Final Weekly Report IV

WEEKLY REPORT
SUPERVISOR:
DR. SIGIT PRADONO DIPTOADI, Sp.OG
PRESENTED BY:
Aisyah Novita D.P.
2014-061-035
Stephanie Lukita
2014-061-041
Jessie
2014-061-046
Michelle Felicia W.
2015-061-050
Bonifasius
2015-061-052
R.R. Gabriela W.T.K
2015-061-054
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MEDICAL FACULTY OF ATMA JAYA CATHOLIC UNIVERSITY
2016
WEEKLY REPORT
SUPERVISOR:
DR. SIGIT PRADONO DIPTOADI, Sp.OG
PRESENTED BY:
Aisyah Novita D.P.
2014-061-035
Stephanie Lukita
2014-061-041
Jessie
2014-061-046
Michelle Felicia W.
2015-061-050
Bonifasius
2015-061-052
R.R. Gabriela W.T.K
2015-061-054
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MEDICAL FACULTY OF ATMA JAYA CATHOLIC UNIVERSITY
2016
OBSTETRICS
No
Admission
Identity
Date
1
February 29
th
Mrs. A
2016
Working
Final
Diagnosis of
Diagnosis
Diagnosis
the baby
G2P1A0, 41 years
P2A0, 41 years
Term Male
old, gravid 37-38
old, post partus
Neonate, 38-
weeks according
maturus by
39 weeks of
to USG, not in
Caesarean
gestational age
labor, with a
Section
according to
history of one
indicated by
New Ballard
time Caesarean
patient age and
Score, birth
Section, with
post bilateral
weight 2580
chronic
tubectomy
grams, 45 cm,
hypertension, with
indicated by
APGAR score
single living fetus
patient
9/9. Diagnosed
intrauterine, head
preference
as healthy
presentation.
2
February 29th
Mrs. A
2016
neonate
G1P0A0, 25 years
P1A0,25years
Aterm male
old, gravid 38-39
old,postpartus
neonate, birth
weeks according
maturusby
weight 3220
to USG, in first
caesarean
gr, birth length
stage labor, latent
sectionwith
phase, with
indication
APGAR score
cephalopelvic
cephalopelvic
9/9, diagnosed
disproportion,
disproportion
with single living
48 cm,
as healthy
neonate
fetus intrauterine,
head presentation
3
February 29th
2016
Mrs. SA
G2P1A0, 34 years
P2A0, 34 Years
Term Female
old, gravid 40-41
old, post partus
Neonate, 40-
weeks according
maturus by
41 weeks of
to first day of last
vaginal delivery
gestational age
period, prolonged
with vacuum
according to
active phase, with
extraction
New Ballard
single living fetus
indicated by
Score, birth
intrauterine, head
fetal distress
weight 3080
presentation
grams, 49 cm,
APGAR score
3/5. Diagnosed
as healthy
March 1
st
Mrs. H
2016
G2P0A1 32 years
P1A1, 32 years
neonate
Term male
old, gravid 38-39
old, post partus
neonate,
weeks of gestation
matures by
appropriate for
according to USG,
caesarian
gestational
not in labor, with
section indicated
age, 38-39
single live fetus
by CPD
weeks
intrauterine, head
(Cephalo Pelvic
according to
presentation, with
Disproportion)
New Ballard
CPD
Score, birth
weight 2920
gr, birth length
46 cm,
APGAR score
8/9
March 1st
2016
Mrs. E
G3P1A1, 29 years P2A1, 29 years Term female

old, Gestational
old, post partus neonate,
age 40-41 weeks
maturus
based on USG
caesarian
with Feto-Pelvic
by appropriatefor
gestational
sectionindicated age, 4041
Disproportion and
by Feto Pelvic weeks
single living fetus
Disproportion
intrauterine, head
presentation
according to
New Ballard
Score, birth
weight 3580
gr, 48 cm,
APGAR score
8/9, diagnosed
as
healty
neonate
6
March 3rd
Mrs. S
2016
G2P1A0, 30 years
P2A0, 30 years
Aterm male
old, gravid 38-39
old, post partus
neonate,
weeks according
prematurus by
appropriate
to USG, not in
spontaneous
for gestational
labor, with
vaginal delivery
age, 38-39
premature rupture
and post hecting
weeks
of the membrane,
indicated by
according to
with single fetus
perineal rupture
New Ballard
live intrauterine,
grade I.
Score, birth
head presentation
weight 2860
g, 47 cm,
APGAR score
9/9 with well
baby
7.
March 3rd
Mrs. H
2016
8.
March 3
rd
Mrs. SW
G5P4A0, 37 years
P5A0, 37 years
Term male
old, gravid 39-40
old, post partus
neonate, 39-40
weeks according
maturus by
weeks of
to USG, with
caesarean
gestational age
premature rupture
section indicated
according to
of membrane,
by
New Ballard
single living fetus
oligohydramnio
Score, birth
intrauterine, head
s and fetal
weight 3570
presentation.
distress, post
gr, birth length
tubectomy with
49 cm,
indication of
APGAR score
patient
8/9. Diagnosed
preferences.
as healthy
P3A0,35years
neonate
Termfemale
G3P2A0,35years
6
2016
old,gravid3940
old,postpartus
neonate,
weeksaccording
maturesby
appropriatefor
tofirstdayoflast
caesarian
gestational
menstrualcycle
sectionindicated
age,3940
withprolonged
bybreech
minggu
labourstageII,
presentation
accordingto
withsingleliving
withprolonged
NewBallard
fetusintrauterine,
labourstageII
Score,birth
breech
weight2930
presentation
gram,birth
length47cm,
APGARScore
6/9
9.
March 4th
2016
Mrs. S
G3P2A0 29 years
P3A0, 29 years
Term male
old, gravid 38-39
old, post partus
neonate,
weeks according
matures by
appropriate for
to USG, inpartu,
caesarian
gestational
stage one of labor,
section indicated
age, 38-39
with gemelli live
by patient
weeks
fetus intrauterine,
preference
according to
head presentation.
New Ballard
Score, birth
weight 2900
gr, birth length
48 cm,
APGAR score
9/9
Term male
neonate,
appropriate for
gestational
age, 38-39
weeks
according to
New Ballard
Score, birth
weight 2730
gr, birth length
48 cm,
APGAR score
8/9
CASE 1
G2P1A0, 41 years old, gravid 37-38 weeks according to USG, not in labor, with a history
of one time CS, with chronic hypertension, with single living fetus intrauterine, head
presentation.
Identity
Name
: Mrs. A
Age
: 41 years old
Ethnicity
: Javanese
Religion
: Moslem
Occupation
: Housewife
Education
: Junior High School
Date of admission
: February 29th 2016
Anamnesis
Chief complaints
:
Patient came to the hospital to have antenatal care examination.
History of present illness :
Patient was admitted to obstetrics and gynecology ward from Atma Jaya clinic to have
antenatal care examination. Patients expected labor is 4th March 2016. Patient didnt feel any
abdominal discomfort and didnt have any vaginal discharge. During the pregnancy, patient
has a high blood pressure and didnt have other complaints.
History of past illness
o
History of hypertension
: Patient has history of chronic

hypertension
History of diabetes mellitus
: Denied.
History of allergy
: Denied.
History of epilepsy
: Denied.
History of hematologic disease
: Denied.
History of urinary tract/kidney disease : Denied.
History of trauma
: Denied.
History of surgery
: Patient has a history of C-Section

from her 1st pregnancy & sweat
gland surgery
History of Menstrual Cycle

o Menarche
o Menstrual Cycle
: Approximately 13 years old

: irregular menstrual cycle, with every period lasting for
7 days and sometimes with dysmenorrhea.

o First day of last period : June, 6th 2015
Marital History:
Patient has married once, has lasted 20 years with current husband.
Obstetric history:
No
Date
2011
Gestationa
Labor
l Age
History
9 months
CS
Gender
Male
indicated by
Birth
Breast
Weight
feeding
2600
history
Breastfed
grams
15 days
old age
2
2016
37-38
(this
weeks
pregna
according
ncy)
to USG
Contraception History
Patient has used contraceptive injection for 3 months after giving birth to the first child.
History of antenatal care:
Patient has a routine antenatal care with 5 visits at community health center during this
pregnancy.
Physical Examination
General Condition
Consciousness Level
Vital Signs
- Blood Pressure
- Temperature
: Moderately ill
: Compos Mentis
: 130/90 mmHg
: 36,2oC
10
Respiratory rate
Heart rate
Weight (before pregnancy)
Weight (after pregnancy)
Height
BMI
: 20 times a minute
: 76 BPM
: 66 kg
: 74 kg
: 160 cm
: 25.8 kg/m2 (obese I)
General Examination
Eyes
Mouth
Thorax
Heart
Lungs
Mammae
: Anemic conjunctiva -/-, Icteric sclera -/: Wet oral mucosa

:
: Regular 1st and 2nd heart sounds, murmur -, gallop : vesicular breath sounds +/+, rhonchi -, wheezing : Areola hyperpigmentation +/+, Nipple retraction -/-,
breast milk -/Abdomen

:
Inspection
: Convex, Striae Gravidarum (+), Linea Nigra (+)
Auscultation : Bowel sounds (+), 6 times/minute

Extremities
: No Edema in any extremities, physiologic reflex
+/+/+/+, pathological reflex -/-
Obstetric examination
Estimated due date

Fundal Height
Fetal Weight Examination
Uterine Contraction
Fetal Heart Rate
Leopold maneuver
Leopold I
Leopold II
Leopold III
Leopold IV
Vaginal toucher
Inspeculo
Rectal Toucher
: March, 4th 2016

: 31 cm
: 2790 gr
:: 140 bpm
: Buttocks
: Back on left side
: Head
: convergent, 5/5
: not performed
: not performed
: not performed
Laboratory Examination
Hemoglobin
Hematocrit
Leucocyte
: 11.7 g/dl
: 35%
: 14300/l
11
Platelets
Blood Type
SGOT/AST
SGPT/ALT
Ureum
Creatinine
Fasting glucose
Urine protein
HBsAg
: 273000/l
: B/Rh (+)
: 18 U/I
: 11 U/I
: 17 mg/dL
: 0.5 mg/dL
: 78 mg/dL
: Negative
: Negative
Working Diagnosis
G2P1A0, 41 years old, gravid 37-38 weeks according to USG, not in labor, with a history of
one time CS, with chronic hypertension, with single living fetus intrauterine, head
presentation.
Planning
Observation of general condition and vital signs
Cefotaxim 1 gram IV
Infusion of RL 12 drips/minute
Follow Up
Day
S
1st March 2016

Post operation pain
2nd March 2016

Post operation pain
3rd March 2016

Post operation pain
VAS 2, flatus (+),
VAS 2, flatus (+),
VAS 1, flatus (+),
urinate with catheter,
urinate with catheter,
urinate (+), defecate
defecate (-)
defecate (-), normal
(+), normal diet
diet
Generalcondition: Generalcondition: Generalcondition:
well
Levelof
well
Levelof
well
Levelof
consciousness:CM
consciousness:CM
Vitalsigns:
Vitalsigns:
- BP: 140/90 mmHg

-BP: 140/90 mmHg - HR : 64 bpm
-HR : 64 bpm
- RR: 20 x/minute
-RR: 20 x/minute
o
o
- Temperature: 36.1 C -Temperature: 36.1 C -
consciousness:CM
Vitalsigns:
BP: 130/90 mmHg
HR : 88 bpm
RR: 20 x/minute
Temperature: 36.7oC
Palpation: tenderness
Breast milk +/+
Breast milk +/+
Breast milk +/+
12
Fundus: 1 finger
Fundus: 1 finger
Fundus: 3 finger
below umbilicus
below umbilicus
below umbilicus
Lokia rubra 30 cc
Lokia rubra 30 cc,
Lokia rubra 20 cc
Good contraction
good contraction
Good contraction
Mobilization: Tilt to
Mobilization: Active
P2A0, 41 years old,
P2A0, 41 years old,
P2A0, 41 years old,
post partus maturus
post partus maturus
post partus matures
by CS indicated by
by CS indicated by
by CS indicated by
patient age and post
bilateral tubectomy
bilateral tubectomy
bilateral tubectomy
indicated by patient
preference (POD-1)
preference (POD-2)
preference (POD-3)
Cefadroxil 3x500 mg
Cefadroxil 3x500 mg
Cefadroxil 3x500 mg
Misoprostol 2x200g
Misoprostol 2x1 tab
Misoprostol 2x1 tab
Mefinal 3x500 mg
Mefinal 3x500 mg
Mefinal 3x500 mg
Amlodipin 1x10mg
Amlodipin 1x10mg
Amlodipin 1x10mg
the left and right

A
Dulcolax
Aff catheter
Final Diagnosis
Mother:
P2A0, 41 years old, post partus maturus by CS indicated by patient age and post bilateral
tubectomy indicated by patient preference
Baby : Term Male Neonate, 38-39 weeks of gestational age according to New Ballard Score,
birth weight 2580 grams, 45 cm, APGAR score 9/9. Diagnosed as healthy neonate
Post Partum Treatment
Observe patients vital signs every 30 minutes, and 4 hours if signs are stable
Observe vaginal bleeding, uterine contraction, and bleeding
Oral Medication
o Futrolit 500 cc + Oxytocin 20 U (8 hour)
13

o Cefotaxim 3x1 gram IV
o Kaltrofen 3x1 gram
CASE 2
G1P0A0, 25 years old, gravid 38-39 weeks according to USG, in first stage labor, latent
phase, with cephalopelvic disproportion, with single living fetus intrauterine, head
presentation
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Date of Admission
: Mrs. A
: 25 years old
: Javanese
: Moslem
: Housewife
: Senior high school
Anamnesis
Chief Complaint
Blood discharge form the vagina
History of Present Illness

Patient complained about having small amount of blood discharge from vagina since
yesterday night before hopsital admission. The total amount of blood discharge was
around 20 cc. Patient didn't feel any pain. Patient denied any trauma before bleeding.
Patient didn't feel any abdominal discomfort.
History of Past Illness

