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Duty Report RSUDZASunday, January 11th 2015
Supervisor:
dr. Tg. !uspa De"i, #$gyn
Resident:
%arrah
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Reporting
2 &esarean Se'tion
1 (agina) De)iveries
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1. Spontaneous Delivery
Farrah/dr.Puspa, Obgyn
Mrs. M, 38 yoMR 13!"8!#"
*+!2 ter pregnan'y,sing)eton )ive headpresentation, !R#- 1 dayA%/ , unripe 'ervi !S1
Process:
CTG reassuring Inductionwith modality misoprostol 4x50mcg po after 1stmisoprostolrippened 'ervi acceleration with oxytocyn5iu/R 500 cc titration o$s. 2
hours acti!e phase of la"or #$cm% o"s& ' hours'ndphase ofla"or
$%&: Re3erred $y #$gyn
4orn a)e $a$y 200, 67 ', AS89104S +7;60 "ga
&)ear s'anty anioti'
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#. &esareanSe'tion
/&D 10 and 8
#72.1
Z+.0
#62.0
Z+0.0
/&D 8
6.1
Farrah/dr.Puspa, Obgyn
Doe to $ree'h presentation!riigravida
Mrs. DM, #) yo$RM* 13!"8!+#
*1 ter pregnan'y, $ree'hpresentation !R#- hours,
#)igohydranios, in )a$or
$%&* Re3erred $y #$gyn
4orn 3ea)e $a$y 2500, 67 ', AS8910
4S +7;60 "g
%! : /UD transesarean
-other and $a$y are in good'ondition, Rooing in
Pro'edures
&ase Out'o(e
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Pro'edure &ase Out'o(e
3. &esareanSe'tion
Farrah/dr.Puspa, Obgyn
Mrs. $, 38 yo$RM* 13!3"!"
*+!1A1 60;61 "ga,sing)eton )ive headpresentation, !revious &;Se'tion 1 /DT 7 years,=atent phase o3 )a$orProcess:
CTG reassuring > + 'o"ser!ation $ hours > + ',"ater $roe o"ser!ation( hours > + ', his 29109+0?3ai)ed o3 (4A& de'ided'esarean se'tion
$%&* &ae $y her o"n "i))
#@ !R#&SS . . .
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han- ou
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Mrs. M, 38 yo
*+!2 ter pregnan'y, sing)eton )ive head presentation, !R#- 1 dayA%/ , unripe 'ervi !S1
11/1/#1", .
&hie3 'op)aint : Bater $roe sin'e 1 day $e3ore adissionCistory : Aditted 8 onths pregnan'y. =-! 3orget. A@& regu)ar)y at id"i3e,
US eaination ;. The patient 'op)aint "ater $roe sin'e 1 day $e3oreadission. &ontar'tion ;, $)oody sho" ;. %uor a)$us ;, 'aries dentis ;.A'tive 3eta) oveent.
%ai)y !revious Cistory o3 /))ness * Astha, Cypertension, heart disase, D-,A))ergy denied-enstrua) history : enar'he 1+ yo, regu)ar)y, days, + pads9day,disenorrhea ;-arried history: 1, 22 yo
%! history: D-!A
#$stetri' history :
1. 4oy,15 yo, +200 gra, nora) de)ivery, $orn at id"i3e, no" hea)thy
2. *ir), 8 yo, +600 gra, nora) de)ivery, $orn at id"i3e, no" hea)thy
+. This pregnan'y
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Physi'al 0a(ination *3u))y a)ert, 4! 110970 Cg ! : 77 R : 17 T : +,60&1+ '97 g 4-/ 25,
2eneral Status *yes : no anei' 'onEungtive, no i'teri' s')era
Ceart : S1;S2 regu)er, no urur, no ga))op
!u)o : vesi'u)ar, no rai)s, no "heeFing
A$doen : Gua) to pregnan'y
treity: "ar, no edea
Obstetri'al Status *
%C +2 ', %B 2865 gra, right $a', head presentation, 595, %CR 165dp. C/S /rregu)ar
/ : (9U "n)
/o : Sooth portio, open #U,
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aboratory*
C$ : 11,2 gra9d) 12;16 gra9d)
=eu'o'yte : 10.009u) 6100;10500 9u)
Tro$o'yte : 2+0.000 9u) 150000;600000 9u)
Ct : ++ L 60;55 L
Rando $)ood g)u'ose : 87 g9d)
4T : 2? 1;M
&T : M 5;15M
&on')ution : "ithin nora) )iit
&T* :4ase)ine : 165$p(aria$i)ity : 5;25 $pA''e)eration : H
2910?De'e)eration : ;Cis : ;%eta) oveent : H&T* &ategory 1
US :4!D : 78 %B : 2700graA& : +10 %CR : H
%= : 6 A%/ : !)a'enta at anrerior 'orpus&on')ution: Ter pregnan'y, )ivehead sing)eton $a$y, diinishedanioti'
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A: *+!2 ter pregnan'y, sing)eton )ive head presentation, !R#- 1day A%/ , unripe 'ervi !S1
! : R. D9 #$servation o3 vita) sign, 'ontra'tion,%CR9hour?
