OBSTETRIC WARD

Tuesday, January 23th 2024

Supervisor:

Residents:

Obstetric and Gynecology Department

Medical Faculty of Universitas Sumatera Utara
Prof CPL USU General Hospital
2024
1. Mrs. A, 28 yo, P3A2
Diagnosis :Post C-Section d/t Previous C-Section 2x + Severe Adhesion + PD-4 + Urinary Bladder Injury
Supervisor : dr. Pebri W. Pulungan, Sp. O.G
Planning : Ambulatory
ICD X : O.34.21 Maternal Care For Scar From Previous Caserean Delivery
S.37.2 Injury of Bladder
ICD IX : O82.1 Delivery by Caesarean Section
On January 17th 2024 at 11.30 a.m, by C-Section, born a female baby with BW 3.040 gr, BL 48 cm, Apgar Score 6/9
Anal (+) NBS 36 appropriate with 37 wga
PATIENT 12
Mrs. A, 28 y.o, G5P2A2, Javanese, Moslem, Senior High School, Housewife, married to Mr. M, 34 y.o,
Javanese, Moslem, Bachelor, National Army. The patient was came to Emergency Room of Prof. dr. CPL USU
General Hospital on January 16th 2024 with :

Cc : Plan for Elective C-Section with ERACS Method

E : History of labor contraction (-). History of amniotic leakage (-). History of blood slime (-). History
of abdominal pain (-), history of vaginal bleeding (-) History of abdominal massage (-) History of post coital
bleeding (-) History of herbal consumption (-) History of fever, shortness of breath and cough (-). Defecation
and Micturition within normal limit.
History of previous illness :-
History of Medication :-
History of Surgery : Curretage 1 time, C-Section 2 times
LMP : 28/04/2023 (37w4d)
EDD : 02/02/2024
ANC : Obstetrician 3 times

History Of Pregnancy :
1. Incomplete Abortion, Curretage (2014)
2. Female, Preterm, 2.700 gr, C-Section d/t CPD, Obstetrician, Hospital, 2015, 9 y.o, Healthy
3. Female, Aterm, 2.800 gr, C-Section d/t Previous C-Section 1x, Obstetrician, Hospital, 2028, 6 y.o, Healthy
4. Complete Abortion ( 2022)
5. Current Pregnancy
MEOWS

Total Score : 1
Vital Signs
Cons : CM Anemic : (-)
BP : 120/90 mmHg Icteric : (-)
Pulse : 80 bpm Cyanosis : (-)
RR : 20 rpm Dypsnoe : (-)
Temp : 36.5 ⁰C Edema : (-)

General state : Moderate BW : 70 kg

Nutritional state : Overweight BH : 160cm
Illness State : Moderate UAC : 235 cm

Generalized Status
• Head : Inferior palpebra conj anemic (-/-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : Vesiculer (+/+)
Additional sound : wheezing(-)/(-), rhales (-)/(-)
• Extremities : oedema (-/-)
• Lymph nodes : no enlargement
Obstetric Examination
Abdomen : Asymmetrically enlarged
Fundal height : 3 fingers below processus xyphoideus (31 cm)
Tension part : Left
Lower part : Head
Uterine Contraction : (-)
FM : (+)
FHR : 152 bpm
EFW (Johnson Tossack) : (31-13) x 155 = 2.790 gr

Vaginal Examination
VT : Not performed
Inspeculo : Not performed
Transabdominal Sonography
January 17th 2024
Transabdominal Sonography
January 17th 2024
Transabdominal Sonography
January 17th 2024
Transabdominal Sonography
January 17th 2024
Transabdominal Sonography
January 17th 2024
 Transabdominal Sonography
January 17th 2024
- Single fetus, Intrauterine, Live Fetus
- FM (+), FHR (+) 144 bpm, Regular
- BPD : 91.6 mm
- HC : 338.9 mm
- AC : 310.1 mm
- FL : 71.8 mm
- S/D ratio : 2.11
- FHR : 144 bpm
- MVP : 4,3 cm
- EFW : 2.818 gr
- Placenta corpus Anterior grade 3

Conclusion:
IUP (36) wga + Head Presentation + Live Fetus
 Laboratory Findings
January, 16th 2024
• Hb : 10.6 N: 12-14 gr/dL
• Leukocyte : 8.300 N: 4.000-11.000/uL
• Hematocrit : 29.8 N: 36,0-42,0/%
• Platelet : 193.000 N: 150.000-400.000/uL
• MCV : 79.5 N: 82 – 92 fL
• MCH : 26.3 N: 27 – 33.7 pg
• MCHC : 35.6 N: 32 – 36 %
• RDW-SD : 41.4 N: 11.5 – 14.5%
• Neutrophil : 74.3 N: 50.00 – 70.00%
• Lymphocyte : 19 N: 20.00 – 40.00%
• Monocyte : 9.4 N: 2.00 – 8.00%
• Eosinophil : 2.9 N: 1.00 – 3.00%
• Basophil : 0.3 N: 0.00 – 1.00%
• Neutrophil Abs : 6.91 N: 2,7-6,5 10^3/l
• Monocyte Abs : 0.63 N: 0,2-0,4 10^3/l
• Eosinophil Abs : 0.27 N: 0-0,1 10^3/l
• Basophil Abs : 0.03 N: 0-0.1 10^3/l
 Laboratory Findings
January, 16th 2024

