case no

IDENTITY
Patient Husband
Name : Mrs. E Name : Mr. M
Age : 38 years old Age : 42 years old
Admission number : 01100730 Education : Senior high school
Education : Senior high school Occupation : Enterpreuner
Occupation : Housewife Address : Padang
Address : Padang
Admission date: 08/03/2021
Mrs. E, 38 years old, MR 01100730
Admission Preparation for
Origin Diagnosis Plan
date surgery
Date : Origin: Consult to Retained placenta on Manual
08/032021 Mutiara Bunda Hospital Anaesthesiologist P4A0H4 post spontaneous placental
Agree for operation delivery from other
Time : Diagnose : institution + perineal
13.50 Retained placenta ruptured grade 2
DPJP :
HY
 Clinical Data Physical examination Supportive examination
Anamnesis GA Cons BP HR RR T
• Patient was referred from Private Hospital in Padang mdrt CMC 130/80 88 20 36,8 Laboratory (08/03/2021) :
Padang with diagnose retained placenta Hb : 13,2 g/dL
• Previously the patient gave birth to the 4th child Eyes: Leukosit : 14.870 mm3
spontaneously in the midwife at 09.00 a.m., the conjunctiva wasn’t anemic , sclera wasn’t icteric Hematokrit : 37%
gestational age was 39-40 weeks, the baby's weight Chest : Trombosit : 276.000/mm3
was 3800 gr, after 1 hour of delivery, the placenta was heart within normal limit Diff count : 0/0/87/3/5
not born. Then patient was referred to RSIA Mutiara
Bunda, at RSIA Mutiara Bunda , doctor tried to lung : rhonci -/-, wheezing -/- PT/APTT :
performed manual placenta but not succeed and the Abdomen : Tot protein : 5,8
umbilical cord was ripped out. Then patient was Inspection : seem slightly bulged Albumin : 2,9
referred to M.Djamil General Hospital with IV line and Globulin : 2,9
folley catheter were inserted. Palpation : Bil Direk/indirek : 0,4/0,8
• vaginam bleeding (+) Uterine Fundal high was palpable 3 fingers above SGOT/SGPT : 43/21
• History of early pregnancy: nausea (-), vomiting (-), umbilical Ur/Cr : 11/0,4
bleeding (-) GDS : 112
• History of late pregnancy: nausea (-), vomiting (-),
Genitalia Na/K/Cl : 142/2,1/108
bleeding (-) HBsAg :Non Reactive
• ANC: routine control to the Puskesmas every month • V/U within normal , vaginal bleeding (+), Placenta
was not came out and placental cor was ripped out HIV : Non Reactive
from 1 month of pregnancy, 4x Sp.OG control, 3, 6, 7,
8 months of gestation • Inspeculo: stolcell (+), umbilical cord was not seen, TCM : Negative
• Cough(-) runny nose(-),shortness of breath(-),fever (-) OUE was dilated 3 cm, fluxus (+) in fornix posterior
• Travel history abroad / out of town (-) Bleeding came out from OUE (+) non active,
• History of contact with a positive Covid-19 patient (-) Perineum was seen ruptured grade 2
• History of contact with people who returned from out
of town / abroad (-)
History of pregnancy / abortion / childbirth: 4/0/4
1) 2009 / female / 3000 / spontaneous/ midwives / alive
2) 2013 / male / 3300 / spontaneous / midwives / alive
3) 2017 / male / 3400 / spontaneous / midwives / alive
4) 2021 / male / 3800 / spontaneous / midwives / alive
Operation Diagnose Outcome
Date

Date : Diagnose Manual Placenta was performed

08/03/2021 Retained placenta on P4A0H4 post spontaneous delivery from other Placenta was born with manual placenta with size 17 x
institution + perineal ruptured grade 2 16x 4 cm and weight  500 gr.
ACC DPJP Impression: complete
14. Plan Perineal ruptured grade 2 was visible. Performed
• Informed consent hecting perineum
Time • IVFD 2 line
15.05 1. RL + oxytocin 20 IU 28 gtt Diagnose
2. RL 28 tpm Post manual plasenta oi retained placenta on P4A0H4
DPJP : • Chateteritation post spontaneous delivery from other institution +
HY • Inj. Cefazoline 2 gr IV (profilaxes) post hecting perineum oi perineal ruptured grade 2
• Consult anesthesiologist
• Report to OR Instruction
• Manual placental • Control GA, VS, Contraction, Vaginal Bleedding
• Stage IV management
• IVFD RL + oxytocin 10 IU + methergine 0,2 mg 
Process 20gtt
Retained placenta on P4A0H4 post spontaneous delivery from other • Catheter insertion for 12 hours
institution + perineal ruptured grade 2  Manual placenta on • Inj.Ceftriaxone 2x1 gram
narcose + Hecting perineum • Pronalges supp II k/p
• Paracetamol 3x500mg
• Sf 2x180mg
• Vit C 3x50 mg
• Cek labor 6 hours after delivery
• Admitted t0 HCU
Referral letter
USG before manual placenta :
Laboratorium
Operation Report
 Table of Control IV Stage
Time Cons GA T P R Temp Uterine PPV Urine
Contraction
16.15 DPO Mod 154/94 93 20 36,8 Strong, 2 finger - 50 cc
above umbilical
16.30 DPO Mod 152/94 108 20 36,5 Strong, 2 finger - 70 cc
above umbilical
16.45 DPO Mod 152/94 102 20 36,6 Strong, 2 finger - 80 cc
above umbilical
17.00 DPO Mod 151/90 100 20 36,7 Strong, 2 finger - 80cc
above umbilical
17.30 DPO Mod 152/94 98 20 36,5 Strong, 2 finger - 100 cc
above umbilical
18.00 DPO Mod 150/93 95 20 36,6 Strong, 2 finger - 120 cc
above umbilical
Laboratory post op
Follow Up 09-03-2021 (07.00 am)
S/vaginal bleeding (-), fever (-)
O/
GA Cons. BP PR RR T
Moderate CMC 120/90 90x/’ 20x/’ 36,5OC

• Abdomen : FUT 2 finger under umbilical. Contraction was good

• Genitalia : V/U whitin normal limits
A/ Post manual plasenta oi retained placenta on P4A0H4 post spontaneous delivery from other institution + post hecting perineum oi perineal
ruptured grade 2 Puerperium day 1
P/
• Control GA, VS, Contraction, Vaginal Bleedding
• Stage IV management
• IVFD RL + oxytocin 10 IU + methergine 0,2 mg  20gtt
• Catheter insertion for 12 hours
• Inj.Ceftriaxone 2x1 gram
• Paracetamol 3x500mg
• Sf 2x180mg
• Vit C 3x50 mg
• Cek labor 6 hours after delivery
Thank You
Lubchenko Curve