#$servation 3or 'ord 'opression
R. Th9 !)an to vagina) de)ivery/nitia) p)an repenned 'ervi indu'tion "ith 'ervi'a)rippening "ith isoprosto) 650 'g po A4 proN)ais: /nE 'e3triaon 2 gr926 Ea
Informed consent
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A: *+!2 ter pregnan'y, sing)eton )ive head presentation, !R#- 1day A%/ , unripe 'ervi !S1
Diagnosti' !)an
#$servation o3 vita) sign, 'ontra'tion,%CR9hour
#$servasion 'ord 'opression and intrauterin in3e'tion
Therapy!)an
!)an to vagina) de)ivery/nitia) p)an repenned 'ervi indu'tion "ith'ervi'a) rippening "ith isoprosto) 650 'gpo A4 proN)ais: /nE 'e3triaon 2 gr926 Ea
du'ation !)an
p)aining a$out patient 'ondition and p)an o3diagnosis and p)an o3 therapy 3or patients and3ai)y
4reast i) and 'ontra'eption otivation
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January 11th2015
1. 4ib
Repenned 'erviindu'tion "ithisoprosto) / 50 'g po.Reeva)uate hours )ater07.00
07.00 wib
S/Contraction continuously (+), fetal
movement (+),
O/
GC : good, CM, B : !!"/#" mm$g,
% : &&'/mnt, %% : '/mnt, em* :
-C,
General status : .nl
Ostetric status :
0$% !1" *m, contraction '/!"2/"34: normal 5/65: soft *ortio, a'ial, effacement 7"8, cm, amnion memranes (9), ead$ 4944
;/
*+!2 ter pregnan'y, sing)eton)ive head presentation, !R#- 1day A%/ , unripe 'ervi !S1,
ripened 'ervi/
lan to vagianl delivery
o'ytocin 7 46 in 7"" cc %< egin at
&m46/mnt titrated 1m46/mnt every "2
until ade=uate contraction
%eevaluate ours after ade=uate
contraction
).3 4ib
Rea'h adeGuate 'ontra'tion6910?960O at 12 drop9ntReeva)uate in + hours
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January 11th2015
+. 4ib
S9&ontra'tion ore regu)arH, 3eta) oveent H,#9*& : good, &-, 4! : 11090Cg, !R : 79nt, RR :209nt, Tep : +.5&,*enera) status : "n)#$stetri' status :
%CR 1+5 $p, 'ontra'tion6910?960O/: nora) (9U(T: thin portio, anterior,eIa'eent 5L, 7 ',anion e$ranes ;,sa)) 3ontane) in rightanterior, head C //;///A9
*+!2 ter pregnan'y,sing)eton )ive headpresentation, a'tive phaseo3 )a$or!9!)an 3or vagina) de)iveryReeva)uate 2 hours )ater22.00
11. 4ib
S9-other "ants to $ear do"n,3eta) oveent H,#9*& : good, &-, 4! : 11090Cg, !R : 779nt, RR :229nt, Tep : +.+&,*enera) status : "n)#$stetri' status :
%CR 150 $p, 'ontra'tion6910?950O/: nora) (9U(T: 'op)ete 'ervi'a) di)atation ,e$rane ;, ')ear anioti'
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Su((ary/!+ !ost (agina) De)ivery
"ith /ndu'tionAppropriate 3orgestationa) age
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!artogra3
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han- ou
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Mrs. DM, #) yo*1 ter pregnan'y, $ree'h presentation !R#- hours, #)igohydranios, in)a$or
11/1/#1" 1+.3 p(
&hie3 'op)ain : &ontra'tion sin'e 6 hours $e3ore adissionR!S : !atient aditted 8 onth pregnan'y, =-! Apri) 2016 ter pregnan'y.