14
o
o
o
o
o
o
o
Hitory of allergy
History of epilepsy
History of trauma
History of surgery

o Menarche
o Menstrual cycle
o First day of last menstrual cycle
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: 12 years old
: 23 days, regularly, with duration of 7
days, changed 2-3 pads a day,
dysmenorrhea (-)
: June 10th 2015
Marital History
Married once, already 1 year with this husband
Obstetric History
No
1.
Date
Gestational
Labour
History
This
Age
38-39 weeks
pregnancy
Patient never use contraception
History of Antenatal Care

Thirteen times at primary health care
General Condition
Level of Conciousness
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Height
BMI
: well
: compos mentis
: 100/70 mmHg
: 78 x/minutes
: 18 x/minutes
: 36C
: 55 kg
: 155 cm
: 22,89 kg/m2
15
Sex
Birth
Breast
Weight
Feeding
General Examination
Eyes
: anemic conjunctiva -/-, icteric sclera -/Mouth
: wet oral mucosa membrane
Thorax
o Heart
: regular 1st and 2nd heart sounds, murmur -, gallop o Lung
: vesicular breath sounds +/+, ronchi -/-, wheezing -/o Mammae
: areola hyperpigmentation +/+, nipple retraction -/-, breast
milk -/Abdomen
o Inspection
: convex, linea nigra (+), striae gravidarum (+)
o Auscultation : bowel sounds, 6-7 x/min
o Palpation
: supel, tenderness (-)
Extremities : Edema -/-, CRT <2 seconds
Physiologic reflex +/+/+/+, pathologic reflexes (-)
Obstetric Examination
Estimated due date

Fundal height
Fetal weight estimation
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV
Vaginal Toucher
Inspeculo
: March 5th 2016

: 32 cm
: 3.500 grams
:: 150 bpm
: buttocks
: back on the left side
: head
: convergent, 5/5
: at 12.00: dilatation 2 cm, head hasn't entered pelvic
inlet
: not performed
Hb
Ht
Leucocyte
Platelets
Bleeding Time
Clotting time
Blood Glucose
HbsAg
Hb level 2 hours post partus
: 12,2 gr/dL
: 37%
: 12.300/uL
: 216.000/uL
: 3 minutes
: 5 minutes
: 79 mg/dL
: (-)
: 10,4 gr/dL
16
Ultrasonography (USG)
Estimated Fetal Weight : 3500 grams

GA
: 38-39 weeks
CTG
Baseline
Variable
Acceleration
Deceleration
Fetal Movement
His
Result
: 150 bpm
: Normal
::+
:+
:: NST suspicious
Working Diagnosis
G1P0A0, 25 years old, gravid 38-39 weeks according to USG, in first stage labor, latent
phase, with cephalopelvic disproportion, with single living fetus intrauterine, head
presentation
Planning
Pro Caesarean Section

Cefotaxim 2gr/IV
17
Final Diagnosis
P1A0, 25 years old, post partus maturus by caesarean section with indication
cephalopelvicdisproportion
Aterm male neonate, birth weight 3220 gr, birth length 48 cm, APGAR score 9/9,
diagnosed as healthy neonate
Post Operation Treatment

-
o
o
o
Observe vital signs for every 15 minutes/first one hour, every 30 minutes/second hour,
and once in the third hour. If stable, observe vital signs every 4 hours.
- Normal diet
- Infuse:
RL 500cc + Syntocinon 2 ampule for 8 hours
RL 500cc + Syntocinon 1 ampule + Ondansetron 8 mg for 8 hours
RL 500cc + Syntocinon 1 ampule + Extrace 1 ampule for 8 hours
- Cefotaxime 1gr/IV/12 hours
- Check hemoglobin 2 hours post-operation
- Check urine balance every 6 hours
Follow up
Day
S
1st March 2016

Painpostoperation
2nd March 2016

Painpostoperation
3rd March 2016

Painpostoperation
(VAS45),urination
(VAS2),urination(+),
(VAS1),urination(+),
(+),defecation(),
defecation(),flatus
defecation(+),flatus
flatus(),breastfeeding (+),breastfeeding(+)
(+),breastfeeding(+)
(+)
Generalcondition:
Generalcondition:
appearedcalm
Levelof
well
well
Levelofconsciousness: Levelofconsciousness:
Generalcondition:
consciousness:CM
CM
CM
Vitalsigns:
Vitalsigns:
Vitalsigns:
o BP:110/80mmHg
o BP:100/70mmHg o BP:100/70mmHg
o HR:108x/minutes
o HR:64x/minutes
o HR:80x/minutes
o RR:20x/minutes
o RR:20x/minutes
o RR:18x/minutes
o Temp:35,6C
o Temp:35,3C
o Temp:35,3C
Abdomen:
Abdomen:
Abdomen:
o I:convex
o I:convex
o I:convex
o A:bowelsounds
o A:bowelsounds
o A:bowel
(+),15x/minute
(+),8x/minute
18
sounds(+),
o P:supple,painon
o P:supple,pain
palpation(+)
Obstetric
8x/minute
o P:supple,pain
onpalpation()
Obstetric
onpalpation()
o Fundalheight:2 Obstetric
o Fundalheight:as
highasumbilicus
o Fundalheight:
fingersbelow
o Contraction:
theumbilicus
3fingersbelow
o Contraction:
strong
o Mobilization:tilt
theumbilicus
o Contraction:
moderate
o Mobilization:
toleftandright
o Lochia:rubra60
moderate
o Mobilization:
active
cc
active
o Lochia:rubra,
o Lochia:
20cc
A
P1A0,26yearsold,
P1A0,26yearsold,post
spotting
postpartusmaturusby
partusmaturusby
partusmaturusby
caesareansectione.c.
cephalopelvic
cephalopelvic
cephalopelvic
disproportion,POD1
disproportion,POD2
disproportion,POD3
Oxytocin10IU/IV
Cefadroxil3x500gr
Patientcangoback
drip
Pospargin2x0,125
homewiththe
mg
medications:
Ondansetron
1ampule/IV
Mefenamicacid
Cefadroxil3x500gr
Pospargin2x0,125
Cefotaxim2x1gIV
3x500mg
Cefadroxil3x500gr
Pospargin3x0,125
mg
Ketroz2x100mg
MolocoB123x1
Kalk1x1
Dulcolax
Mefenamicacid
3x500mg
Ketroz2x100mg
MoloccoB123x1
Kalk1x1
affcathether
affIVFD
19
mg
Mefenamicacid
3x500mg
MolocoB123x1
Kalk1x1
20
CASE 3
G2P1A0, 34 years old, gravid 40-41 weeks according to first day of last period, in first
stage of labor, active phase, with single living fetus intrauterine, head presentation
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Date of Admission
: Mrs. SA
: 34 years old
: Javanese
: Moslem
: Housewife
: Junior high school
Anamnesis
Chief Complaint
Patient was having abdominal cramps since 16 hours before admission to the hospital.

Patient complained about having abdominal cramps since morning and patient still
feel the fetal movement.

o History of hypertension
o History of diabetes mellitus
o History of allergy
o History of epilepsy
o History of hematologic disease
o History of trauma
o History of surgery
o Menarche
o Menstrual cycle
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: 11 years old
dysmenorrhea (-)
: May 9th 2015
Marital History
Obstetric History
21
No
Date
Gestational
Labour
Sex
Birth
Breast
1.
2008
Age
9 months
History
Psp +
Boy
Weight
3100
Feeding
+
oxytocin
induced
2.
2015
This
pregnancy
-

Three times at primary health care.
General Condition
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Weight before pregnant
Height
BMI
: appeared moderately ill

: compos mentis
: 120/80 mmHg
: 80 x/minutes
: 32 x/minutes
: 37,3C
: - kg
: 41 kg
: 141 cm
: 20,7 kg/m2
General Examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
Abdomen
o Inspection
o Auscultation
o Palpation
Extremities
: anemic conjunctiva -/-, icteric sclera -/: wet oral mucosa membrane
: regular 1st and 2nd heart sounds, murmur -, gallop : vesicular breath sounds +/+, ronchi -/-, wheezing -/: areola hyperpigmentation +/+, nipple retraction -/-, breast
milk -/: convex, linea nigra (+), striae gravidarum (+)
: bowel sounds, 3-4 x/min
: tenderness (-)
: Edema -/-, CRT <2 seconds
22
Estimated due date

Fundal height
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV
Inspeculo
Vaginal Touche

: 31 cm
: 2.790 grams
: 4 times/10 minutes, duration 40-45 seconds
: 158 x/min
: buttocks
: back on the right side
: head
: divergent, 4/5
: not performed
: cervical dilatation 9 cm, cervical
effacement 90%, amnion is intact, Hodge II
Hb
Ht
Leucocyte
Platelets
Blood Type
: 13,9 gr/dL
: 39 %
: 24.000 /uL
: 238.000 /uL
: B /Rh (+)
: 12,1 gr/dL
Cardiotocography (CTG)
23
Baseline
: 158 bpm
Variable
: Normal
Acceleration
:+
Deceleration
: + (early)
Fetal Movement
:+
His
:+
Result
: CST non reassuring
Working Diagnosis
G2P1A0, 34 years old, gravid 40-41 weeks according to first day of last period, in first stage
of labor, active phase, with single living fetus intrauterine, head presentation
24
Planning
Oxytosin 1 amp/drip
Lidocaine 2 amp
Do the delivery with vacuum extraction
Treatment
Observation of patients condition after deliver (vital sign) every 15 minutes in the
first hour, every 30 minutes in the second hours, next 1 hour and after the condition is
stable observe every 4 hours.

Check 6 hours post-op Hb
Gradually mobilization
Cefadroxil 3 x 500 mg
Methergin 3 x 0,125mg
Mefinal 3 x 500 mg
Final Diagnosis
Mother: P2A0, 34 years old, post partus maturus by vaginal delivery with vacuum
extraction indicated by fetal distress

Baby: Term Female Neonate, 40-41 weeks of gestational age according to New
Ballard Score, birth weight 3080 grams, 49 cm, APGAR score 3/5. Diagnosed as
healthy neonate.
Follow Up
Day
S
1st March 2016

Post hecting pain VAS 2, flatus
2nd March 2016

Post hecting pain VAS 1, flatus
(-), urinate (-), defecate (-)
(+), urinate (+), defecate (-),
BP: 130/80 mmHg
normal diet
BP: 110/80 mmHg
HR : 96 bpm
HR : 80 bpm
RR: 20 x/minute
RR: 20 x/minute
Temperature: 36.7oC
Temperature: 35.8oC
Palpation: tenderness +
Palpation: tenderness -
Breast milk -/-
Breast milk +/+
Fundus: umbilicus
Fundus: 2 finger below
Lokia rubra 50 cc
umbilicus
Good contraction
Lokia rubra 15 cc
25
Mobilization: Tilt to the left and
Good contraction
right
P2A0, 34 years old, post partus
P2A0, 34 years old, post partus
maturus by vaginal delivery
maturus by vaginal delivery
with vacuum extraction
with vacuum extraction
indicated by fetal distress (D-1)

indicated by fetal distress (D-2)

Mefinal 3 x 500 mg
Mefinal 3 x 500 mg
26
CASE 4
G2P0A1 32 years old, gravid 38-39 weeks of gestation according to USG, not in labor,
with single living fetus intrauterine, head presentation, with CPD
Identity
Name
: Mrs. H
Age
: 32 years old
Ethnicity
: Javanese
Religion
: Moslem
Occupation
: Housewife
Education
: High school
Date of admission
: March 1st 2016
History
Chief complaints
:
Patient came for her 9th Ante Natal Care.
Patient was admitted to obstetrics and gynecology ward. Patient had no vaginal discharge
including blood or mucus. Actually, patients expected labor is February 12nd 2016 according
to first day of last menstruation.
: Denied.
: Denied.
History of allergy
: Denied.
History of epilepsy
: Denied.
: Denied.
History of trauma
: Denied.
History of surgery
: Curettage on 2014 because of
abortion
Family History
27
History of pelvic organ prolapse
: denied
: denied
: denied
History of allergy
: denied

o Menarche
o Menstrual Cycle
: 11 years old
: 20 days with regular menstrual cycle, with every
period lasting for 7 days and no dysmenorrhea.

o First day of last period : May, 5th 2015
Marital History:
Obstetric history:
No
Date
Gestati
Labor History
Gender
onal
1
2
Birth
Breast
Weight
feeding
2014
Age
3
Abortion -
2016
months
38-39
Curettage
-
weeks
Patient never used contraceptive pill
Patient has a routine antenatal care at midwife.
General Condition
: Well
Consciousness Level : Compos Mentis
Vital Signs
Blood Pressure
: 120/80 mmHg
o
Temperature : 36,2 C
Respiratory rate : 80 times a minute
Heart rate
: 20 BPM
Weight before pregnancy : 30 kg
Weight
: 38 kg
28
history
-
Height
BMI
: 145 cm
: 14,26 kg/m2
General Examination
Eyes
Mouth
Thorax

:
Heart : Regular 1st and 2nd heart sounds, murmur -, gallop Lungs : vesicular breath sounds +/+, rhonchi -, wheezing Mammae
: Areola hyperpigmentation +/+, Nipple retraction -/-,

:
Inspection
: Convex, Striae Gravidarum (-),Linea nigra(+)
Auscultation : Bowel sounds (+), 8x/minute
Extremities
: No Edema in any extremities, physiologic reflex +/
+/+/+, pathological reflex -/-
Obstetric examination
Estimated due date

Fundal Height
Fetal Weight Examination
Uterine Contraction
Fetal Heart Rate
Leopold maneuver
Leopold I
Leopold II
right side
Leopold III
Leopold IV
Vaginal toucher
Inspeculo
Rectal Toucher
: February, 12nd 2016

: 31 cm
: 2790 gr
:: 156 bpm
: Buttocks
: Back on left side and extremity on the
: Head
: convergent 5/5
: not performed
: not performed
: not performed
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood Type
Glucose blood test
: 12,2 g/dl
: 39%
: 7900/l
: 308000/l
: B/Rh (+)
: 99 mg/dL
29
HBsAg
: Negative
USG
Gestational Age : 38-39 weeks