Clinical Chemistry
• PT : 12.1 N: 14

• INR : 0.82 N:0.8-1.3

• APTT : 29.0 N:32.7
• TT : 15.6

• Glucose : 85 N:<200

• Anti HIV (Rapid) : Non-Reactive N: Non-Reactive

• HbsAg : Non-Reactive N: Non-Reactive
Diagnosis:
Previous C-Section 2 times + MG + IUP (36) wga + Head Presentation + Live Fetus

Therapy
IVFD RL 20 tpm
Inj Cefazoline 2gr  prophylaxis
Inj Dexamethason 15 mg Single Dose

Planning:
Elective C-Section ERACS on Wednesday, January 17th 2024
Consult to Perinatology Department
Consult to Anesthesiology Department

Reported to supervisor on duty dr. Pebri W. Pulungan, Sp.O.G Approved

Follow Up
January 17th 2024 (08.00 am)
S Pain on Surgical wound
O Sens : CM
BP : 114/75 mmHg
HR : 79 bpm
RR : 20 rpm
T : 36.5
SpO2 : 99% Via RA

Obstetric Examination
Abdomen : Asymmetrically enlarged
Fundal height : 3 fingers below processus xyphoideus (34cm)
Tension part : Left
Lower part : Head
Uterine Contraction : (-)
FM : (+)
FHR : 142 bpm

A Post C-Section d/t Previous C-Section 1x + PD-1

P - IVFD RL 500 ml 20 gtt
I Sectio Caesarea ERACS Methode at 11.00 a.m
 C-Section Report d/t Previous C-Section 2x
On January 17th 2024 at 11.30 a.m, by C-Section, born a female baby with BW 3.040 gr, BL 48 cm, Apgar Score
6/9 Anal (+) NBS 36 appropriate with 37 wga

• The patient was laid on the operating table. IV cath and Folley catheter was inserted
• Antiseptic and aseptic procedures were performed using povidone iodine on the abdomen, and then draped leaving the
surgical field exposed.
• Under spinal anesthesia, pfannenstil incision was performed through cutis, subcutis, until fascia. The fascia was incised
and extended laterally using scissor. Fascia was elevated using Kocher, and the underlying rectus muscles were separated.
• 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. Seen uterus
appropriate to gestational age. Lower uterine segment was identified, a transversal incision in the uterus performed until
subendometrium layer. Endometrium penetrated and widened bluntly.
• By pulling the legs born a female baby with BW 3.040 gr, BL 48 cm, Apgar Score 6/9, Anal (+)
• The umbilical cord was clamped in two places and cut in between.
• The placenta was born with traction on the umbilical cord. Uterine cavity was cleaned with gauze, evaluated there was
no active bleeding.
• Uterus was sutured double layer continuously, evaluate  Bleeding was controlled.
• Evaluating urinary bladder  impression urinary bladder injury and Consult to urology department on durante operation
• Evaluating both adnexa  No abnormalities.
• Abdominal wall closed layer by layer.
• Peritoneum sutured continuously, muscle approximation using simple suture and fascial closure using continuous suture.
• Subcutaneous layer was sutured with simple suture and cutis was sutured with subcuticular suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Patient was stable after the operation.
Clinical Findings
Surgical Findings
Surgical Findings
Surgical Findings
Surgical Findings
Diagnosis :
Post C-Section d/t Previous C-Section 2x + Severe Adhesion + PD-0 + Urinary Bladder Injury

Therapy :
- IVFD RL 30 dpm
- Inj. Ceftriaxone 1 gr / 12 hours
- Inj. Ketorolac 30 mg / 8 hours
- Inj. Kalnex 500mg/8 hours
- Inj. Metoclopramide/ 8 hours
- Inj. Vit K 1 amp/24 hours
- Ketoprofen Supp 2/8hours
- Paracetamol 3x500mg
- Vitamin C 2x1
- SF 2x1

Plan :
• Monitoring Vital Sign, Vaginal Bleeding, Urine Output, Uterine contraction, Drain production
• Check CBC 2 hours post Operation
• Other Theraphy according to Urology Department

Reported to supervisor on duty dr. Pebri W. Pulungan, Sp.O.G  Approved

Follow Up
January 18th 2024 (08.00 am)

S Pain on Surgical wound

O Sens : CM
BP : 120/80 mmHg
HR : 70 bpm
RR : 20 rpm
T : 36.5
SpO2 : 99% Via RA

Localized State:
Abdomen : Laxed, Peristaltic (+)
Operation wound : Covered by Gauzed, seems dry
Vaginal Bleeding : (-) , Lochia rubra (+)
Drain : 200cc, Serous Hemorraghe
Micturition : via cathether, 48cc/hours, , cystostomy, yellowish
Defecation : (-) Flatus (+)

