LAPORAN JAGA

16 Oktober - 17 Oktober 2014

MRS
:
Obstetri
:
Ginekologi
:
TINDAKAN OBSTETRI DAN GINEKOLOGI
Obstetri
Fisiologis
:
Patologis Pervaginam
:
SC
:
Ginekologi
Histerotomi
:
Kuretase
:
Biopsi PA
:
Manual Plasenta
:
Sisa Kamar Bersalin
:
ICU
:
Bangsal Cempaka / Tulip :
Poliklinik
:
Meninggal
:

PREFACE
NO

1.

NAME

DIAGNOSIS

LATEST CONDITION

NO

NAME

DIAGNOSIS

LATEST CONDITION

PREFACE
NO

NAME

DIAGNOSIS

LATEST CONDITION

KAMAR BERSALIN
Jumlah Persalinan :
Fisiologis :
Patologis
- Pervaginam :
- Perabdominam :
Sisa Kamar Bersalin

PARTUS FISIOLOGIS
(2) Pasien

Mrs. Dahliani/38 Y.o/ hospitalized October 16 th 2014/ 08.05 WITA

G4P3A0 38-39 WoP + SLIUF+ bottom presentation+ in labor second stage + age 35 y.o + EFW
3200 g
Chief complain: contraction
Patient referred from midwife with diagnosed G4P3A0 39 WoP + SLIUF+ in labor second stage +
bottom presentation. Patient complained about uterus contraction since 8 hours before
admission. watery discharge (+), bloody show (+)
History of illness
: hipertention (-), DM (-), asthma (-)
History of family illness : hipertention (-), DM (-), asthma (-)
History of marriage
: 1x, years
History of contaseption :
History Of labor :
1. 1998/midwife/aterm / male/3200 gr/alive/spontaneus
2. 2003/midwife/aterm/male/2700 gr/alive/spontaneus
3. 2009/midwife/aterm/male/2700 gr/alive/spontaneus
4. 2014/current pregnancy
1st day of LMP : january 15th 2014
WoP :39 40 weeks
EDD :october 22th 2014

Status Of Present:
GCS 4-5-6
A/I/C/D (-/-/-/-)
BP
: 100/70 mmhg,
HR
RR
: 20x/menit
Temp

: 84 x/m
: 36,7

Status Obstetri:
FH : 31 cm
EFW :3200 gr

FHR
contraction

:12-11-12
:4x/45-50/10

VT: complete/ amnion (-)/ bottom presentation /H III

A) G4P3A0 38-39 WoP + SLIUB + bottom presentation+ in labor second
stage + age 35 y.o + EFW 3200 g
P) Lead mother for straining
08.10
Baby was born bracht spontaneous /male/ 3200 g/50 cm/AS 7-8-9
Placenta born by active mangement stage III

Labor Report
Complete dilatation, the head in front of the vulva, lead
mother for straining. The right hand was holding the
perineum, left hand was holding deflection head. Head born
spontaneously. Hold head in biparietal. Pull out to posterior
to born front shoulder under the symphysis. Then pull out to
anterior to born back shoulder . Pull out equal to the floor, till
body, buttocks, and legs born
Baby was born spt-bh, gender : male, weight ;3200 gram,
length ;50 cm, AS :7-8-9, anus (+), congenital anomaly (-)
Clamp on 2 position of the umbilical cord, cut the umbilical
cord. Inject the oxytosin 10 IU (IM) and strecth the umbilical
cord.