Estimated Fetal Weight : 3200 gram
Working diagnosis
G2P0A1, 32 years old, 38-39 weeks of gestation according USG, not in labor, with single
living intrauterine fetus, head presentation, with CPD
Planning
Pro Caesarian section

Cefixime 1 gr intravenous
Fasting
Final Diagnosis
Mother:
P1A1, 32 years old, post partus matures by caesarian section indicated by CPD (Cephalo
Pelvic Disproportion)
Baby:
Term male neonate, appropriate for gestational age, 38-39 weeks according to New Ballard
Score, birth weight 2920 gr, birth length 46 cm, APGAR score 8/9
Placenta:
Placenta delivery in 3 minutes, placental size 20 x 17 x 2 cm, weight 510 gr. Insertion central
umbilical cord, the cord length 30 cm, stool cell +, intact cotyledon, intact membrane,
calcification -. Placental bleeding 100 cc.
Post operation instruction :
IVFD
o Futrolit + 20 IU oxytocin for 8 hours
Cefotaxime IV
3x1g
Kaltrofen
Supp 3x1
Ranitidine
Amp 1x1
30
Haemoglobin check after 6 hours post operation

Gradual diet
Follow up
S:
March 1st 2016

March 2nd 2016
Patient came for her 9th Ante Natal Care. S: Flatus (-), Defecation (-), Urination (+ with
Theres no vaginal discharge including blood
cathether), post operation wound pain
or mucus
(VAS 2), POD-1
O: General condition
: well
: well
Consciousness
: compos mentis
Consciousness
: compos mentis
Blood pressure
: 120/80 mmHg
Blood pressure
: 110/70 mmHg
Pulse
: 80 bpm
Pulse
: 64 bpm
Respiratory Rate
: 20 bpm
Respiratory Rate
: 20 bpm
Temperature
: 36,2o C
Temperature
: 35,3o C
Eye : palpebral edema -/-, anemic conjunctiva
UO : 1,05 cc/kg/hour
-/-, icteric sclera -/-.
Eye : palpebral edema -/-, anemic
Oral : Wet oral mucous
conjunctiva -/-, icteric sclera -/-.
Thorax:

: Auscultation: regular 1st and 2nd
Cor
Thorax:
heart sound, Gallop (-), Murmur (-)

Pulmo
Cor
: Auscultation: regular
1st and 2nd heart sound, Gallop
Inspection : symmetrical in both static and
dynamic breathing
Percussion : sonor on both lungs
Auscultation : vesicular breath sound +/+,
Inspection : symmetrical in both static
wheezing -/-, crackles -/Mammae : hyperpigmentation of areola +/
and dynamic breathing

Auscultation : vesicular breath sound
+/+, wheezing -/-, crackles -/Mammae : hyperpigmentation
(-), Murmur (-)
+, nipple retraction -/-, breastmilk -/Abdomen
Pulmo :
of
areola +/+, nipple retraction -/-,
o Inspection : convex, striae
breastmilk +/+
gravidarum -, linea nigra+,
Abdomen
o Palpation : supple in all

abdominal region, tenderness
o Percussion: tympanic sound in all
abdominal region
Inspection : convex, striae

gravidarum -, linea nigra+
Palpation : supple in all

31
o Auscultation : bowel sound +, 7
+ around operation wound
x/minutes
Percussion: tympanic sound in

all abdominal region
Extremities: Warm
o Edema: Lower extremities -/o Physiological reflex: ++/++/++/++
o Pathological reflex : --/--
Auscultation : bowel sound +,

5 x/minutes
Puerpurium examination
Workup:
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood Type
Glucose blood test
HBsAg
: 12,2 g/dl
: 39%
: 7900/l
: 308000/l
: B/Rh (+)
: 99 mg/dL
: Negative
Fundal height: one fingers below

umbilicus
32 cm
Lochia: 45 cc rubra
Contraction: moderate
Mobilization: tilt to the left and
right
A: G2P0A1, 32 years old, 38 weeks of gestation
Extremities: Warm
Edema: Lower extremities -/ Physiological reflex: ++/++/+
according to USG , not in labor, with single

live intrauterine fetus, head presentation, with
CPD
+/++
Pathological reflex
: --/--
P:
Pro cesarean section

Pre operation:
o Oxygen via nasal cannule 3 lpm
o Cefotaxim 1x1 gram (an hour
before operation)
Workup:
Laboratory:
- Hemoglobin : 11,4 g/ dL
A: P1A1, 32 years old, postpartus maturus
Post operation
by cesarean section indicated by CPD,
A: P1A1, 32 years old, postpartus maturus by

cesarean section indicated by CPD
P:
P: Gradual diet
POD-1
IVFD
o Futrolit + 20IU oxytocin for 8
hours
hours
32
Cefadroxil 3 x 500 mg PO
Methergin 3 x 0,125 mg PO
Mefenamate acid 3 x 500 mg PO
Aff catheter
March 3nd 2016

S: Flatus (+), Defecation (+), Urination (+),
post operation wound pain (VAS 1), POD
2
hours : well
Cefotaxime IV
3x1g
Consciousness
:
compos
Kaltrofen
Supp 3x1 mentis
Blood
pressure
: 110/70
Ranitidine
Amp
1x1 mmHg
Haemoglobin check
Pulse
: 76after
bpm6 hours post
operation
Respiratory
Rate
: 18 bpm
Temperature
: 36,4o C

Thorax:
Cor
: Auscultation: regular
1st and 2nd heart sound, Gallop

(-), Murmur (-)
Pulmo :

of

breastmilk +/+
Abdomen
Inspection : convex, striae

gravidarum -, linea nigra +,
Palpation : supple in all



5 x/minutes
-
Fundal height: two fingers below

umbilicus
32 cm
Lochia: 15 cc rubra
33
CASE 5
G3P1A1,29yearsold,Gestationalage4041weeksbasedonUSGwithFetoPelvic
Disproportionandsinglelivingfetusintrauterine,headpresentation
Identity
Name
:Mrs.E
Age
:29yearsold
Ethnicity
:Javanese
Religion
:Moslem
Occupation
:Housewife
Education
:HighSchool
Dateofadmission
:March1st2016
History
ChiefComplaints
Patienthadnosignsoflaboreventhoughitsalreadyherestimatedtimeofdelivery
Historyofpresentillness
PatientcametoobstetricsandgynecologyoutpatientclinicandwasreferredfromTritunggal
clinicbecauseitwasaboutherduedatebuttheresnosignsoflaboryet.Patientsexpected
laborwasMarch01st2016
Historyofpastillness
o
Historyofhypertension
:Denied
Historyofdiabetesmellitus
:Denied
Historyofallergy
:Denied
Historyofepilepsy
:Denied
Historyofhematologicdisease
Historyofurinarytract/kidneydisease :Denied
Historyoftrauma
:Denied
Historyofsurgery
:Denied
34
:Denied
HistoryofMenstrualCycle
o Menarche
o MenstrualCycle
:Approximately14yearsold
:3035dayswithirregularmenstrualcycle,withevery
periodlastingfor78daysandnodysmenorrhea.
o Firstdayoflastperiod
:May,18th2015
MaritalHistory:
Patienthasmarriedonce,haslasted7yearswithcurrenthusband
Obstetrichistory:
No
Date
Gestationa
Labor
1
2
2009
September
lAge
4months
9months
History
Abortus
Spontaneo Male
15th2010
Gender
Birth
Breastfeeding
Weight
history
3600gr
1year
us
Vaginal
delivery
2016(This
Pregnancy
)
ContraceptionHistory
Patienthasusedinjectioncontraceptive,lasttimeusingin2015.
Historyofantenatalcare:
PatienthasaroutineantenatalcareatTritunggalclinicduringthispregnancy.
PhysicalExamination
GeneralCondition
:Mildlyill
ConsciousnessLevel
:ComposMentis
VitalSigns
o
BloodPressure
:120/80mmHg
o
Temperature :36,7oC
o
Respiratoryrate
:20timesaminute
o
Heartrate
:100bpm
Weight
:65kg
Height
:158cm
35
BMI
:26,0kg/m2
GeneralExamination
Eyes
Mouth
Thorax
- Heart
- Lungs
- Mammae
:Anemicconjunctiva/,Ictericsclera/
:Wetoralmucosa
:
:Regular1stand2ndheartsounds,murmur,gallop
:vesicularbreathsounds+/+,rhonchi,wheezing
:Areolahyperpigmentation+/+,Nippleretraction/,
breastmilk/
Abdomen
:
- Inspection :Convex,StriaeGravidarum(),Lineanigra (+)
- Auscultation
:Bowelsounds(+)
Extremities
:NoEdemainanyextremities,physiologicreflex+/+/
+/+,pathologicalreflex/
Obstetricexamination
Estimatedduedate
FundalHeight
FetalWeightExamination
UterineContraction
FetalHeartRate
Leopoldmaneuver
LeopoldI
LeopoldII
LeopoldIII
LeopoldIV
Vaginaltoucher
Inspeculo
RectalToucher
:March,01st2016
:36cm
:3565gr
:
:158bpm
:Buttocks
:Backonrightside
:Head
:convergent5/5
:notperformed
:notperformed
:notperformed
Cardiotocography
Notperformed
LaboratoryExamination
Hemoglobin
Hematocrit
:12.3g/dl
:36%
36
Leucocyte
Platelets
BloodType
HBsAg
HIV
BPD
HC
FHR
AC
FL
EFW
EDD
GA
:10,34cm
:34,99cm
:158bpm
:34,76cm
:7,81cm
:3791gr
:March1st2016
:40w0d
:9400/l
:245000/l
:0/Rh(+)
:Negative
:Negative
USG
WorkingDiagnosis
G3P1A1,29years old,Gestationalage4041weeksaccordingtoUSGwithFetoPelvic
Disproportionandsinglelivingfetusintrauterine,headpresentation
Planning
Procaesariansection
Ceftriaxone1grIV
Consultanesthesiologist
FinalDiagnosis
Mother
P2A1, 29 years old, post partus maturus by caesarian section indicated by Feto Pelvic
Disproportion
Baby
Termfemaleneonate,appropriateforgestationalage,4041weeksaccordingtoNewBallard
Score,birthweight3580gr,48cm,APGARscore8/9,diagnosedashealthyneonate
37
Postpartuminstruction
Observedvitalsignsevery15minutesforthefirstonehour,every30minutesforthe
secondhourandeveryhouruntil4hour
IVFD:Futrolite+oxcytocyn20ufor8hours
Futrolite+oxcytocyn10ufor8hours
Cefotaxime3x1gIV
Ranitidine1x50mgIVafter8hours
Kaltrofen3x1supp
Followup
March01st2016
March2nd2016
S:feltcontraction
O:Generalcondition
S:postoppainvas23
: mildlyill
O:Generalcondition
: mildlyill
Consciousness
: composmentis
Consciousness
: composmentis
Bloodpressure
: 120/80mmHg
Bloodpressure
: 110/70mmHg
Pulse
: 100bpm
Pulse
: 80bpm
RespiratoryRate
: 20bpm
RespiratoryRate
: 20bpm
Temperature
: 36,7oC
Temperature
: 36.5oC
Eye:palpebraledema/,anemicconjunctiva
Eye : palpebral edema /, anemic
/,ictericsclera/.
conjunctiva/,ictericsclera/.
Oral:Wetoralmucous
Oral:Wetoralmucous
Thorax:
Thorax:
Cor
:Auscultation:irregular1stand2nd
Cor
:Auscultation:irregular1stand
heartsound,Gallop(),Murmur()
2ndheartsound,Gallop(),Murmur()
Pulmo
Pulmo
Inspection:symmetricalinbothstaticand
Inspection:symmetricalinbothstatic
dynamicbreathing
Percussion:sonoronbothlungs
Auscultation:vesicularbreathsound+/+,
anddynamicbreathing
Auscultation:vesicularbreathsound
38
wheezing/,crackles/
Mammae:hyperpigmentationofareola+/
+,nippleretraction/
areola +/+, nippleretraction /,

breastmilk+/+
Abdomen
Inspection:convex,striaegravidarum,
lineanigra(+),
,lineanigra(+),
Palpation:suppleinallabdominalregion,
o Palpation:suppleinallabdominal
region,tenderness
Percussion:tympanicsoundinall
abdominalregion
Abdomen:
o Inspection:convex,striaegravidarum
tenderness
o Percussion:tympanicsoundinall
abdominalregion
Auscultation:bowelsound(+)
Extremities:Warm
Edema:Lowerextremities/
Physiologicalreflex:++/++/++/++
Pathologicalreflex
:/
Sensoryexamination+/+
x/minutes
Extremities:Warm
o Edema:Lowerextremities/
o Physiologicalreflex:++/++/++/++
o Pathologicalreflex
:/
o Sensoryexamination+/+
Workup:
Laboratory:
Hemoglobin
Hematocrit
Leucocyte
Platelets
BloodType
HBsAg
HIV
+/+,wheezing/,crackles/
Mammae : hyperpigmentation of
PuerperiumStatus:
:12.3g/dl
:36%
:9400/l
:245000/l
:0/Rh(+)
:Negative
:Negative
Fundal height : 1 fingers above the
umbilical
Contraction:strong
Lochia:approximately20cc
Mobilitation:shifttotheleftandright
A: P2A1,29yearsold,postpartusmaturus
A: G3P1A1,29yearsold,Gestationalage4041
weeks according to USG with Feto Pelvic
bycaesariansectionindicatedbyFetoPelvic
Disproportion
Disproportionandsinglelivingfetusintrauterine, P:Medication
39
March 3rd 2016

S: post-op pain vas 1
headpresentation
Consciousness
P: Blood pressure
: mildly ill
o Cefadroxil3x500mg
o Methergin3x0,125mg
o Mefinal3x500mg
: compos mentis
: 110/70 mmHg
Pulse
: 84 bpm
Procaesariansection
Respiratory
Rate
: 18 bpm
Ceftriaxone1grIV
Temperature
: 36.0o C
Affcatheterin1x24hours

