Case No

IDENTITY
Patient Husband
Name : Mrs. S Name : Mr. A
Age : 20 years old Age : 23 years old
Admission number : 01 10 61 02 Education : Senior high school
Education : Senior high school Occupation : entrepreneur
Occupation : Housewife Address : Bawan
Address : Bawan
Admission date: 26/05/2021
Mrs. S, 20 Years Old, MR 01 10 61 02
Preparation for
Admission date Origin Diagnose Plan
surgery

Date : Referred from: Consult to G1P0A0L0 35-36 weeks of Emergency CS

26/05/2021 Rizki Bunda Mother and Perinatology preterm parturien laten
Children Hospital Will be occupied for phase of first stage +
Time : operation and do oligohydramnion due to
14.25 WIB Diagnosis : rescucitation to prologed PPROM
G1P0A0L0 34-35 weeks of neonates Fetal alive, singleton, intra
DPJP : preterm pregnancy + PPROM + uterine, breech presentation
DH, HjYW oligohydramnios Consult to
Fetal alive singleton Anaesthesiologist
intrauterine breech ASA II
presentation
 Clinical Data Physical examination Supportive examination

Anamnesis GA Cons BP HR RR T Ultrasound

• Patient was referred from Rizki Bunda Mother and Children Mdt CMC 110/80 90 20 36,7
Hospital with diagnosed G1P0A0L0 34-35 weeks of preterm Weight Before pregnancy: 50 kg 35-36 weeks of pregnancy according to biometry
During pregnancy :  60 kg Fetal alive, singleton, breech presentation
pregnancy + PPROM + oligohydramnios Height  : 152 cm
• Previously patient was came to Rizki Bunda Mother and BMI :  25,97 (overweight) Oligohydramnios
Children Hospital with chief complain fluid leakage from the Upper Arm Circumferrence : 26 cm
vagina since 2 days ago, wetting 3 underpad, clear fluid,
smelly odor. Because of limited facilities (NICU), patient was •Eyes : conjunctiva wasn’t anemic, sclera wasn’t icteric CTG : 1st category
referred to RSUP Dr. M. Djamil Padang with iv line and •Thorax : cor and pulmo within normal limits
catheter inserted Abdomen Laboratorium
Ins : Abdomen seemed enlarged in accordance to preterm pregnancy,
• Fluid leakage from the vagina (+) since 2 days ago, wetting 3 striaegravidarum (+), mediana line hyperpigmentation (+), cicatrix (-) Hb : 10.9
underpad, clear fluid, smelly odor Leopold : Leukosit : 13.130
• Pelvic pain reffered to the groin (+) since 4 hours ago L1 Uterine fundal palpated between xyphoid process and umbilical, A Trombosit : 340.000
• Bloody show from the vagina was (+) since 4 hours ago hard and round mass was palpated Hematokrit : 32
• Bleeding come out from vagina (-) L2 Hard and resistance structure was palpated on the Right side.
Numerous small, irregular structure were palpated on the left side DC : 0/0/90/9/1
• History of vaginal discharge (+), yellowish, smelly odor since L3 A large, soft, nodular mass was palpated, fixated PT : 9,7
a week ago, fever (-) L4 convergen APTT : 24.3
• Urinary disorders (-) Uterine contraction : 2-3x/20”/weak D-dimer : 3504
• Fetal movement was felt since 3.5 months ago UFH : 28 cm EFW: 2380gr
• Amenorrhea since 8.5 months ago A: Auscultation : Fetal heart sound : 140-145 bpm Alb/Glb : 3,5/38
• First date of last menstrual 25-09-2020 Genitalia Bilirubin total : 0,3
• Estimation delivery date 2-07-2021 V/U within normal limit, vaginal bleeding (-) Bilirubin direk/indirek : 0,2/0,1
VT : dilatation 1-2 cm, portio effacemen on 90%, portio posterior, firm, SGOT/SGPT : 13/5
• No complain of nausea, vomiting and vaginal bleeding amniotic sac (-) clear residue, Breech was palpated on H I-II
during early pregnancy. Nitrazin test (+) Ur/Cr : 11/0,7
• Prenatal care to midwife 5 times on 2,3,5,7, and 8 month of Pelvic inlet​ GDS : 96
pregnancy, and control to obstetricians 2 times on 3 and 8 Promontorium cannot be assessed​ Na/K/Cl/Ca : 135/3,3/111
month of pregnancy, breech position was known at Last Innominata line palpable one third of whole body​ Anti HIV : NR
control Pelvic side wall was straight​
Sacrum bone : concave​ HbsAg : NR
• Menstruation History : menarche at 13 years old, regular Ischiadic spine ; little protruded​ TCM : negative
cycle, every month which last for about 4-6 days each cycle Coccygeus bone : moveable​
with the amount of 2-3 times pad ,pain (-) Arc of pubic > 90​ Chest X-Ray
• History of marriage 1x at 2020 Pelvic outlet​ Heart and lung in normal limit
History of pregnancy/abortion/delivery: 1/0/0 Inter tuberous distance can be passed through by normal adult fist (>10.5cm)​
1. Current pregnancy Impression : adequate pelvic
Operation Diagnosis Outcome
Date

