Examination : Head was crowning, amniotic membrane (-),
minor fontanelle at 12 o’clock
Gloves : Blood slime (+), amniotic fluid (+)
 Laboratory Findings
September, 10 th 2018
• Hb : 12.7 N: 12-14 gr/dL
• Leukocyte : 17990 N:4000-11000/uL
• Hematocrite : 39 N: 36,0-42,0/%
• Platelet : 235.000 N:150.000 - 400.000/uL
• BG adR : 118 N: < 200
• pT : 11.8 N: 17.9 s
• apTT : 27.9 N: 33.0 s
• INR : 0.95
• HbsAg : Non reactive
• AntiHIV : Non reactive
Diagnosis : Susp. Abdominal Birth Defect (Gastroschisis dd
Omphalocele) + MG + IUP (37-38) wga + Head
Presentation + Alive Fetus + 2nd stage of labor
Plan :
- Vaginal Delivery Assistance
- Consult to Perinatology Department

Therapy :
- O2 4 L/min via nasal canule
- IVFD RL 20 dpm

Reported to Supervisor on duty dr. Yostoto B. Kaban, Sp.OG(K)

Approved
 Report of SVD
On Sept 10th 2018 at 06.45 am born a baby boy, BW 2550 gr, BL 45cm,
Apgar Score 7/8, Anus (+), NBS appopriate 36-38 wga
• Mother was in lithotomy position on the gynecology table
• During adequate contraction, the mother was lead to push. Amniotomy was
performed. Seen meconium.
• After the next adequate contraction the head was delivered followed by forehead,
nose and mouth. With biparietal hold, shoulder was delivered followed with
whole body, born baby boy, BW 2550 gr, BL 45 cm, Apgar Score 7/8, Anal (+).
• Seen baby’s intestines were found outside of the abdominal cavity, membrane (-).
Impression : Gastroschisis
• Umbilical cord was clamped at two places and cut in between.
• Inj Oxytocin 10 IU IM
• Active management of 3rd stage was performed. Controlled umbilical cord
traction was performed, placenta was delivered completely.
• Uterine contraction (+) adequate.
• Vaginal evaluation no laceration and active bleeding
• Mother condition after SVD was stable.
Therapy :
• IVFD RL  20 dpm
• Cefadroxil 2 x 500 mg PO
• Mefenamic Acid 3 x 500 mg PO
• Vit B. Comp 2x1

Plan :
- Monitoring Vital sign, uterine contraction, and vaginal
bleeding.
C-Section as mode of delivery gastroschisis ?

Caesarean delivery may Researh evidence found no

improve outcomes by benefit of C-Section d/t
decreasing risk of bowel Gastroschisis in terms of
contamination and injury, and ischemic bowel, small bowel
allow optimal coordination of obs, necrotizing enterocolitis,
pediatric surgical care1 sepsis, and mortality 2

1. Segel SY, Marder SJ, Parry S, Macones GA. Fetal abdominal wall defects and mode of delivery: a systematic review.
Obstetrics and gynecology 2001;98:867
2. Friedman MA, Ananth CV, Siddiq Z, Alton ME, Wright JD. Gastroschisis: Epidemiology and Mode of Delivery, 2005-201
. AJOG.2016. 10.1016/j.ajog.2016.03.039
MODE OF DELIVERY ?
TIMING OF DELIVERY ?
BUT WHEN?
THANK YOU