Postoperation
conjunctiva -/-,ictericsclera -/-.
A:
Mother:
P2A1, 29 years old, post partus maturus by
Thorax:
caesarian section indicated by Feto Pelvic
Disproportion
Cor
: Auscultation: irregular 1st and
2nd heart sound, Gallop (-), Murmur (-)
Baby:
Pulmo
:
Termfemaleneonate,appropriateforgestational
4041
Inspection
: symmetrical
static
age,
weeks
according in
toboth
New
Ballard

Score,birthweight3580gr,48cm,APGARscore
Percussion :sonor on both lungs
8/9,diagnosedashealtyneonate
+/+, wheezing -/-, crackles -/ Mammae : hyperpigmentation
PostOperationInstruction:
of
+/+, nippleretraction -/-,

areola
Observedvitalsignsevery15minutesfor
breastmilk
+/+
thefirstonehour,every30minutesforthe
Abdomen
:
IVFD:
gravidarum -, lineanigra (+),
Cefotaxime3x1gIV
Ranitidine1x50mgIVafter8hours
Kaltrofen3x1supp
abdominal region, tenderness o


7 x/minutes
Extremities: Warm
40
CASE 6
G2P1A0, 30 years old, gravid 38-39 weeks according to USG, not in labor, with
premature rupture of the membrane, with single fetus living intrauterine, head
presentation
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Date of Admission
: Mrs. S
: 30 years old
: Javanese
: Christian
: Employee
: Diploma 3
: March 3rd 2016
Anamnesis
Chief Complaint
Liquid discharge from the vagina since 7 hours before hospital admission

Patient came to emergency unit with complained about having clear liquid discharge
from vagina since 7 hours before hospital admission. Patient said that the total amount
of liquid discharge was approximately 50 cc. The liquid didn't accompanied by blood
or mucus and the patient also didn't feel any contraction. Patient said that she had
white vaginal discharge since 1 week ago and the color turned into brown since 2 days
ago. Patient didn't feel any pain.

o Hitory of allergy
o History of trauma
o Menarche
o Menstrual cycle
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: 14 years old
: 28 days, regularly, with duration of 7-8
days, changed 4 pads a day,
dysmenorrhea (-)
41
: May 23rd 2015
Marital History
Married once, already 6 years with the last husband
Obstetric History
No
1.
Date
Gestational
Labour
Sex
2012
Age
39 weeks
History
Spontaneou
s
Complication
fema -
per le
Birth
Breast
Weight
2.800
Feeding
2
gr
months
vaginam
2
This
40 weeks
pregnancy
Patient used intra uterine device contraception from 2012-2015

Eight times at primary health care.
General Condition
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Height
BMI

: compos mentis
: 120/70 mmHg
: 80 x/minutes
: 18 x/minutes
: 37,1C
: 55 kg (before pregnancy)
: 157 cm
: 22,31 kg/m2 (normal)
General Examination
Eyes
: wet oral mucous membrane
Thorax
o Heart
milk -/Abdomen
o Inspection
: convex, lieenea nigra (+), striae gravidarum (-)
42

o Palpation
o Percussion
: tympanic in all quadrant
Estimated due date

Fundal height
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV
Vaginal Toucher

: 31 cm
: 3.100 grams
:: 150x/minute
: buttocks
: back on the left side
: head
: convergen, 5/5
: (15.00) vulvovaginal within normal limit, portio thick
and soft, dilatation 1 cm, effacement 20%,
denominator vertex left anterior, Hodge I, amniotic
Inspeculo
membrane not intact

: -
Hb
Ht
Leucocyte
Platelets
Blood Type
Anti HIV
HbsAg
Bleeding time
Clotting time
Urine
: 13 gr/dL
: 38%
: 10.400/uL
: 222.000/uL
: O/Rh (+)
: (-)
: (-)
: 2 minutes
: 4 minutes
Glucose
: (-)
Protein
: (-)
Bilirubin
: (-)
Urobilinogen
: normal
pH
: 6,5
43
Specific gravity test
: <1005
Occult blood
: (++)
Ketone
: (+)
Nitrite
: (-)
Leucocyte
: (-)
Sediment
Leucocyte
: 7-10/High power field
Erythrocyte
Epithel
: (+)/Low power field
Cylinder
: (-)
Crystal
: (-)/Low power field
Bacteri
: (+)
Others
: (-)
USG
Single living fetus intrauterine
Fetal heart rate
Amniotic fluid index : 9 cm
Biometry
Estimated Fetal Weight : 3100 gram
: 150 bpm
: 38-39 weeks
Nitrazine test : (+)

CTG
44
Baseline
: 145 bpm
Variability
: normal
Acceleration
: (+) following fetal movement
Decceleration
: (-)
Uterine contraction
: (-)
Fetal movement
: 8x/20 minutes
CTG Diagnosis
: Reactive NST
Working Diagnosis
G2P1A0, 30 years old, gravid 38-39 weeks according to USG, not in labor, with premature
rupture of the membrane, with single living fetus intrauterine, head presentation
Planning
15.00
Hospitalization
Induction: RL + 5 IU oxytocin, start from 8 drip/minute. Increase 4
drip/minute every 30 minutes until reach adequate his contraction

Cefotaxime 2 gr/IV
Routine urine Test
Routine blood test
Test bleeding time / clotting time
Repeat Cardiotocography in 3 hours
45
18.00
- Repeat Vaginal Toucher in 3 hours

Vagina Toucher examination: dilation 10 cm, effacement 100%, portio thin
and soft, his 4x in 10 minutes with duration 40 seconds.
Lead the second stage labour
18.26
Male baby born, with birth weight 2860 gram, fetal length 47 cm, 38-39 weeks
18.30
according to NBS, APGAR score 9/9, with well baby

Placenta was born, with total bleeding 80 cc
Placenta examination
Size : 20 x 18 x1,5 cm
Weight : 550 gr
46
Cotyledon : complete
Membrane: complete
Calcification : Hematoma : Stolcel : +
Umbilical cord : 60 cm
Insertion : marginalis
Treatment
Post partus instruction:

o Observation for vital signs, contraction, and bleeding 2 hours after labour
o Normal diet
o Infuse RL + 10 IU oxytocin / 8 hours
Infuse RL + 10 IU oxytocin / 8 hours
o
o
o
o
o
Cefadroxil tab 3 x 500 mg

Mefenamic acid tab 3 x 500 mg
Methergin tab 3 x 0,125 mg
Molocco B12 3x1
Observe urination in 6 hours post partum
Final Diagnosis
P2A0, 30 years old, post partus prematurus by spontaneous vaginal delivery and post
hecting indicated by perineal rupture grade I.

Aterm male neonate, appropriate for gestational age, 38-39 weeks according to New
Ballard Score, birth weight 2860 g, 47 cm, APGAR score 9/9 with well baby
Follow up
Date
Subjectiv
March
Assesment
Planning
e
Pain post- General Condition :
P2A0, 30 years old,
o Cefadroxil tab 3 x
, 5th
hecting
moderately ill
post partus
2016
area (+)
Conciousness : CM
prematurus by
500 mg
o Mefenamic acid tab
VAS 2-3,
Vitalsigns:
spontaneous vaginal
defecation
(-),
urination
Objective
o BP : 100/60 mmHg
o RR: 24 x/minute
delivery and post

hecting indicated by
perineal rupture
o Pulse : 72 bpm
47
3 x 500 mg
o Methergin tab 3 x
0,125 mg
o Molocco B12 3x1
(+)
o S: 36,2oC
grade I.
Abdomen:
oI:convex
oA:bowelsounds(+),
8x/minute
oP:supple,painon
palpation(+)
Obstetric:
o Fundalheight:2
fingersbelowthe
umbilical
o Contraction:strong
o Lochia:10cc
o Mobilization : shift
totheleftandright
March
Pain post- General Condition :
, 6th
hecting
moderately ill
post partus
2016
area (+)
Conciousness : CM
prematurus by
o Cefadroxil tab 3 x
VAS 1,
Vitalsigns:
spontaneous vaginal
500 mg
o Mefenamic acid tab
defecation
(+),
urination
(+)
P2A0, 30 years old,
o BP : 110/70 mmHg
o RR: 20 x/minute
delivery and post

hecting indicated by
perineal rupture
o Pulse : 72 bpm
grade I.
o S: 36,2oC
Abdomen:
oI:convex
oA:bowelsounds(+),
8x/minute
oP:supple,painon
palpation(+)
Obstetric
o Fundalheight:2
fingersbelowthe
48
Patient discharged
with:
3 x 500 mg
o Methergin tab 3 x
0,125 mg
umbilical
o Contraction:strong
o Lochia:7cc
Mobilization:active
49
CASE 7
G5P4A0, 37 years old, gravid 39-40 weeks according to USG, with premature rupture of
membrane, single living fetus intrauterine, head presentation.
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Date of Admission
: Mrs. H
: 37 years old
: Javanese
: Moslem
: Housewife
: Elementary school
: March 3rd 2016
Anamnesis
Chief Complaint
Vaginal discharge since 6 hours before hospital admission

Patient came to the hospital because she had clear vaginal discharge with total amount
approximately 200 cc since 6 hours before hospital admission. The patient also
complained about having abdominal cramps and pain. Patient still felt the fetal
movement.

o History of trauma
o Menarche
o Menstrual cycle
Marital History
50
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: 16 years old
dysmenorrhea (-)
: June 3th 2015
Obstetric History
No
1.
2.
3.
4.
5.
Date
Gestational
Labour
2000
2003
2005
2013
2015
Age
9 months
9 months
6 months
9 months
This
History
Psp
Psp
Psp - IUFD
Psp
Sex
Birth
Breast
Boy
Boy
Girl
Weight
4000
3000
3000
Feeding
+
+
-
pregnancy
Patient ever use inject, implant, pill contraception. Last use in 2 years ago.

Three times at Bhakti Hospital
General Condition
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Weight before pregnant
Height
BMI

: compos mentis
: 130/70 mmHg
: 84 x/minutes
: 24 x/minutes
: 37,1C
: 65 kg
: 52 kg
: 156 cm
: 21.36 kg/m2
General Examination
Eyes
Mouth
Thorax
o Heart
o Lung
o Mammae
: anemic conjunctiva -/-, icteric sclera -/: wet oral mucosa membrane
: regular 1st and 2nd heart sounds, murmur -, gallop : vesicular breath sounds +/+, ronchi -/-, wheezing -/: areola hyperpigmentation +/+, nipple retraction -/-, breast
milk -/-
Abdomen
o Inspection
: convex, linea nigra (+), striae gravidarum (+)
o Palpation
: tenderness (-)
51
Extremities
: Edema -/-, CRT <2 seconds

Estimated due date

Fundal height
Uterine contraction
Fetal heart rate
Leopold maneuver
o Leopold I
o Leopold II
o Leopold III
o Leopold IV
Inspeculo
Vaginal Toucher
: March 10th 2016

: 37 cm
: 3.720 grams
: 3-4 times/10 minutes, duration 30 seconds
: 160 x/min
: buttocks
: back on the right side
: head
: divergent, 4/5
: not performed
: cervical dilation 6 cm, cervical
effacement 60%, amnion is rupture, Hodge II
Hb
Ht
Leucocyte
Platelets
Blood Type
Bleeding Time
Clotting time
Blood Glucose
: 11,1 gr/dL
: 33 %
: 21.800 /uL
: 209.000 /uL
: A /Rh (+)
: 3 minutes
: 5 minutes
: 98 mg/dL
: 10,8 gr/dL
Living fetus intrauterine, fetal heart rate: 170 bpm, ICA: 2 cm.
Cardiotocography (CTG)
52
Baseline
: 160 bpm
Variable
: Normal
Acceleration
:-
Deceleration
:+
Fetal Movement
:+
His
:+
Result
: CST non reassuring
Working Diagnosis
G5P4A0, 37 years old, gravid 39-40 weeks according to USG, with premature rupture of
membrane, single living fetus intrauterine, head presentation.
Planning
Pre Op:
o O2 via nasal cannule 4L/min
o IVFD RL 100 cc in 20 drops/min
o Cefotaxime 2 gr IV
Pro Caesarean Section
53
Treatment
Observation of patients condition after delivery (vital sign) every 15 minutes in the
first hour, every 30 minutes in the second hours, next 1 hour and after the condition is
stable observe every 4 hours.