A@& regu)ar)y to id"i3e and #4*P@, )ast u)trasound 1 "ee ago "ithresu)t $a$y in good 'ondition, $ree'h presentation. &ontra'tion sin'e 6hour $e3ore adission. Bater $roe danied, and $)oody dis'harge H.)eu'orrhea H, se))y ;, it'hy ;. A'tive 3eta) oveent.
%ai)y previous i))nes : Astha, Cypertension, heart disease, D-, A))ergydenied
-enstrua) diary: enar'he 12 yo, regu)ar)y, day, disenorrhea denied-arried history: 1 , 2 yo%! history: ;
#$stetri' history:1. &urrent pregnan'y
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Physi'al ea(ination
*enera) 'ondition: *ood, &- "eight: 0 g height: 155 ' 4-/ : 25
4! 120970 Cg, !u)se 77 $p. RR 20 9inute, Tep. +,6Q &
2eneral status *ye : @o Anei' 'onEun'tiva, no i'teri' s')era
Ceart : /;// regu)er nora) heart sound, no urur, no ga))op
=ung : vesiu)er )e3tright, no "heeFing, no rai)s
A$doen : Gua) to pregnan'y
treity : "ar etreity, edea ;
Obstetri' status *
%C: +0 ', %B: 25 gr, 'ontra'tion 2910?9+5O, %CR 165 $p
/ : v9u 'a), no a'tive $)eeding
/o : sooth )ivid portio, open ostiu,
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aboratory*
C$ : 12,+ gra9d) 12;16 gra9d)
=eu'o'yte : 8.2009u) 6100;10500 9u)
Tro$o'yte : 220.000 9u) 150000;600000 9u) Ct : +6 L 60;55 L
Rando $)ood g)u'ose : 8 g9d)
4T : 2? 1;M
&T : M 5;15M
&on'lution * 5$
&2 *4ase)ine : 165$p(aria$i)ity : 5;25 $pA''e)eration : H
2910?De'e)eration : ;Cis : H 2910%eta) oveent : H&2 'ategory 1
6S2 *%CR H, sing)e, $ree'hpresentation4!D : 80 %B : 2700graA& : +20 A%/ : 10%= : 6!)a'enta on anterior 'orpus7sses(ent * sing)eton )ive$ree'h presentation
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A: *1 ter pregnan'y, $ree'h presentation !R#- hours,#)igohydranios, in )a$or
Diagnosti' !)an
#$servation vita) sign, 'ontra'tion and%CR9hour
#$servation o3 'ord 'opression sign andintrauterin in3e'tion
Therapy!)an
ergen'y &;se'tion/n3ored 'onsent&onsu)t to Anastesio)ogist&onsu)t to !erinato)ogy departent
du'ation !)an
p)aining a$out patient 'ondition and p)an o3diagnosis and p)an o3 therapy 3or patients and3ai)y
4reast i) and 'ontra'eption otivation
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#peration reportJanuary, 11th2015, 21.00;22.00&esarean Se'tion due to $ree'h presentation on priigravida,
1. !atient "as "ithin supine position in spina) anesthesia
2. Asepti' and antisepti' on surgery part "ith povidon iodine
+. !3annenstie) in'ision around the o)d s'ar
6. A$doina) "a)) "as opened )ayer $y )ayer, no adhesion
5. A3ter peritoneu "as opened, there "as a gravid uterus ter pregnan'y
. /dentiN'ation )o"er uterine segent. =US "as in'ised sharp)y, penetrated
$)unt)y, etended sharp)y. 4y )uated the $ree'h, $orn 3ea)e $a$y 4B +500 gra, 50 ', AS 8910
7. Anioti'
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Su((ary/!1 !ost &esarean Se'tiondoe to $ree'h presentation
on priigravidaAppropriate 3or gestationa)age
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han- ou
M $ 38
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Mrs. $, 38 yo*+!1A1 60;61 "ga, sing)eton )ive head presentation, !revious &;Se'tion 1/DT 7 years, =atent phase o3 )a$or11/1/#1" pu-ul 1). 4ib
&hie3 'op)ain : 'ontra'tion sin'e 5 hours $e3ore adission 'ae a)oneR!S : !atient aditted 8 onth pregnan'y, =-! 0+90692016 60;61 "ga .A@& regu)ar)y to id"i3e, #$gyn. U)trasound +. =ast US + "ee ago said the$a$y is good 'ondition. !atients 'op)aint 'ontra'tion sin'e 5 hours $e3oreadission. Bater $roe denied, $)oody dis'harge H. A'tive 3eta) oveentH.
