case no

IDENTITY
Patient Husband
Name : Mrs. H Name : Mr.
Age : 28 years old Age : years old
Admission number : 01.08.24.58 Education :
Education : Occupation :
Occupation : Address :
Address :
Admission date:
 Clinical Data
/07/2022 at Previous illness history
Anamnesis • History of DM, HT, lungs, Heart, liver, kidneys are
Patient came to PONEK Dr. M. Djamil Hospital referrd from Muara Labuh denied
Hospital
with diagnose G2P1A0L0 38-39 weeks + Previous CS oi contracted pelvic Family illness history
+ placenta previa + close distance of pregnancy + oligohydramnions by dr. • There were no history of congenital, psychiatric and
Herry Arianto Sp.OG (K) contagius disease
• Pain referred to the groin (-)
• Bloody show from the vagina (-) Marriage history 1x ,at 2021
• Vaginal bleeding from the vagina (-) History of pregnancy/abortion/delivery: 2/0/0
• Fluid leakage from the vagina (-) 1. 2020/Boys/3100/ CS oi contracted pelvic/alive
• Amenorrhea since 9 months ago 2. Present
• LMP : //2021, EDD : //2022
• Fetal movement was felt since 5 months ago
• History early pregnancy : nausea (+) vomite (-) bleding (-)
• Chest palpitations (-), shaking hands (-), excessive sweating (-), weight
loss (-)
• History menstrual : menarch 14 years old, reguler 28 days cycle, duration 4-6
days, 2-3 pad changes per day, menstrual pain (-)
• ANC control to obstetriciant 5 times on 3,5,7,8,9 month of pregnancy.
• Fever (-), cough (-), dyspneu (-), cold (-)
• History of contact with COVID-19 confirmed positive patient denied
 Physical examination
GA Cons BP HR RR T Pelvic Examination :​
mdrt CMC 132/86 82 22 36,6 Pelvic Inlet:
Promontorium can determined​
Weight Before pregnancy: 50 kg Inominata line whole palpable
During pregnancy :  61 kg Os sacrum concave​
Height  : 153 cm The pelvic side walls are straight​
BMI : 21,3 ( Normoweight) Ischiadika spina is protruded
Os Coxygis rigid​
Abdomen : Arcus pubis < 90​
I : Abdomen according to aterm of pregnancy. Striae gravidarum (+),
hyperpigmentation (+), cicatrix (-) Pelvic Outlet : ​
L1 : fundal uterine palpated 3 fingers below processus xyphoideus. A large, soft, Inter tuberous distance couldn’t be passed through by normal adult fist  (<10.5
nodular mass cm)​
L2: big resistence of baby was palpated on right side, small parts of the baby was Impression : Contracted pelvic primary CS
palpated on left side
L3: A hard, round mass was palpated, not fixated Osborn Test (+)
L4 : convergen

UFH : cm
EFW : gr
Uterine contraction : x/”/
Fetal heart rate : 135- 145x/i

Genitalia
V/U within normal limit, vaginal bleeding (-)

VT :Dilatation (-),portio posterior, effacement 0%, hard, amnion sac (+). Head was

palpated on HI-II
 Supportive examination
Lab Ponek ultrasound
Hb : • Fetal alive, singleton, intra uterine, head presentation
Leuko :
Trombo : • Fetal movement activity was good
Ht : • Fetal Biometri :
Diff : BPD : 9.53 cm EFW : 3596 gram
PT : AC : 35.43 cm FHR : 131
APTT: FL : 7.27 cm
D dimer :
Albumin : AFI : 8.79 cm
Globulin : Placenta implanted in anterior corpus, Maturity grade III
Ureum :
Creatinin : Impression :
GDS : 39-40 weeks of term pregnancy according fetal biometry
Na :
Ka : Fetal alive, singleton, intra uterine, head presentation
Cl :
HbSAg : NR
HIV Rapid : NR
 Diagnosis and Management
Diagnose 11-07-2022 at 14.50 LSCS was performed
• G2P1A0L0 38-39 weeks + previous CS oi contracted pelvic male baby was born at
• Fetal alive, singleton, intrauterine, head presentation BW: 3000 gram
Plan BL: 50 cm
A/S:8/9
Instruction : Diagnose Post Op
Control GA, VS, FHR, impartu sign • P1A0L1 Post LSCS oi contracted pelvic + uncontrolled
IVFD RL 20 hyperthyroid
Inj Cefazoline 2gr • Mother and baby were in care
Consult to anaesthesiologist, perinatologist
Report Operation Room Instruction
Control GC, VS, Vaginal Bleeding
IVFD RL drip Oxytocin 10 iu + metergin 0.2 !:
Process Inj. Ceftriaxone 2 x 1 gram iv
G1P0A0L0 40-41 weeks of term parturient latent phase of first stage + Pronalges supp (if needed) per rectal
uncontrolled Hyperthyroid Laboratory check up post operation
 LSCS Care in HCU green zone
Protocol post operative hyperthyroid :
Inj. Dexamethasone 4x10mg iv
PTU 4 x 200mg po
Lugol 4x10gtt
Propanolol 4x10mg
Admitted letter
USG Ponek
USG Ponek
USG Ponek
USG
• Fetal alive, singleton, intra uterine, head presentation
• Fetal movement activity was good
• Fetal Biometri :
BPD : 9.53 cm EFW : 3596 gram
AC : 35.43 cm FHR : 131
FL : 7.27 cm
AFI : 8.79 cm
Placenta implanted in anterior corpus, Maturity grade III

Impression :
39-40 weeks of term pregnancy according fetal biometry
Fetal alive, singleton, intra uterine, head presentation
 CTG -07-2022
• Baseline :
• Variability :
• Acceleration : (+)
• Deceleration : (-)
• Fetal movement : (+)
• Contraction : (-)
• Impression : 1st category
Labor result (11-07-2022)
Operation Report
• Patient on supine position under spinal anaesthesia
• Antiseptic and septic procedure was performed
• Phanensteil incision was performed, layer by layer was
opened until peritoneal
• Semilunar incicision at lower uterine segment was
performed
• Female baby was born by deliver the head, BW :
gram, BL cm, A/S : 8/9
• Placenta was born with mild traction on the umbilical
cord
• Double layer closure then performed
• Abdomen was closed layer by layer
• Skin closed by subcuticular closure
• Bleeding during operation approximately 250 cc
DOCUMENTATION
LUBCHENKO CURVE
Ballard Score

40→40 minggu
 Follow Up 2 hours Post Operation
S Post operative pain (+) P Control GA, VS, uterine contraction, vaginal
bleeding, urine output
O GA Cons BP HR RR T IVFD RL drip Oxytocin 10 iu + metergin 0.2 !:
Mdt CM 128/69 104 20 36.9 Inj. Ceftriaxone 2 x 1 gram
Pronalges supp (if needed)
Abd : Laboratory check up post operation
Operation wound closed by verband. Uterine fundal Care in HCU green zone
palpated 2 fingers below umbilical, contraction (+) Protocol post operative hyperthyroid :
Genitalia : Inj. Dexamethasone 4x10mg iv
V/U normal. Vaginal bleeding (-) PTU 4 x 200mg po
Urine : 150 cc/hours Lugol 4x10gtt
Propanolol 4x10mg
A • P1A0L1 Post LSCS oi contracted pelvic + uncontrolled
hyperthyroid
• Mother and baby were in care
Thank You