Count urine output and fluid balance every 6 hours
Free diet
Check 2 hours post-op Hb
Gradual mobilization
IVFD:
o RL 500 cc + 1 amp syntocinon + 1 amp tramal 8 hours
o RL 500 cc + 1 amp syntocinon + 1 amp omeprazole 8 hours
o RL 500 cc + 1 amp syntocinon + 1 amp extruce 8 hours
Pospargin 2 x 0,125 mg
Mefenamat Acid 3 x 500 mg
Molocco B 12 3 x 1
Kaltrofen rectal sup 2 x 1
Final Diagnosis
Mother: P5A0, 37 years old, post partus maturus by caesarean section indicated by
oligohydramnios and fetal distress, post tubectomy with indication of patient
preferences.
Baby: Term male neonate, 39-40 weeks of gestational age according to New Ballard
Score, birth weight 3570 gr, birth length 49 cm, APGAR score 8/9. Diagnosed as
healthy neonate.
Follow Up
Day
S
4th March 2016

Post operation pain VAS
5th March 2016

Post operation pain VAS
6th March 2016

Post operation pain
3-4, flatus (-), urinate
2-3, flatus (+), urinate
VAS 1, flatus (+),
with catheter, defecate (-) (+), defecate (-), normal

O
urinate (+), defecate
BP: 110/70 mmHg
diet
BP: 120/70 mmHg
(+), normal diet

BP: 130/80 mmHg
HR : 84 bpm
HR : 100 bpm
HR : 88 bpm
RR: 14 x/minute
RR: 16 x/minute
RR: 18 x/minute
Temperature: 36.6oC
Temperature: 36.3oC
Temperature: 36.2oC
Palpation: tenderness -
Breast milk +/+
Breast milk +/+
Breast milk +/+
54
Fundus: 2 finger above
umbilicus
umbilicus
umbilicus
Lokia rubra 30 cc
Lokia rubra 15 cc
Lokia rubra 10 cc
Good contraction
Good contraction
Good contraction
Mobilization: -
Mobilization: Tilt to the
UO: 1,1 cc/kg/hour

Mother: P5A0, 37 years
left and right

Mother: P5A0, 37 years
Mother: P5A0, 37
old, post partus maturus
old, post partus maturus
years old, post partus
by caesarean section
by caesarean section
maturus by caesarean
indicated by
indicated by
section indicated by
oligohydramnios and
oligohydramnios and
oligohydramnios and
fetal distress, post
tubectomy with
tubectomy with
tubectomy with
indication of patient
preferences.
preferences.
preferences.
(POD-1)
(POD-2)
(POD-3)
Mefenamat Acid 3 x 500 Mefenamat Acid 3 x 500 Mefenamat Acid 3 x

mg
mg
500 mg
Molocco B 12 3 x 1
Molocco B 12 3 x 1
Molocco B 12 3 x 1
Disflatyl tab 3 x 1
Aff catheter
55
CASE 8
G3P2A0,35years,gravid3940weeksaccordingtofirstdayoflastmenstrualcyclewith
singlelivingfetusintrauterine,breechpresentation
Identity
Name
:Mrs.SW
Age
:35yearsold
Ethnicity
:Javanese
Religion
:Moslem
Occupation
:Housewife
Education
:JuniorHighSchool
Dateofadmission
:3rdMarch2016
History
Chiefcomplaints
:
Patientwasreferredfromprimaryhealthcarebecauseshealreadyhaddilation9cmandher
babywasbreechpresentation
Historyofpresentillness :
Patientwasadmittedtoobstetricsandgynecologywardfromtheemergencyroom.Patient
experiencesanabdominaldiscomfortsince2ndofMarchandshecametotheprimaryhealth
care.ShewasthenreferredtoAtmajayaHospitalandshealreadyhaddilation9 cmandher
babywasinbreechpresentation.PatientsexpectedlaborisMarch,3rd2016
56
:Denied.
:Denied.
Historyofallergy
:Denied.
Historyofepilepsy
:Denied.
:Denied.
Historyofurinarytract/kidneydisease :Denied.
Historyoftrauma
:Denied.
Historyofsurgery
:Denied.
o Menarche
o MenstrualCycle
:3040dayswithirregularmenstrualcycle,withevery
o Firstdayoflastperiod :May,25th2015
MaritalHistory:
Patienthasmarriedonce,haslasted12yearswithcurrenthusband.
Obstetrichistory:
No
Date
Gestationa
LaborHistory
Gender
lAge
1
2004
9months
Spontaneous
Female
Vaginal
2
2005
9months
Delivery
Spontaneous
Vaginal
Delivery
2016
(this
pregna
ncy)
57
Female
Birth
Breast
Weight
feeding
3000
history
Breastfed6
grams
months
2800
Breastfed1
grams
year
Patienthasusedinjectioncontraceptive,lasttimeusingin2015
Patienthasaroutineantenatalcarewith9visitsatAtmajayaclinicduringthispregnancy.
PhysicalExamination
GeneralCondition
:Mildlyill
ConsciousnessLevel :ComposMentis
VitalSigns
BloodPressure
:120/80mmHg
o
Temperature :36,9 C
Respiratoryrate :16timesaminute
Heartrate
:96BPM
Weight
:72kg
Height
:149cm
BMI
:32,4kg/m2
GeneralExamination
Eyes
Mouth
Thorax
Heart
Lungs
Mammae
:Wetoralmucosa
:
:Areolahyperpigmentation/,Nippleretraction/,
Abdomen
Inspection
breastmilk/
:
:Convex,StriaeGravidarum(),LineaAlba
(+)
Auscultation :Bowelsounds(+)6times/minute
Extremities
Obstetricexamination
Estimatedduedate
:March,3rd2016
58
FundalHeight
FetalWeightExamination
UterineContraction
FetalHeartRate
Leopoldmaneuver
LeopoldI
LeopoldII
LeopoldIII
LeopoldIV
Vaginaltoucher
:31cm
:3100gr
:
:140bpm
:Head
:Backonleftside
:Buttocks
:divergent2/5
:vulvainnormallimit,vaginawallinnormal
limit,portiothinandsoft,cervicaldilation9cm,rupturemembranerupture,
HodgeII
Inspeculo
RectalToucher
:notperformed
:notperformed
Cardiotocography
Baseline
: 140 bpm
Variable
: normal
Acceleration
:+
Deceleration
:+
Fetal movement
:+
59
His
: Frequency :4x/10 minute, Duration : 10 seconds/His, Power : 40-80
mmHg
Result
: CST reassuring
Laboratoryexamination
Hemoglobin
Hematocrit
Leucocyte
Platelets
Bloodtype
Bloodglucose
HbsAg()
:12.9g/dL
:38%
:8,900/L
:171,000/L
:B/Rh(+)
:96mg/dL
Workingdiagnosis
G3P2A0,35yearsold,gravid3940weeksaccordingtofirstdayoflastmenstrualcyclewith
prolongedlabourstageII,withsinglelivingfetusintrauterine,breechpresentation
Planning
Procaesariansection
Cefixime1grintravenous
Primperan10mgintravenous
o Accforanesthesia
o IVlineperformed
FinalDiagnosis
Mother:
P3A0,35yearsold,postpartusmaturesbycaesariansectionindicatedbybreechpresentation
withprolongedlabourstageII
Baby:
Term female neonate, appropriate for gestational age, 3940 minggu according to New
BallardScore,birthweight2930gram,birthlength47cm,APGARScore6/9
60
2hourspostoperationHaemoglobintest
observedvaginalbleedinganduterinecontraction
measureurineoutputandfluidbalanceevery6hours
regulardiet
phasesmobilitation
IVFD:
o RL500cc+1ampSyntocinon+1ampTramalfor8hours
o RL500cc+1ampSyntocinon+1ampOmeprazolefor8hours
o RL500cc+1ampSyntocinon+1ampExtracefor8hours
Oral:
o Cefadroxil3x500mg
o Pospargin3x0,125mg
o Mefenamicacid3x500mg
o MoloccoB123x1
o Kaltrofen2x1supp
FollowUp:
March 4rd 2016
March 5th 2016
S: abdominal discomforst since 1 day before S: post-op pain vas 3-4, flatus +, defecation admission
: mildly ill
: mildly ill
Consciousness
: compos mentis
Consciousness
: compos mentis
Blood pressure
: 90/60 mmHg
Blood pressure
: 120/80 mmHg
Pulse
: 88 bpm
Pulse
: 96 bpm
Respiratory Rate
: 24 bpm
Respiratory Rate
: 16bpm
Temperature
: 36o C
Temperature
: 36,9o C

-/-,ictericsclera -/-.

Thorax:
Thorax:
Cor
61
Cor
: Auscultation: irregular 1st and 2nd

Pulmo

Pulmo
dynamic breathing


areola
+, nippleretraction -/-
Inspection : convex, striae gravidarum +,

gravidarum -, lineanigra (-),
Palpation : supple in all abdominal region,
tenderness
abdominal region, tenderness -
Percussion: tympanic sound in all
o Percussion: tympanic sound in
abdominal region
Auscultation : bowel sound (+)
o Auscultation : bowel sound +,

6 x/minutes
Extremities: Warm
Edema:Lower extremities -/ Physiological reflex: ++/++/++/++
Pathological reflex
: --/- Sensory examination +/+
Extremities: Warm
o Edema:Lower extremities -/o Physiological reflex: ++/++/+
Workup:
+/++
o Pathological reflex : --/-o Sensory examination +/+
Laboratory:
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
Blood glucose
-/-,
Abdomen :
lineanigra (+),
nippleretraction
breastmilk +/+
Abdomen
+/+,
of
: 12.9 g/dL
: 38%
: 8,900/L
: 171,000/L
: B/Rh(+)
: 96 mg/dL
Puerperium Status :
Fundal height : 2 fingers under the

umbilical
62
HbsAg (-)
A: G3P2A0, 35 years old, gravid 39-40 weeks

according to first day of last menstrual cycle with
Contraction : strong
Lochia : approximately 30 cc
Mobilitation : shift to the left and right
prolonged labour stage II, with single living fetus

A: P3A0, 35 years old, post partus matures by
intrauterine, breech presentation
caesarian
P:
section
indicated
by
breech
presentation with prolonged labour stage II
Pro caesarian section

Cefixime 1gr intravenous
Primperan 10mg intravenous
Consult anesthesiologist
o Acc for anesthesia
o IV line performed
P: Medication
o
o
o
o
o
Post operation
A:
Aff catheter in 1x24 hours
Mother :
P3A0, 35 years old, post partus matures by
caesarian section indicated by breech presentation
with prolonged labour stage II
Baby :
Term female neonate, appropriate for gestational
age, 39-40 minggu according to New Ballard
Score, birth weight 2930 gram, birth length 47
cm, APGAR Score 6/9
Post Operation Instruction :
Cefadroxil 3x500mg
Pospargin 3x0,125mg
Mefenamic acid 3x500mg
Molocco B12 3x1
Kaltrofen 2x1 supp
Observed vital signs every 15 minutes for

the first one hour, every 30 minutes for the
second hour and every hour until 4 hour

2 hours post-operation Haemoglobin test
observed vaginal bleeding and uterine
contraction
measure urine output and fluid balance
63
every 6 hours
regular diet
phases mobilitation
IVFD :
o RL 500cc + 1amp Syntocinon + 1
amp Tramal for 8 hours
amp Omeprazole for 8 hours
amp Extrace for 8 hours

Oral :
o Cefadroxil 3x500mg
o Pospargin 3x0,125mg
o Mefenamic acid 3x500mg
o Molocco B12 3x1
o Kaltrofen 2x1 supp
March 6th 2016

S: post-op pain vas 2, flatus +, defecation
March 7th 2016

S: post-op pain vas 2, flatus +, defecation
urination +
urination +
: mildly ill
: mildly ill
Consciousness
: compos mentis
Consciousness
: compos mentis
Blood pressure
: 100/60 mmHg
Blood pressure
: 110/70 mmHg
Pulse
: 72 bpm
Pulse
: 68 bpm
Respiratory Rate
: 20 bpm
Respiratory Rate
: 20 bpm
Temperature
: 36,5o C
Temperature
: 35,4o C
Thorax:
Thorax:
Cor
Cor

64
Pulmo
Pulmo


areola
+/+,
nippleretraction
of

-/-,
areola
breastmilk +/+
+/+,
nippleretraction
of
-/-,
breastmilk +/+
Abdomen :
Abdomen :
6 x/minutes
6 x/minutes
Extremities: Warm
Extremities: Warm
+/++
+/++
Puerperium Status :
Puerperium Status :
umbilical
Mobilitation : shift to the left and
65
umbilical
Mobilitation : shift to the left and
right
right
A: G3P2A0, 35 years old, gravid 39-40 A: G3P2A0, 35 years old, gravid 39-40
weeks according to first day of last menstrual weeks according to first day of last menstrual
cycle with prolonged labour stage II, with cycle with prolonged labour stage II, with
single
living
fetus
intrauterine,
breech single
living
presentation
presentation
P: Medication
P: Medication
o
o
o
o
o
Cefadroxil 3x500mg
Pospargin 3x0,125mg
Molocco B12 3x1
Kaltrofen 2x1 supp
o
o
o
o
o
66
fetus
intrauterine,
Cefadroxil 3x500mg
Pospargin 3x0,125mg
Molocco B12 3x1
Kaltrofen 2x1 supp
breech
CASE 9
G3P2A0 29 years old, gravid 38-39 weeks according to USG, in partu, stage one of
labor, with gemelli living fetus intrauterine, head presentation.
Identity
Name
: Mrs. S
Age
: 29 years old
Ethnicity
: Javanese
Religion
: Moslem
Occupation
: Housewife
Education
: High school
Date of admission
: March 4th 2016
History
Chief complaints
:
Patient experienced vagina discharge including mucus and blood since 15 hours before
hospital admission
Patient was admitted to obstetrics and gynecology ward. Patient experiences a abdominal
discomfort intermittently. Patients expected labor is February 22nd 2016 according to first
day of last menstruation
o
: gestational hypertension in 2014
(second birth)
o
: Denied.
History of allergy
: Denied.
History of epilepsy
: Denied.
: Denied.
History of trauma
: Denied.
History of surgery
: Denied
Family History
67
History of pelvic organ prolapse
: Her father has hypertension

: denied
: denied
History of allergy
: All foods made of eggs.

o Menarche
o Menstrual Cycle
: 12 years old
: 28 days with regular menstrual cycle, with every
period lasting for 7 days and no dysmenorrhea.

o First day of last period : May, 15th 2015
Marital History:
Obstetric history:
No
Date
Gestatio
Labor History
Gender
nal Age
1
2
Birth
Breast
Other
Weight
feeding
informations
-
2010 9 months
Delivery per
A girl
2900
history
1 year
2014
vaginam
Delivery per
A boy
3200
1 year
9 months
vaginam
3
2016
hypertension
38-39
weeks
Patient used contraceptive pil until 2015
Patient has a routine antenatal care at midwife.
Gestational
General Condition
: Well
Consciousness Level : Compos Mentis
Vital Signs
Blood Pressure
: 120/80 mmHg
o
Temperature : 36,1 C
Respiratory rate : 22 times a minute
Heart rate
: 88 BPM
Weight
: 101 kg
68
Weight before pregnancy : 75 kg

Gain weight
: 26 kg
Height
: 155 cm
BMI
: 31,21kg/m2 (obese)
General Examination
Eyes
Mouth
Thorax

:
Heart : Regular 1st and 2nd heart sounds, murmur -, gallop Lungs : vesicular breath sounds +/+, rhonchi -, wheezing Mammae
: Areola hyperpigmentation +/+, Nipple retraction -/-,

:
Inspection
: Convex, Striae Gravidarum (+), linea nigra (-)
Auscultation : Bowel sounds (+), 7x/minute
Extremities
: Edema in lower extremities, physiologic reflex
+/
+/+/+, pathological reflex -/Obstetric examination
Estimated due date