%ai)y previous i))ness : Astha, Cypertension, heart disease, D-, A))ergy"as denied
-enstruasi diary: enar'he 1+ yo, regu)ar)y, day, disenorrhea denied-arried history: 1, 27 yo%! history: pi))
#$stetri' history:1. 4oy, 7 y, +800 gra, S& e' 3ai)ed indu'tion, RSUD ZA hospita)2. -es'arriage, 2 ont pregnan'y, 'urretage histiry ;+. &urrent pregnan'y
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Physi'hal ea(ination
U: *ood, &- B: 70 g C : 15 ' 4-/ +2,8
4! 110970 Cg, CR 70 9-inute. RR 20 9-inute, T +,6Q &
2eneralis Status *ye : @o aneis , no iteri
&or : 4J /;// regu)ar, no urur, no ga))op
!u)o : (esiu)er right)e3t, no "heeFing, no ra)es
A$doen : n)argent eGua) "ith pregnan'y, appear operation
s'artreity : "ar a'ra), no oedea
Obstetri' state*
%unda) height +6 ', )e3t $a', head presentation, %B: +255 gr,'ontra'tion H 2910?9+0O, %CR 150 dp,
/ : (9U "n), a'tive $)eeding ;
(T : so3t portio, aia), eI 50, + ', anion e$ranes H, head C /;//
&lini'al pelvi(etri*
!roontoriu no pa)pa$)e, D/ 8.5 ', )inea innoinata 19+;19+,Sa'ru ona3, Spina proinent, A! 80K adeGuate pe)vi'
&T*
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aboratory*
C$ : 11,2 gra9d) 12;16 gra9d)
=eu'o'yte : 12.2009u) 6100;10500 9u)
Tro$o'yte : 215.000 9u) 150000;600000 9u)
Ct : +1 L 60;55 L
Rando $)ood g)u'ose : 70 g9d)
4T : +? 1;M
&T : 7M 5;15M
Assesent : "ithin nora) )iit
&T* :4ase)ine : 150$p(aria$i)ity : 5;25 $pA''e)eration : H
2910?De'e)eration : ;Cis : H 2910?%eta) oveent : H&T* 'ategory 1
US* :4!D : 86 %CR HA%/ : 10 %B : +600graA& : +65%= : 5!)a'enta on 3unda)7sses(ent * sing)eton )ive$ree'h presentation
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A9 *+!1A1 60;61 "ga, sing)eton )ive head presentation, !revious &;Se'tion 1 /DT 7 years, =atent phase o3 )a$or
!9 R. D9 #$servation o3 vita) sign, 'ontra'tion,%CR9hours
#$servation RU/ sign
R. Th9 /nitia) p)an 3or vagina) de)ivery "ith (4A& Reeva)uate 7 hours )ater 05.00
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January 12th2015
1. 4ib
S9 Bater $roe H, &ontra'tionH, 3eta) oveent H#9*& : good, &-, 4! : 120970Cg, !R : 779nt, RR :229nt, Tep : +.5&,*enera) status : "n)#$stetri' status :%CR 160 $p, 'ontra'tion
+910?960O/: nora) (9U(T: so3t portio, aia), eI 50, +', anion e$ranes ;, headC /;//A9*+!1A1 60;61 "ga, sing)eton)ive head presentation, !revious&;Se'tion 1 /DT 7 years,
=atent phase o3 )a$or!9#$servation o3 vita) sign,
'ontra'tion,%CR#$servation RU/ sign!)an vagina) de)ivery "ith (4A&,Reeva)uate hours )ater 1.00
). 4ib
S9 -oS9 Bater $roe H, &ontra'tionH, 3eta) oveent H#9*& : good, &-, 4! : 11090Cg, !R :869nt, RR :229nt, Tep : +.5&,*enera) status : "n)#$stetri' status :
%CR 166 $p, 'ontra'tion6910?965;50O/: nora) (9U(T: (T: so3t portio, aia), eI 50,+ ', anion e$ranes;, head C /;//A9*+!1A1 60;61 "ga, sing)eton)ive head presentation, !revious
&;Se'tion 1 /DT 7 years,=atent phase o3 )a$or, 3ai)ed(4A&!9!resarean se'tion
#@ !R#&SS..
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han- ou