Date : Pre OP Female baby was born at 15.05

26/05/2021 G1P0A0L0 35-36 weeks of preterm parturien laten phase of first stage + BW : 2380 gram
oligohydramnion due to prologed PPROM BH : 46 cm
Operation: Fetal alive, singleton, intra uterine, breech presentation A/S : 7/8
15.00 AM Placenta was delivered with mild traction on the umbilical cord,
Plan placenta size 13 x 10 x 2 cm, weight 350 gram
DPJP Emergency CS Bleeding during operation approximately 250 cc
DH, HjYW
Instruction Post operative diagnosed
• Control GA, VS, FHR, labor sign P1A0L1 post LSCS oi breech presentation + prolonged PPROM
• Informed consent Mother and baby in care
• Consult to Anesthesiologist
• Consult to Perinatology Instuction
• Report to OR • Control GA, VS, contraction, vaginal bleeding
• Inj Cefaztriaxone 2 gram • IVFD RL + 10 IU oxytocin + metergin 0,2 mg  28 tpm
• Inj. Ceftriaxone 2 x1 gram
Process • Pronalges supp (if needed)
G1P0A0L0 35-36 weeks of preterm parturien laten phase of first stage + • Post operation laboratory check
oligohydramnion due to prologed PPROM  LSCS • Care in HCU Obstetrics
Admission Letter Admission Letter
Laboratorium
Swab TCM
Ultrasound
Ultrasound
• Fetal alive, singleton, intra uterine, breech presentation
• Fetal movement activity was limited
• Fetal Biometry :
• BPD : 8,67 mm EFW : 2374 gr
• AC : 291,3 mm FHR : 144 x/I
• HC : 314.1 mm SDAU : 3.21
• FL : 68,8 mm
• AFI : 1.68cm
• Placenta insertion at fundus, maturation grade II

Impression :
35-36 weeks of pregnancy according to biometry
Fetal alive, singleton, intra uterine, breech presentation
Oligohydramnios
 CTG
Baseline : 140
Variability : 5-15
Acceleration : (+)
Deceleration : (-)
Fetal movement : (+)
Contraction : (-)
Impression : 1st category
Chest X-Ray
Nitrazine test
Perinatology Consultation
• P/ will accompany during the operation
Operation Report
• Patient on supine position under spinal anaesthesia
• Antiseptic and septic procedure was performed
• Pfanenstiel incision was performed
• Layer by layer was opened until peritoneal
• Gravid uterine was seen
• Semilunar incision was performed
• By delivered the buttocks, a female baby was born
• BW : 2380gram, BL : 46 cm, A/S : 7/8
• Placenta was born with mild traction on the umbilical
cord, placenta size 13 x 10 x 2 cm, weight 350 gram
• Uterine sutured 2 layer, plica sutured 1 layer
• Abdomen was closed layer by layer
• Skin closed by subcuticular closure
• Bleeding during operation approximately 250 cc
Baby and Plasenta
 Follow up 26/05/2021 (2 jam post Op)
S Post operative pain (+), vaginal bleeding (-) P • Control GA, VS, contraction, vaginal
bleeding
• IVFD RL + 10 IU oxytocin + metergin
0,2 mg  28 tpm
O GA Cons BP HR RR
• Inj. Ceftriaxone 2 x1 gram
T
• Pronalges supp (if needed)
Mdt CM 120/70 92 22
• Post operation laboratory check
36.8
• Care in HCU Obstetrics
Abd : Operative wound closed by verban
Uterine fundal palpated 3 finger below
umbilicus , Contraction was good
Gen : V/U normal, vaginal bleeding (-)
Urine : 200 cc/2 hours clear
A P1A0L1 post LSCS oi breech presentation +
prolonged PPROM
Mother and baby in care
Post Operative Laboratory
KURVA LUBCHENCO
Ballard Score : 30  36 weeks
Thank You