Fundal Height
Fetal Heart Rate
Leopold maneuver
Leopold I
Leopold II
: February, 22nd 2016

: 47 cm
: 150 bpm and 146 bpm
: Buttocks
: Back on left side for 1st gemelli and extremity
on the right side for 2nd gemelli

Leopold III : Head
69
Leopold IV
Vaginal toucher
Inspeculo
Rectal Toucher
: divergen, 3/5
: at 17:30 dilation cervix 9 cm, effacement (+).
: not performed
: not performed
CTG
Baseline
Variability
Fetus activity
Uterus contraction
Acceleration
Deceleration
Impression
:
:
:
:
:
:
:
130 bpm (1st gemelli) and 140 bpm (2nd gemelli)

normal
positive
1x/10minutes for 15 seconds, 60mmHg
positive
CST negative
USG
Results:
- Gemelli live fetal intrauterine
Ist gemelli
Head presentation
2nd gemelli
Head presentation
Longitudinal lie
Longitudinal lie
Biparietal diameter = 8,70 cm
Biparietal diameter = 8,45 cm
Head circumference = 29,45 cm
Head circumference = 29,47 cm
Fetal heart rate = 142 bpm
Fetal heart rate = 142 bpm
Abdominal circumference= 31,87cm
Abdominal circumference = 32,83cm
Estimated fetal weight = 2,486 kg
Estimated fetal weight = 2,366 kg
70
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood Type
Glucose blood test
HBsAg
: 10,7 g/dl
: 35%
: 10400/l
: 360000/l
: B/Rh (+)
: 81 mg/dL
: Negative
Working diagnosis
G3P2A0 29 years old, gravid 38-39 weeks according to USG, inpartu, stage one of labor,
with gemelli live fetus intrauterine, head presentation.
Planning

Fasting
Final Diagnosis
Mother:
P3A0, 29 years old, post partus matures by caesarian section indicated by patient preference
Baby:
Placenta:
Placenta delivery in 3 minutes, placental size 30 x 20 x 2,5 cm, weight 1100 gr. Insertion
marginal for 1st and 2nd umbilical cord, the 1st cord length is 40 cm and the 2nd cord length is
45cm, stool cell +, intact cotyledon, intact membrane, calcification -. Placental bleeding 200
cc.
Post operation instruction :
71
IVFD RL : NaCl = 2 : 1
Oxytocin 3x1 amp IV
Cefotaxime IV 2 x 1 g
Tramadol 3 x 100 mg drip
Ranitidine 2 x 1 amp
Kaltrofen Supp 3x II
Tranexamat acid 3 x 250mg IV
Follow up
March 4th 2016
S: Patient experienced vagina discharge
S:
March 5th 2016

Flatus (-), Defecation (-), Urination (+
including mucus and blood. It happened 15 hours
with cathether), post operation wound pain
before coming to hospital.
(VAS 1), POD-1
: well
: well
Consciousness
: compos mentis
Consciousness
: compos mentis
Blood pressure
: 120/80 mmHg
Blood pressure
: 130/80 mmHg
Pulse
: 88 bpm
Pulse
: 88 bpm
Respiratory Rate
: 22 bpm
Respiratory Rate
: 24 bpm
Temperature
: 36,1o C
Temperature
: 36o C
-/-, icteric sclera -/-.
conjunctiva +/+, icteric sclera -/-.
Thorax:
Thorax:
: Auscultation: regular 1st and 2nd
Cor
Cor
: Auscultation: regular 1st and
Pulmo
Pulmo
dynamic breathing

+, nipple retraction -/-, breastmilk -/-

of
Abdomen
breastmilk +/+
Abdomen
72
gravidarum +, linea nigra -,
gravidarum +, linea nigra-,
abdominal region
o Percussion: tympanic sound in all
abdominal region
x/minutes
Extremities: Warm
o Edema: Lower extremities +/+
o Physiological reflex: ++/++/++/++
o Pathological reflex : --/--

5 x/minutes
Workup:
o
o
o
o
o
o
o
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood Type
Glucose blood test
HBsAg
: 10,7 g/dl
: 35%
: 10400/l
: 360000/l
: B/Rh (+)
: 81 mg/dL
: Negative
Fundal height: two fingers upper

umbilicus
32 cm
Lochia: 75-100cc rubra
Mobilization: tilt to the left and
right
Extremities: Warm
o Edema: Lower extremities -/o Physiological reflex: ++/++/+

according to USG, inpartu, stage one of labor with
+/++
o Pathological reflex
gemelli living fetus intrauterine, head

presentation.
: --/--
Workup:
P:
o Hemoglobin

Fasting
A:
: 9,9g/dl
P3A0, 29 years old, post partus matures
by caesarian section indicated by patient

preference, POD-1
Post operation
A:
P3A0, 29 years old, post partus matures by
caesarian section indicated by patient preference

P:
73
P:
Oxytocin 3x1 amp IV
Cefotaxime IV
2x1g
Tramadol 3x100 mg drip
Ranitidine 2x1 amp
Kaltrofen
Supp 3x II
Tranexamat acid 3x250mg IV
Oxytocin 3x1 amp IV
Cefotaxime IV
2x1g
Tramadol 3x100 mg drip
Ranitidine 2x1 amp
Kaltrofen
Supp 3x II
Tranexamat acid 3x250mg IV
After 24 hour post op:
Cefadroxil 3 x 500mg
Tramadol 3 x 50mg
Mefenamat acid 3 x 500 mg
Molocco 3 x 1
Ranitidine 3 x 1
March 6th 2016

S: Flatus (+), Defecation (-), Urination (+ S:
March 7th 2016

Urination (+), Defecation (-),
with cathether), eat (+), drink (+) post
operation wound pain (VAS 1), POD-3
post
operation wound pain (VAS 1), POD-2

: well
: well
Consciousness
: compos mentis
Consciousness
: compos mentis
Blood pressure
: 110/70 mmHg
Blood pressure
: 130/80 mmHg
Pulse
: 80 bpm
Pulse
: 82 bpm
Respiratory Rate
: 20 bpm
Respiratory Rate
: 16 bpm
Temperature
: 36o C
Temperature
: 36,5o C
UO: 0,6 cc/kg/hour

conjunctiva +/+, icteric sclera -/-.
Thorax:
Thorax:
Cor
Cor
Pulmo
Pulmo


74

of

breastmilk +/+
breastmilk +/+
Abdomen
Abdomen
7 x/minutes
8 x/minutes
-
-
Fundal height: one fingers upper
Fundal height: one fingers upper
umbilicus
umbilicus
32 cm
Lochia: 40 cc rubra
Mobilization: active
32 cm
Lochia: 30 cc rubra
Mobilization: active
Extremities: Warm
+/++
Extremities: Warm
+/++
: --/--
Workup:
o Hemoglobin
A:
of
: --/--
Workup:
: 9,9g/dl
o Hemoglobin
: 9,9g/dl

A:
75
by caesarian section indicated by patient by caesarian section indicated by patient

preference, POD-2
preference, POD-3
P:
P:
Tramadol 3 x 50mg
Molocco 3 x 1
Ranitidine 3 x 1
Aff catheter
Tramadol 3 x 50mg
Molocco 3 x 1
Ranitidine 3 x 1
GYNECOLOGY
76
No
Admissio
Identity
Working Diagnosis
Final Diagnosis
10
n Date
March 2nd,
Mrs. C
P3A1, 41 years old, with
P3A1, 41 years old, post
septal vagina
vaginal septum excicion
2016
indicated by septal vagina

11
March 2
nd
Mrs. S
2016
G4P3A0, 40 years old,
gravid 15-16 weeks
curretage with indication
according to USG with
chronic hypertension and
missed abortion and
missed abortion
chronic hypertention
12.
March 3rd
Mrs. NY
2016
13.
March 4th
Mrs. SH
2016
P0A1, 21 years old, with post
gravid 19-20 weeks
partus immaturus by
according to USG,
spontaneous vaginal delivery,
with missed abortion
G2P0A1,35yearsold,
gravid1617weeks
Salphingectomyindicatedby
accordingtofirstdayof
ectopicpregnacyatright
lastmenstrualcycle,with
fallopiantube
ectopicpregnancy
14.
March 5nd
Mrs. L
2016
15.
March 6
2016
th
Mrs.Y
gravid 7-8 weeks
according to USG, with
abortus incomplete
abortus incomplete
gravid 17-18 weeks
according to USG, with
abortus incomplete
abortus incomplete
CASE 10
P3A1, 41 years old, with septal vagina
77
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Date of Admission
: Mrs. C
: 41 years old
: Javanese
: Moslem
: employee
: elementary school
: March 2nd 2016
Anamnesis
Chief Complaint
Lump in her vagina since 1 year ago

Patient came to Atma Jaya hospital complaining about lump in her vagina since 1 year
ago. The patient said that she felt more discomfort these days because of that. She also
said that she didn't felt pain on the lump.

o Hitory of allergy
o History of trauma
o Menarche
o Menstrual cycle
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: 16 years old
dysmenorrhea (-)
: 2015
Marital History
Married twice, already 17 year with this husband
Obstetric History
No
1.
Date
Gestational
Labour
1992
Age
28-29 weeks
History
Vaginal
78
Sex
Birth
Breast
Male
Weight
2500 g
Feeding
(+)
2.
1995
delivery
(not yet test Abortion
the
3.
4.
2000
2011
pregnancy)
28-29 weeks
Vaginal
Male
2600 g
(+)
28-29 weeks
delivery
Vaginal
Male
1700 g
(+)
delivery
Patient used inject contraception for 1 year, and the last contraception she used was
pills (from 2015 till now)

Three times at primary health care, three times at Bhakti Hospital
General Condition
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Height
BMI
: appeared mildly ill

: compos mentis
: 100/70 mmHg
: 84 x/minutes
: 20 x/minutes
: 36,7C
: 62 kg
: 155 cm
: 25.81 kg/m2 (obese I)
General Examination
Eyes
Thorax
o Heart
milk -/Abdomen
o Inspection
: convex, linea nigra (-), striae gravidarum (-)
o Palpation
79

Hb
Ht
Leucocyte
Platelets
Blood Type
Bleeding Time
Clotting time
Blood Glucose
HbSAg
: 12,2 gr/dL
: 35%
: 7.200/uL
: 344.000/uL
: A/Rh (+)
: 2 minutes
: 4 minutes
: 110 mg/dL
: Negative
Electrocardiogram
Interpretation:
Normal
Working Diagnosis
P3A1, 41 years old,
with septal vagina
80
Planning
Cefadroxil 3x500 mg
Mefinal 3x500 mg
Pro excision septal vagina
Follow up
Day
S
O
3rd March 2016

No pain, urinated (+), flatus (+), defecate (-), diet normal
Pressure: 120/80 mmHg
HR : 72 x/min
RR: 16 x/min
A
P
Temp: 36.9oC
P3A1, 41 years old, post vaginal septum excicion indicated by septal vagina
Go home with:
Cefadroxil 3x500mg
Mefinal 3x500mg
Final Diagnosis
P3A1, 41 years old, post septal vaginal excicion indicated by septal vagina
Treatment
Cefadroxil 3x500mg
Mefinal 3x500mg
81
CASE 11
G4P3A0, 40 years old, gravid 15-16 weeks according to USG with missed abortion and
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Address
Date of Admission
: Mrs. S
: 40 years old
: Javanese
: Moslem
: Housewife
: Elementary school
: Luar Batang
: March 2nd, 2016
Anamnesis
Chief Complaint
Liquid and blood discharge form the vagina 3 days before admission.

Patient complained about having small amount of clear liquid and blood discharge
from vagina since 3 days before hospital admission. Abdominal pain and abdominal
cramp was denied.
82
o
o
o
o
o
o
: since first pregnancy, uncontrolled,
consume captopril 2x25mg

History of allergy
History of epilepsy
History of trauma
History of surgery

o Menarche
o Menstrual cycle
: denied
: denied
: denied
: denied
: denied
: denied
: 15 years old
days, changed 4-5 pads a day, dysmenorrhea (+)

: September 9th 2015
Marital History
Married once, already 22 years with this husband
Obstetric History
No
Date
Gestationa
1994
l Age
9 months
1998
2004
Labor History
Gender
Birth
Breast feeding
Spontaneous
Male
Weight
?
history
Breastfed 6
9 months
Vaginal Delivery
Spontaneous
Male
months
Breastfed 6
9 months
Vaginal Delivery
Spontaneous
Female
2500 grams
months
Breastfed 6
Vaginal Delivery
4
months
2016 (this
pregnancy)
History of using 3 months injectable contraception for 4 years and stop at 1998.