 10.10
2 hours Post partum
S) Active bleeding (-)
pain (-)
O) BP=110/70
HR;86
RR = 24 x/mnt
T=36,8
STO
FH ~ umbilicus
Contraction (+)
A)P4004 post partum spontaneous
P) p.o cefadroxil 3x500mg
mefenamic acid 3x500 mg
SF 1x1

Latest condition
S) Active bleeding (-)
pain (-)
O) BP=110/70
HR;86
RR = 24 x/mnt
T=36,8
A)P4004 post partum spontaneous
P) p.o cefadroxil 3x500mg
mefenamic acid 3x500 mg
SF 1x1

PARTUS PATOLOGIS
PERABDOMINAN
(1 Pasien)

Mrs. Fauziah/30 Y.o/ hospitalized October 16 th 2014/ 01.00 WITA

G4P3A0 38-39 WoP + SLIUB + head presentation+ HAP ec. Totally plasenta previa + obesitas gr

Chief complain: vaginal bleeding

Patient referred from public health Jambu Burung with diagnosed G4P3A0 + HAP. Patient complain
vaginal bleeding since 3 hours before admission. Uterus contraction (-), watery discharge (-), bloody
show (-)
History of illness
: hipertention (-), DM (-), asthma (-)
History of family illness : hipertention (-), DM (-), asthma (-)
History of marriage
: 1x, 17 years
History of contaseption :
History Of labor :
1. 2000/midwife/aterm / male/3500 gr/alive/spontaneus
2. 2002/midwife/aterm/female/3000 gr/alive/spontaneus
3. 2007/midwife/aterm/female/3000 gr/alive/spontaneus
4. 2014/current pregnancy
1st day of LMP
WoP :
EDD :

: forget

Status Of Present:
GCS 4-5-6
A/I/C/D (+/-/-/-)
BP
: 130/80 mmhg,
RR
: 24x/menit

HR
: 88 x/m
Temp : 36,7

Status Obstetri:
FH
: 32 cm
EFW :3800 gr

FHR :11-11-12
contraction :-

VT: 2cm/ eff 25%/ smnion (+)/ head presentation /SS mell/ H1
A) G4P3A0

38-39 WoP + SLIUB + head presentation+ HAP ec. Totally

plasenta previa + obesitas gr
1

P) Laboratory check
NST, USG
Report current condition with dr. Renny, Sp.OG
-IVFD RL 1 liter
O2 masker
left
prepare 2 kolf of WB
Pro SC cito

USG

Laboratory

examination

result

Hemoglobin

9,4

g/dl

Leukocyte

8,6

ribu/ul

Eritrocyte

3,46

juta/ul

Hematocrit

30,3

vol%

Trombocyte

266

ribu/ul

BSN

139

Mg/dl

LDH

420

U/L

SGOT

27

U/I

SGPT

18

U/I

Ureum

17

Mg/dL

Creatinin

0,6

Mg/dL

Uriic acid

5,0

Mg/dL

Natrium

137,9

Mmol/l

Kalium

3,6

Mmol/l

103,4

Mmol/l

Chlorida

07.30
Patient sent to operating room
08.40
Cesarian sectio was begun
09.00
Baby was born
Gender : male, weight 3500 gr, length ,AS 678, anus (+),
congenital anomaly (-)

Surgery report
Informed consent and antibiotic prophylaxis
Patient was lied on supine position under spinal anesthetic
Performed disinfection of operating area & drapped operating area
Performed incision on middle abdomen, axplorating of cavum abdomen
1.
2.

1.
2.
3.
4.
5.
6.

Gravid aterm uterine

Normal PA d et s
Performed LSCS
Performed bladder flap
Performed low segment uterine incition (2 cm), widened to lateral bluntly
Teared amniotic membrangt
Baby was born (male/ 3500 g/49 cm/AS 6-7-8)
Placenta was born completely
Performed evaluation of bleeding
Suture the surgical wound layer by layer

 10.30
Post operation
S) Active bleeding (-), pain (-)
O) BP= 130/80 HR =86
RR= 24 T =37,0
FH~ umbilicus
Contraction (+)
A) P40004 post cesarian section due to totally placenta previa
P) IVFD : RL =2;2/24 hour
inj alinamin F 3x1
inj ketorolac 3x1
inj vit c 3x1
inj ceftriaxon 2x1
inj transamin 3x500 mg
laboratory check post cesarian section
oxytocin drip 2 amp 20 dpm till 24 hours post op
observation VS/fluxux/uterus contraction