A Post C-Section d/t Previous C-Section 2x + Severe Adhesion + PD-1 + Urinary Bladder Injury
P - IVFD RL 30 dpm
- Inj. Ceftriaxone 1 gr / 12 hours
- Inj. Ketorolac 30 mg / 8 hours
- Inj. Kalnex 500mg/8 hours
- Inj. Metoclopramide/ 8 hours
- Inj. Vit K 1 amp/24 hours
- Ketoprofen Supp 2/8hours
- Paracetamol 3x500mg
- Vitamin C 2x1
- SF 2x1
I Keep drain and DC (Off based only Urology Department)
Other Theraphy according to Urology Department
 Urology Department
January, 18th 2024

A : Post Repair Buli POD-1 d/t Rupture Buli Iatrogenic + Post C-

Section d/t Previous C-Section 2x + Severe Adhesion

P:
Other Therapy According to Obgyn Department
Monitoring drain and cyctostomy
Follow Up
January 19th 2024 (08.00 am)

S Pain on Surgical wound

O Sens : CM
BP : 120/80 mmHg
HR : 70 bpm
RR : 20 rpm
T : 36.5
SpO2 : 99% Via RA

Localized State:
Abdomen : Laxed, Peristaltic (+)
Operation wound : Covered by Gauzed, seems dry
Vaginal Bleeding : (-) , Lochia rubra (+)
Drain : 80cc, Serous Hemorraghe
Micturition : via cathether, 51cc/hours, , cystostomy, yellowish
Defecation : (-) Flatus (+)

A Post C-Section d/t Previous C-Section 2x + Severe Adhesion + PD-2 + Urinary Bladder Injury
P - IVFD RL 30 dpm
- Inj. Ceftriaxone 1 gr / 12 hours
- Inj. Ketorolac 30 mg / 8 hours
- Inj. Kalnex 500mg/8 hours
- Inj. Metoclopramide/ 8 hours
- Inj. Vit K 1 amp/24 hours
- Ketoprofen Supp 2/8hours
- Paracetamol 3x500mg
- Vitamin C 2x1
- SF 2x1
I IV Line removal
Oral theraphy
 Urology Department
January, 19th 2024

A : Post Repair Buli POD-2 d/t Rupture Buli Iatrogenic + Post C-

Section d/t Previous C-Section 2x + Severe Adhesion

P:
Other Therapy According to Obgyn Department
Farlosin 1x0.4mg
Drain removal tomorrow  if drain <50cc/24hours
Follow Up
January 20th 2024 (08.00 am)

S Pain on Surgical wound

O Sens : CM
BP : 120/80 mmHg
HR : 70 bpm
RR : 20 rpm
T : 36.5
SpO2 : 99% Via RA

Localized State:
Abdomen : Laxed, Peristaltic (+)
Operation wound : Covered by Gauzed, seems dry
Vaginal Bleeding : (-) , Lochia rubra (+)
Drain : 80cc, Serous Hemorraghe
Micturition : via cathether, 51cc/hours, , cystostomy, yellowish
Defecation : (-) Flatus (+)

A Post C-Section d/t Previous C-Section 2x + Severe Adhesion + PD-3 + Urinary Bladder Injury
P - Natrium Diclofenac 2x50mg
- Paracetamol 3x500mg
- Cefadroxil 3x500mg
- Vitamin B Comp 2x1
- Antasida tab 3x1
- Tranexamic Acid 3x1
- Misoprostol 3x1 (for 3 days)
- Labumin 3x2 caps
I Oral Theraphy
Ambulatory
 Urology Department
January, 20th 2024

A : Post Repair Buli POD-3 d/t Rupture Buli Iatrogenic + Post C-Section d/t
Previous C-Section 2x + Severe Adhesion

P:
Other Therapy According to Obgyn Department
Farlosin 1x0.4mg
Drain Removal
Cystostomy and FC take to home
Ambulatory from Urology
Follow Up
January 21th 2024 (08.00 am)

S Pain on Surgical wound

O Sens : CM
BP : 120/80 mmHg
HR : 70 bpm
RR : 20 rpm
T : 36.5
SpO2 : 99% Via RA

Localized State:
Abdomen : Laxed, Peristaltic (+)
Operation wound : Covered by Gauzed, seems dry
Vaginal Bleeding : (-) , Lochia rubra (+)
Micturition : via cathether, 51cc/hours, cystostomy, yellowish
Defecation : (-) Flatus (+)

A Post C-Section d/t Previous C-Section 2x + Severe Adhesion + PD-4 + Urinary Bladder Injury
P - Natrium Diclofenac 2x50mg
- Paracetamol 3x500mg
- Cefadroxil 3x500mg
- Vitamin B Comp 2x1
- Antasida tab 3x1
- Tranexamic Acid 3x1
- Misoprostol 3x1 (for 3 days)
- Labumin 3x2 caps
I Ambulatory
THANK YOU