Two times at primary health care
General Condition
Vital Signs
o Blood pressure

: compos mentis
: 150/90 mmHg
83
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Height
BMI
: 88 x/minutes
: 20 x/minutes
: 36,4C
: 53 kg
: 145 cm
: 25.2 kg/m2
General Examination
Eyes
: anemic conjunctiva +/+, icteric sclera -/Mouth
Thorax
o Heart
milk -/Abdomen
o Inspection
: convex, linea nigra (+), striae gravidarum (-)
o Auscultation : bowel sounds, 5 x/min
o Palpation
Estimated due date

Fundal height
Fetal heart rate
Leopold maneuver
Inspeculo
: June 16th 2016

: two fingers below umbilical
:: not palpable
Vaginal Toucher
:portio:
consistency, dilatation (-), amniotic fluid (-)

: not performed
Hb
Ht
Leucocyte
Platelets
Blood Type
HBsAg
Urinalysis
o Protein
thick
: 10,1 gr/dL
: 30%
: 14.900/uL
: 418.000/uL
: O/Rh (+)
::84
and
hard
30/12/15 : G4P3A0, gravid 15-16 weeks susp. fetal ascites
BPD : 3,02 cm
FL : 12,11 cm
02/03/16 : G4P3A0 gravid 24-25 weeks, with IUFD
BPD : 2,85 cm
GA : 15w 1d
FHR : Working Diagnosis
G4P3A0, 40 years old, gravid 15-16 weeks according to USG with missed abortion and
chronic hypertension
Planning
Misoprostol 100 g/4 hours, per vaginam until the fetus was delivered
Captopril 1 x 25 mg PO
Pro curretage
Final Diagnosis
P3A1, 40 years old, post curretage with indication chronic hypertension and missed abortion
Treatment
Observation of patients condition after delivery (vital sign)

If the condition is stable and no further complication occurs, patient is permitted for
discharge
March2nd2016
March3rd2016
S:Patientcomplainedabouthavingsmallamount S: abdominal discomfort (+), defecate (),

ofliquidandblooddischargefromvagina
O:Generalcondition
: well
urinate(+),appetite(+),fatigue(+)
O:Generalcondition
: well
Consciousness
: composmentis
Consciousness
: composmentis
Bloodpressure
: 150/90mmHg
Bloodpressure
: 100/60mmHg
85
Pulse
: 88bpm
Pulse
: 80bpm
RespiratoryRate
: 20bpm
RespiratoryRate
: 16bpm
Temperature
: 36,4oC
Temperature
: 36oC
+/+,ictericsclera/.
Oral:Wetoralmucous
Oral:Wetoralmucous
Thorax:
Thorax:
Cor
Pulmo
Cor
: Auscultation: irregular 1st
and2ndheartsound,Gallop(),Murmur
()
dynamicbreathing
wheezing/,crackles/
Mammae:hyperpigmentationofareola+/
+,nippleretraction/
Pulmo
Inspection:symmetricalinboth
staticanddynamicbreathing
Abdomen
breastmilk/
o Inspection:convex,striae
Abdomen:
gravidarum,lineanigra(+),
o Palpation:suppleinall
Inspection:convex,striae
abdominalregion,tenderness
o Percussion:tympanicsoundinall
Palpation:suppleinallabdominal
region,tenderness
abdominalregion
abdominalregion
x/minutes
86
Extremities:Warm
o Edema:Lowerextremities/
o Physiologicalreflex:++/++/++/++
o Pathologicalreflex :/
o Sensoryexamination+/+
9x/minutes
Extremities:Warm
Pathologicalreflex
:/
Workup:
o Laboratory:
DeliveryonMarch3th,2016on3am
Hemoglobin:10,1g/dL
Hematocrit:30%
Leucocyte:14,900/L
Platelets:418,000/L
Bloodgroup:O/Rh+
HbSAg:
Fetalweight:90g
Fetallenght:11cm
Minimalbleeding(+200cc)
Postpartusandcurretage
A : G4P3A0, 40 years old, gravid 15-16
Urine:
weeks according to USG with missed
Protein:
abortion and chronic hypertention
Ultrasonography(USG)
30/12/15 : G4P3A0, gravid 1516 weeks susp.
Fetalascites
BPD:3,02cm
P:
FL:12,11cm
Observevitalsign,ifstable,patientwas
permittedtodischarge
02/03/16 : G4P3A0 gravid 2425 weeks, with

IUFD
BPD:2,85cm
GA:15w1d
FHR:
according to USG with missed abortion and
87
P:
Deliverthebaby
Misoprostol100g/4hours,pervaginam
untilthefetuswasdelivered
Captopril1x25mgPO
Procurretage
Observethevitalsignsafterprocedure
88
CASE 12
G1P0A0, 21 years old, gravid 19-20 weeks according to USG,
Identity:
Name
Age
Ethnicity
Religion
Occupation
Education
Address
Date of admission
: Mrs. NY
: 21 years old
: Javanese
: Moslem
: Housewife
: Luar Batang
: March 3rd, 2016
History
Chief complaint
Patient came to the hospital because she was referred from local primary health care and was
diagnosed with IUFD. Patient felt no fetal movement since 4 days prior to admission.
History of present illness
Patient came to the hospital because she felt no fetal movement from 4 days prior to
admission. Abdominal pain felt on suprapubic area. Blood discharge from vagina was denied.
2 weeks before, patient came to local primary health care and she said there was fetal
movement then.
History of past illness:
o History of urinary tract/kidney disease
o History of trauma
History of menstrual cycle:

o Menarche
: Denied.
: Denied.
: Denied.
: Denied.
: Denied.
: Denied.
: Denied.
: Denied.
: 14 years old
89
o Menstrual cycle
: 30 days,
irregularly, with duration of 5-7 days,

changed 2-3 pads (80 cc) a day

: August 8th 2015
History of antenatal care: 1 time at public health care
Marital History:
Married 1 time, already 2 years with this husband
Obstetric history:
No
1.
Date
This
Pregnancy
Gestational
Age
Labour History
Sex
Birth
Breast
Weight
Feeding
28-29 months
Contraception History:
History of using 3 months injectable contraception until June 2014
Family History: -
Physical examination
General condition
Level of consciousness
Vital signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body temperature
Weight
Height
BMI
: Appeared mildly ill

: Compos mentis
: 110/70 mmHg
: 96 x/minutes
: 16 x/minutes
: 37.6 C
: 48 kg
: 155 cm
: 19.97 kg/m2
General examination
Eyes
Mouth
Thorax
o Heart
o Lung
: Anemic conjunctiva -/-, icteric sclera -/: Wet oral mucosa membrane
: Regular 1st and 2nd heart sounds, murmur -, gallop : Vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
90
o Mammae
milk-/Abdomen
o Inspection
o Auscultation
o Palpation
o Percussion
Extremities
: Areola hyperpigmentation +/+, nipple retraction -/-, breast
: Convex, striae gravidarum (-), linea nigra (+)

: Bowel sounds (+), 6 times/minute
: Supple, pain with palpation (+) on suprapubic
: Tympanic
: Leg edema -/-, CRT< 2 seconds
Obstetrics examination
Fundal height
Uterine contraction
Fetal heart rate
Leopold maneuver
Inspeculo
: 1 finger below umbilical

: unknown
:: none
: not palpable
: not performed
Vaginal toucher : portio:
thick
and
consistency, dilatation (-), amniotic fluid (-)

Rectal toucher
: not performed
Laboratory examination
Hemoglobin
Hematocrit
Leucocyte
Platelets
Blood type
HBsAg
Urinalysis
o Protein
o Ketones
o Leucocyte
: 12.8 g/dl
: 39%
: 8,700/l
: 218,000/l
: O / Rh [+]
::: ++
: +++
Ultrasonography
No fetal heart movement. Gravid 19-20 weeks.
Working diagnosis
G1P0A0, 21 years old, gravid 19-20 weeks according to USG, with missed abortion
91
hard
Planning
Deliver the baby

IVFD RL 500 cc + Omeprazole 1 amp + Buscopan 1 amp
Misoprostol 50 mcg/4 hours
Observe the vital signs after procedure
Working diagnosis after deliver the baby

P0A1, 21 years old, with post partus immaturus by spontaneous vaginal delivery, with missed
abortion
Planning
Pro USG
March 4th, 2016 at 9 am : no left tissue.
Final Diagnosis:
P0A1, 21 years old, with post partus immaturus by spontaneous vaginal delivery, with missed
abortion
Treatment
Takehomemedicine
Cefadroxyl3x500mgPO
Pospargin3x1tabPO
Mefenamicacid3x500mgPO
Iftheconditionisstableandnofurthercomplicationoccurs,patientispermittedfor
discharge
March3rd2016
March4th2016
S:Patientfeltnofetalmovement
O:Generalcondition
S: SuprapubicpainVAS45,defecate(+),
urinate(+),appetite(+)
: well
Consciousness
: composmentis
Bloodpressure
: 110/70mmHg
O:Generalcondition
Consciousness
92
: well
: composmentis
Pulse
: 96bpm
Bloodpressure
: 100/60mmHg
RespiratoryRate
: 16bpm
Pulse
: 80bpm
Temperature
: 37,6oC
RespiratoryRate
: 16bpm
Temperature
: 37,1oC
/,ictericsclera/.

Oral:Wetoralmucous
Oral:Wetoralmucous
Thorax:
Cor
Thorax:
Pulmo
Cor
and2ndheartsound,Gallop(),Murmur
()
anddynamicbreathing
Pulmo
Abdomen
Inspection:symmetricalinboth
staticanddynamicbreathing
breastmilk/
Inspection:convex,striaegravidarum
,lineanigra(+),
Abdomen:
region,tenderness+
Inspection:convex,striae
abdominalregion
areola+/+,nippleretraction/
: Auscultation: irregular 1st
region,tenderness
Auscultation : bowel sound +, 6

x/minutes
abdominalregion
93
Extremities:Warm
Pathologicalreflex
:/

9x/minutes
Extremities:Warm
Pathologicalreflex:/
Workup:
Laboratory:
- Hemoglobin:12,8g/dL
- Hematocrit:39%
- Leucocyte:8,700/L
- Platelets:218,000/L
- Bloodgroup:O/Rh+
- HbSAg:
DeliveryonMarch4th,2016
Fetalweight:320g
Fetallenght:18cm
Minimalbleeding(+150cc)
Postpartus
Urine:
A: P0A1, 21 years old, with post partus
- Glucose:
- Protein:
- Ketones:++
- Leucocyte:+++
immaturus by spontaneous vaginal delivery,

A: P0A1, 21 years old, with post partus

immaturus by spontaneous vaginal delivery, with
missed abortion
P:
P:
Observevitalsign
ProUSG
USGon9am:notissuewasleft
Deliverthebaby
IVFDRL500cc+Omeprazole1amp+
Buscopan1amp
Misoprostol50mcg/4hours
Observethevitalsignsafterprocedure
94
Patientpermittedtodischargewith
Cefadroxyl3x500mgPO
Pospargin3x1tabPO
Mefenamicacid3x500mgPO
CASE 13
G2P0A1,35yearsold,gravid1617weeksaccordingtofirstdayoflastmenstrualcycle,
withectopicpregnancy
Identity
Name
:Mrs.SH
Age
:35yearsold
Ethnicity
:Javanese
Religion
:Moslem
Occupation
:Housewife
Education
:JuniorHighSchool
Dateofadmission
:4thMarch2016
History
Chiefcomplaint
Patientfeltpainatherleftlowerabdomensince5hoursbeforehospitaladmission
95
Historyofpresentillness
Patientcametotheemergencyroomwithlowerabdominalpainat2a.m.thepatientsaidthat
sincedecember,hermenstrualcyclecameirregularlyandshetookthepregnanttestandit
wassaidpositive.Theabdominalpainfeltlikeshewasbeingstabbedandsqueezed,itgot
worsesinceonemonthago.Thepatientalsosaidthatsometimesshefeltdizzyafterthe
pregnancytestwaspositive.
:Denied.
:Denied.
Historyofallergy
:Denied.
Historyofepilepsy
:Denied.
:Denied.
Historyofurinarytract/kidneydisease :Denied.
Historyoftrauma
:Denied.
Historyofsurgery
:appendectomy(2004)
o Menarche
o MenstrualCycle
:18dayswithregularmenstrualcycle,withevery
o Firstdayoflastperiod
:December,th2015
MaritalHistory:
Patienthasmarriedtwice,haslasted2yearswithcurrenthusband.
Obstetrichistory:
No
1.
Date
Gestational
Labour
2002
Age
2months
History
Abortus
96
Sex
Complication
Birth
Breast
Weight
Feeding
2016 (this 3months
Abortus
pregnancy)
Nocontraceptionhistory
Patientdidnthavearoutineantenatalcare
PhysicalExamination
GeneralCondition
:Moderateill
ConsciousnessLevel :ComposMentis
VitalSigns
BloodPressure
:120/80mmHg
Temperature :36,7oC
Respiratoryrate :32timesaminute
Heartrate
:96BPM
Weight
:65kg
Height
:165cm
BMI
:23,8kg/m2
GeneralExamination
Eyes
Mouth
Thorax
Heart
Lungs
Mammae
:Wetoralmucosa
:
:Areolahyperpigmentation/,Nippleretraction/,
breastmilk/
Abdomen
Inspection
Auscultation
Extremities
:
:Convex,StriaeGravidarum(),LineaAlba()
:Bowelsounds(decreased)
97
Gynecologicexamination
Firstdayofthelastmenstrualperiod:Decemberth2015
Pelvicexamination
o Vaginatoucher :Cervixdilation()
o Rectovaginaltoucher
:notperformed
o Inspekulo
:Vulva:noabnormality
Vagina:noabnormality
Porsio:erosion()
Slingerpain(+)
Fluksus(+)
Corpusuteri:noabnormality
Douglassicavum:noabnormality
Laboratoryexamination
Hemoglobin
Hematocrit
Leucocyte
Platelets
Bloodtype
HbsAg
Pregnancytest
:11,6g/dl
:35%
:15600/l
:312.000/l
:O/+
:
:(+)
Workingdiagnosis
G2P0A1,35yearsold,gravid1617weeksaccordingtofirstdayoflastmenstrualcycle,with
ectopicpregnancy
Planning
ProLaparotomySalphingectomy
Consulanesthesiaforpreoperativepreparation
Finaldiagnosis
P0A2,35yearsold,postSalphingectomyindicatedbyectopicpregnacyatrightfallopian
tube
98
observedvaginalbleedinganduterinecontraction
measureurineoutputandfluidbalanceevery6hours
ifflatus(+),givemushydiet
phasesmobilitation
IVFD:
o RL500cc+1ampOndancentron+1ampTramalfor8hours
o RL500cc+1ampAlinaminF+1ampOmeprazolefor8hours
o RL500cc+1ampExtracefor8hours
Oral:
o Cefadroxil3x500mg
o Doxycyclin2x100mg
o Tranexamicacid3x500mg
o Kaltrofenrectal2x1supp
Followup:
March4th2016
March5th2016
S:painatthelowerabdominal,feltlikestabbed S:postoppainvas34,flatus+,defecation
andsqueezed
O:Generalcondition
O:Generalcondition
: mildlyill
: moderateill
Consciousness
: composmentis
Consciousness
: composmentis
Bloodpressure
: 110/70mmHg
Bloodpressure
: 120/80mmHg
Pulse
: 80bpm
Pulse
: 96bpm
RespiratoryRate
: 18bpm
RespiratoryRate
: 32bpm
Temperature
: 36,5oC
Temperature
: 36,7oC
/,ictericsclera/.
Oral:Wetoralmucous
Oral:Wetoralmucous
Thorax:
Thorax:
Cor
99
Cor
Pulmo
Pulmo
anddynamicbreathing
dynamicbreathing
wheezing/,crackles/
Mammae : hyperpigmentation of areola
areola /, nippleretraction /,
/,nippleretraction/
breastmilk/
Abdomen
Abdomen:
Inspection:convex,striaegravidarum,
lineanigra(),
Palpation:suppleinallabdominalregion,
abdominalregion
Auscultation:bowelsounddecreased