1. Mrs.Saniti /36 y.o/

hospitalized october 15th 2014 /11.45 WITA
G4P2012 37-38 WoP+ head presentation + chronic
hipertention superimposed severe preeclampsia+ Primitua
sekunder + not in labor + EFW 3200 gram
chief complain : dizziness
patient was referred from policlinic Ulin Hospital with diagnosed
G4P2012 37-38 WoP+ head presentation + chronic hipertention
superimposed severe preeclampsia+ secondary old primi + not
in labor + EFW 3200 gram. patient told that she have dizziness
since 3 hour admission. Nausea (-), vomit (-), cloudy eyesight (-),
uterus contraction (-), watery discharge (-), bloody show (-)
History of illness: HT (+) DM (-) Alergic (-)
History of family illness : DM (-), HT (-)
History ofmarriage : 1x,18 years
History of contraception: injection for 3 month
History of labor : 1. 1997/abortus/12 weeks
2.1998/midwife/aterm/female/3100 g/spontaneous
3. 2004/hospital/aterm/male/3300g/spontaneous
4. 2014/current pregnancy

Status Present:
G C S: 4-5-6
A/I/C/D (-/-/-/-)
BP
: 160/100 mmhg,
RR
: 18x/menit
: vesikuler +/+
Rh -/-

HR : 88 x/m
Temp : 36,7

C/P

Status Obstetri:
LI
: FH 31 cm
contraction : (-)
LII
: punggung kanan
FHR
;11 -11-13
LIII
: letak kepala
LIV
: belum masuk PAP
VT: (-)/ lowest part of fetus still high/PS 2
A )G4P2012 37-38 WoP+ head presentation + chronic hipertention
superimposed severe preeclampsia+ Primitua sekunder + not in
labor + TBJ 3200 gram

P)
O2 masker 6-8 lpm
Infus + DC
Complete laboratory check
MgSO4 regiment
Nifedipine 3x10 mg
Metil dopa 3x250 mg
NST if the result good Pro pervaginam termination and ripening
misoprostol 4x50 mg/6 hours until PS 5
If PS 5 pro OD
Balance cairan
Pro percepat kala II bila inpartu
Observation status present/VS/FHR/tanda2 impending/tanda2
inpartu

USG Policlinic october 15th 2014

BPD: 91,8 cm ~ 36/37
AC: 340,8 ~ 39
HC : 310 ~ 36/37
Plac. Corpus anterior/III/enough
EFW: 3270 gram
Visite dr.Renny Sp.oG
Pkl. 12.00 WITA
Advise:
Informed consent to family
Protap PEB
Terminasi-Repening misoprostol
Evaluation 6 hours
Observation present status /VS/FHR/timpending eklampsia sign
/inpartu sign

Complete blood test october 15th 2014

(11:14)
examination

result

unit

Hemoglobin

11,1

g/dl

Leucocyte

14,5

ribu/ul

Eritroscyte

4.30

juta/ul

Hematokcrite

34

vol%

Trombocyte

335

ribu/ul

MCV

79,3

fl

MCH

25,8

pg

MCHC

32,6

9,5/27,2/0,84

detik

BSN

102

Mg/dL

Urid acid

5,3

mg/dl

27/15/300

U/I

138/4,1/102,5

mmol

PT/APTT/INR

SGOT/SGPT/LDH
Na/K/Cl

Pemeriksaan
15-10-2014 (11:14)

Warna-kekeruhan

Hasil
Kuning muda-jernih

BJ

1.000

pH

7.5

Keton

Negatif

Protein-albumin

Negatif

Glukosa

Negatif

Bilirubin

Negatif

Darah samar

Negatif

Nitrit

Negatif

Urobilinogen

0.2

URINALISA (SEDIMEN)
Leukosit

0-2

Eritrosit

0-1

Selinder

Negatif

Epitel

1+

Bakteri

Negatif

Kristal

Negatif

Lain-lain

Negatif

17.00
PS 2 misoprostol 1
Next evaluation : 23.00
23.00
PS 3 misoprostol 2
05.00
PS 3 misoprostol (-)

50mcg/vag/6 hours

50mcg/vag/6 hours

october 16th 2014, 06.00

S: (-)
O: GCS 456 A- I- C- DBP: 150/90 HR: 88
RR: 20
C/P: normal
STO : contraction (-) 2 x 20/10