x/minutes
Extremities:Warm
Pathologicalreflex
:/
Inspeculo:
region,tenderness
abdominalregion
,lineanigra(),
tendernessatlowerregion
Extremities:Warm
Pathologicalreflex
:/
Vulva:noabnormality
Vagina:noabnormality
Porsio:erosion()
Slingerpain(+)
Fluksus(+)
Corpusuteri:noabnormality
A:P0A2,35yearsold,postSalphingectomy
indicatedbyectopicpregnacyatright
fallopiantube
100
P:
Douglassicavum:noabnormality
Affcatheterin1x24hours
Workup:
Medication
Laboratory:
Hemoglobin:11,6g/dl
Hematocrit:35%
Leucocyte:15600/l
Platelets:312.000/l
Bloodtype:O/+
HbsAg:
Pregnancytest:(+)
A: G2P0A1, 35 years old, gravid 1617 weeks

accordingtofirstdayoflastmenstrualcycle,with
ectopicpregnancy
P:
ProLaparatomySalphingectomy
Consulanesthesiaforpreoperativepreparation
Postoperation
A : P0A2, 35 years old, post Salphingectomy
indicated by ectopic pregnacy at right fallopian
tube
Observedvitalsignsevery15minutesfor
thefirstonehour,every30minutesforthe
observed vaginal bleeding and uterine
contraction
measure urine output and fluid balance
every6hours
101
Cefadroxil3x500mg
Doxycyclin2x100mg
Tranexamicacid3x500mg
Mefenaicacid3x500mg
Kaltrofensupp2x1
Sangobion2x1
Ranitidine2x150mg
ifflatus(+),givemushydiet
phasesmobilitation
IVFD:
o RL500cc+1ampOndancentron+1
ampTramalfor8hours
o RL 500cc + 1amp Alinamin F + 1
ampOmeprazolefor8hours
o RL500cc+1ampExtracefor8hours
Oral:
o Cefadroxil3x500mg
o Doxycyclin2x100mg
o Tranexamicacid3x500mg
o Kaltrofenrectal2x1supp
March6th2016
March7th2016
S: postop pain vas 6, flatus + , S: postop pain vas 12, flatus + ,

defecation+/waterystool,urination+
O:Generalcondition
defecation+,urination+
: mildlyill
O:Generalcondition
: mildlyill
Consciousness
: composmentis
Consciousness
: composmentis
Bloodpressure
: 110/70mmHg
Bloodpressure
: 100/70mmHg
Pulse
: 80bpm
Pulse
: 88bpm
RespiratoryRate
: 18bpm
RespiratoryRate
: 20bpm
Temperature
: 36,5oC
Temperature
: 37oC
Oral:Wetoralmucous
Oral:Wetoralmucous
Thorax:
Thorax:
Cor
102
Cor
Pulmo
Pulmo
anddynamicbreathing
anddynamicbreathing
breastmilk/
Abdomen:
breastmilk/
region,tenderness
abdominalregion
,lineanigra(),
region,tenderness
Abdomen:
,lineanigra(),
abdominalregion

x/minutes

x/minutes
Extremities:Warm
Pathologicalreflex
:/
Extremities:Warm
Pathologicalreflex
:/
fallopiantube
fallopiantube
103
P:
P:
Medication
Medication
Cefadroxil3x500mg
Doxycyclin2x100mg
Mefenaicacid3x500mg
Kaltrofensupp2x1
Sangobion2x1
Ranitidine2x150mg
Cefadroxil3x500mg
Doxycyclin2x100mg
Mefenaicacid3x500mg
Kaltrofensupp2x1
Sangobion2x1
Ranitidine2x150mg
Tramalsuppiftherespain
CASE 14
G1P0A0, 19 years old, gravid 7-8 weeks according to USG, with abortus incomplete
Identity
Name
Age
Ethnicity
Religion
Occupation
Education
Date of Admission
: Mrs. L
: 19 years old
: Javanese
: Moslem
: Housewife
: March 5rh 2016
104
Anamnesis
Chief Complaint
Bleeding from vagina since 2,5 hours before admission

Patient came to emergency ward with vaginal bleeding with total amount 90cc. The
vaginal bleeding was accompanied by some flesh. The patient said that she felt
suprapubic pain and had vaginal spotting since 2 days prior to admission with brown
color.

o Hitory of allergy
o History of trauma

o Menarche
o Menstrual cycle
: denied
: denied
: denied
: denied
: denied
: denied
: denied
: 13 years old
: 28 days, regularly, with duration of 5-6
dysmenorrhea (-)
: December 20th 2015
Marital History
Married once, already 6 months with her husband
Obstetric History
No
Date
Gestational
Labour
This
Age
History
7-8 weeks
pregnancy
according
Sex
Complication
to USG
Patient used pill contraception from August 7-14th ,2015
Two times at primary health care.
105
Birth
Breast
Weight
Feeding
General Condition
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Height
BMI

: compos mentis
: 110/80 mmHg
: 88 x/minutes
: 24 x/minutes
: 35,4C
: 74,5 kg
: 155 cm
: 31 kg/m2 (obese2)
General Examination
Eyes
Thorax
o Heart
milk -/Abdomen
o Inspection
o Palpation
: supel, tenderness (+) in suprapubic
o Percussion
Estimated due date

Fundal height
Uterine contraction
Fetal heart rate
Leopold maneuver
Vaginal Toucher
:: not palpable
:::: ballotement (+)
: thick and rigid consistency, no dilatation, no
Inspeculo
effacement
: fluxus +, bleeding from portio, portio in anterior,
erossion +, stoll cell+, no dilatation
106
Hb
Ht
Leucocyte
Platelets
Blood Type
Urine
: 14,8 gr/dL
: 44%
: 8.800/uL
: 262.000/uL
: O/Rh (+)
Glucose
: (-)
Protein
: (-)
Bilirubin
: (-)
Urobilinogen
: normal
pH
: 5,5
: >1030
Occult blood
: (+)
Ketone
: (-)
Nitrite
: (-)
Leucocyte
: (-)
Sediment
Leucocyte
Erythrocyte
Epithel
Cylinder
: (-)
Crystal
: Ca oxalat (+)
Bacteri
: (-)
Others
: (-)
HbsAg
: (-)
USG (05-03-2016, 11.00 am)

-
GS : 3,5 cm
GA : 7-8 weeks
No fetal pole seen in USG
suspected blighted ovum
Working Diagnosis
Planning
107
Pro USG the next day

Pro curretage if blighted ovum (+)
IVFD RL 500cc for 8 hours
Duphaston 2x1
Final Diagnosis
-
P0A1, 19 years old, post curretage with indication abortus incomplete
Follow up
Date
March,
th
2015
05.00
AM
Subjective
Objective
Abdominal General condition:
Assesment
G1P0A0, 19
pain (VAS
moderately ill
2), fatigue Level of consciousness: CM
Vital signs:
o BP : 100/70 mmHg
o HR : 88x/minutes
o RR : 20 x/minutes
o Temperature : 36,3C
Abdomen :
years old, gravid
Planing
Duphaston
2x1
7-8 weeks
according to
USG, with
abortus
incomplete
o I: convex
o A: bowel sounds
(+), 10x/minute
o P : supple, pain on
palpation (-)
Obstetric
o Fundal height :
ballotement (+)
o Contraction: strong
o Mobilization : (+)
March,
o Lochia: rubra 30 cc
USG shown that there was
6th
still a retained placenta in
2015
the uterus.
11.00
The curretage was
AM
performed.
108
P0A1, 19 years Cefadroxil 3 x

old, post
500 mg p.o
Mefenamic
acid
curretage with
3 x 500 mg p.o
indication abortus
Tranexamic acid
incomplete
3x500 mg
Pospargin
Abdominal General condition: mildly
March,
7th
discomfort
ill
Level
of consciousness: CM
minimal,
Vital signs:
Breast feed o Blood pressure : 110/70
(-)
mmHg
o Heart rate :74x/minutes
o Respiratory rate : 18
2015
05.00
AM
x/minutes
o Body temperature :
36,4C
P0A1, 19 years
3x0.125 mg p.o
Patient can go
old, post
back home with
curretage with
the medications:
indication abortus Cefadroxil 3 x

incomplete
500 mg p.o
Mefenamic acid
3 x 500 mg p.o
Tranexamic acid
3x500 mg
Pospargin
3x0.125 mg p.o
Abdomen :
mg p.o
o I: convex
o A: bowel sounds
(+), 5-6x/minute
o P : supple, pain on
palpation (-)
Obstetric
o Fundal height : not
palpable
o Contraction: o Mobilization : (+)
o Lochia: rubra, 30 cc
'
CASE 15
Identity
Name
Age
Ethnicity
Religion
Occupation
: Mrs. Y
: 19 years old
: Javanese
: Moslem
: Housewife
109
Education
Date of Admission
: Junior high school

: March 6rth 2016
Anamnesis
Chief Complaint
Vaginal spotting since 1 day before admission

Patient came to emergency ward with vaginal spotting and clear vaginal discharge.
After admitted to the obstetric ward, the patient had a fetus hand came out from her
vagina. The patient said that she felt abdominal discomfort since two days before
hospital admission and had her abdominal massaged one day before admission.

o Hitory of allergy
o History of trauma
: denied
: denied
: denied
: denied
: denied
: denied
: denied

o Menarche
o Menstrual cycle
: 13 years old
dysmenorrhea (-)
: September 30th 2015
Marital History
Married once, already 3 years with the last husband
Obstetric History
No
Date
Gestational
Labour
Sex
Complication
1.
2013
Age
7 months
History
Spontaneou
male
livebirth but
per
vaginam
2
This
17-18
pregnancy
weeks
according
110
died after a
few days
Birth
Breast
Weight
Feeding
to USG
Patient used injection contraception from 2013-2014

Two times at primary health care.
General Condition
Vital Signs
o Blood pressure
o Heart rate
o Respiratory rate
o Body Temperature
Weight
Height
BMI

: compos mentis
: 90/40 mmHg
: 124 x/minutes
: 28 x/minutes
: 36,6C
: 41 kg
: 146 cm
: 19,23 kg/m2
General Examination
Eyes
Thorax
o Heart
milk -/Abdomen
o Inspection
o Palpation
o Percussion
Estimated due date

Fundal height
Uterine contraction
Fetal heart rate
: June 7th 2016

: 14 cm
: 2.170 grams
:+
:111
Leopold maneuver
Vaginal Toucher
Inspeculo
: not palpable
: not performed
: not performed
Hb
Ht
Leucocyte
Platelets
Blood Type
Urine
: 10,6 gr/dL
: 31%
: 16.100/uL
: 255.000/uL
: O/Rh (+)
Glucose
: (-)
Protein
: (-)
Bilirubin
: (-)
Urobilinogen
: normal
pH
:7
: 1020
Occult blood
: (++)
Ketone
: (-)
Nitrite
: (-)
Leucocyte
: (-)
Sediment
Leucocyte
Erythrocyte
Epithel
Cylinder
: (-)
Crystal
: (-)/Low power field
Bacteri
: (-)
Others
: (-)
HbsAg
: (-)
Working Diagnosis
Planning
112
Duvadilan 1 ampule in 500 cc RL, 10 dpm

Nifedipine 3 x 10 mg p.o.
USG the next day
Follow up
-
07.30 : an hour after the patient came to obstetric ward, the patient delivered a death
fetus with the placenta

10.00 : USG showed that there was still remaining tissue in the uterus
11.00 : The curretage was performed to take the remaining tissue from the uterus
Final Diagnosis
P1A1, 19 years old, post curretage with indication abortus incomplete
Treatment
Post operation instruction

o Observe vital signs and hemorrhage
o Observe spontaneouts urination in 6 hours
o Infusion RL 500 cc + Syntocinon 1 ampule + Extrace 1 ampule for 8 hours
Medication:
- Cefadroxil 3x500 mg
- Pospargin 3 x 0,125 mg
- Mefenamic acid 3x500 mg
- Tranexamic acid 3x500 mg
113

Final Weekly Report IV

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Final Weekly Report IV

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WEEKLY REPORT

R.R. Gabriela W.T.K

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

R.R. Gabriela W.T.K

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

old, gravid 37-38

old, post partus

patient age and

single living fetus

old, gravid 38-39

gr, birth length

stage labor, latent

with single living

old, gravid 40-41

old, post partus

to first day of last

active phase, with

single living fetus

old, gravid 38-39

old, post partus

not in labor, with

single live fetus

G3P1A1, 29 years P2A1, 29 years Term female

old, post partus neonate,

age 40-41 weeks

sectionindicated age, 4041

by Feto Pelvic weeks

single living fetus

old, gravid 38-39

old, post partus

and post hecting

with single fetus

old, gravid 39-40

old, post partus

single living fetus

gr, birth length

old, gravid 38-39

old, post partus

stage one of labor,

with gemelli live

: Junior High School

: February 29th 2016

: Patient has history of chronic

History of diabetes mellitus

History of hematologic disease

History of urinary tract/kidney disease : Denied.

: Patient has a history of C-Section

History of Menstrual Cycle

: Approximately 13 years old

7 days and sometimes with dysmenorrhea.

: Anemic conjunctiva -/-, Icteric sclera -/: Wet oral mucosa

breast milk -/Abdomen

Auscultation : Bowel sounds (+), 6 times/minute

Estimated due date

: March, 4th 2016

1st March 2016

2nd March 2016

3rd March 2016

VAS 2, flatus (+),

VAS 2, flatus (+),

VAS 1, flatus (+),

urinate with catheter,

urinate with catheter,