T: 36.9

FHR: 12-12-11

A) G4P2012 37-38 WoP+ head presentation +

chronic hipertention superimposed severe
preeclampsia+ secondary old primi+ not in
labor + TBJ 3200 gram on termination ripening
misoprostol

11.15
Patient sent to operating room
11.40
Cesarian sectio was begun
11.50
Baby was born
Gender : female, weight 2450 gr, length 48 ,AS 4 6 7 , anus (+),
congenital anomaly (-)

P)
O2 masker 6-8 lpm
MgSO4 regiment
Nifedipine 3x10 mg
Metil dopa 3x250 mg
Reconsult progress of labour
Fluid balance
Pro accelerated second stage if in partu
Mo: KU/TV/DJJ/impending eklampsia sign/in partu sign

 Informed consent and antibiotic prophylaxis

Patient was lied on supine position under spinal anesthetic
Performed disinfection of operating area & drapped operating area
Performed incision on middle abdomen, axplorating of cavum abdomen

Surgery report

1.
2.

1.
2.
3.
4.
5.
6.

Gravid aterm uterine

Normal PA d et s
Performed LSCS
Performed bladder flap
Performed low segment uterine incition (2 cm), widened to lateral
bluntly
Teared amniotic membrangt
Baby was born (female/ 2450 g/48 cm/AS 4-6-7)
Placenta was born completely
Performed evaluation of bleeding
Suture the surgical wound layer by layer

 13.10
Post operation
S) Active bleeding (-), pain (-)
O) BP= 150/90
HR =88
RR= 22
T =37,0
FH~ umbilicus
Contraction (+)
A) P3013 post cesarian section
P)
laboratory check post cesarian section,if Hb < 8 tranfution PRC until HB >8 IVFD
RD5 1000 cc/24 jam
oxytocin drip 2 amp 20 dpm till 24 hours post op
MgSo4 drip 40% , 20 g until 24 hours post SC
inj alinamin F 3x1
inj ketorolac 3x1
inj vit c 3x1
inj ceftriaxon 2x1
inj transamin 3x500 mg
fluiid balance
nifedipin 3x10 mg if BP > 140/90
observation VS/fluxux/uterus contraction

Sisa Kamar Bersalin

(2 Pasien)

GINEKOLOGI

( 2 PASIEN)

ICU
( 3 PASIEN)

RENCANA OPERASI (1)

RUANG CEMPAKA
Perhatian khusus
Pasien

: (2)

Post operasi
Pasien
( R. TULIP )

: (1)

ABSENSI
VK Bersalin

Nafilah Syella
Ferisa Aprintha
Norhidayah
Grifan R
Riky Novriansyah

Ruang Nifas

Yantari tiyora
Fairuz athiyyah
Devita sekar N
Zainul M
Fathullah
Ara BB

Poliklinik

Nadia Harira
Intan KD
Fatimah Rizky
Redha R
Fajar GR

DAFTAR KONSULEN
12/27/15

KONSULEN STASE :
Kamar Bersalin : dr. Samuel Tobing, Sp.OG (K)
Ruang Cempaka : dr. Ihya Ridlo N, M.Kes, Sp.OG
Operasi Obstetri Berencana : DR. dr. Adjar Wibowo, Sp.OG (K)
Operasi Ginekologi Berencana : dr. H. Sutarinda Z, Sp.OG (K)
Poliklinik : dr. Iwan DP, Sp.OG (K)

KONSULEN JAGA :
dr. Fery Armanza, Sp.OG (K)

TERIMA KASIH