Labuang Baji Hospital / Waode

Radmila
Period June 21st – 24th , 2020

No Patient Name
Date (Age/LMP/RM) Detail of Treatment Recommendation
Patient
1. June 21st Mrs. D Pre Treatment Diagnosis :  Spontaneous vertex - Exclusive breast
, 2020 23 y.o G1P0A0 39 weeks 2 days of Gestational delivery feeding for 6
LMP : Age in Active Phase 1st Stage of Labor  Early breastfeeding months
20/9/2019  Repair of perineal - Vaginal hygiene
MR : 892322 Post Treatment Diagnosis : laceration - Family planning
Term Delivery + Second degree counselling and
perineal laceration education :
Hormonal progestin
Outcome : injection
Male, BW : 3100 gr, BL : 49 cm, AS : 8/10
2. June 22nd Mrs. N Pre Treatment Diagnosis :  Spontaneous vertex - Exclusive breast
, 2020 29 y.o G2P1A0 39 weeks 5 days of Gestational delivery feeding for 6
LMP : Age in Active Phase 1st Stage of Labor  Early breastfeeding months
18/9/2019 - Vaginal hygiene
MR : 389025 Post Treatment Diagnosis : - Family planning
Term Delivery counselling and
education : IUD
Outcome :
Male, BW : 2900 gr, BL : 48 cm, AS : 8/10
3. June 23rd Mrs. S Pre Treatment Diagnosis :  Spontaneous vertex - Exclusive breast
, 2020 21 y.o G1P0A0 39 weeks 1 day of Gestational delivery feeding for 6
LMP : Age in Active Phase 1st Stage of Labor  Early breastfeeding months
23/9/2019  Repair of perineal - Vaginal hygiene
MR : 892349 Post Treatment Diagnosis : laceration - Family planning
 Labuang Baji Hospital / Waode
Radmila
Period June 21st – 24th , 2020
Term Delivery + Second degree counselling and
perineal laceration education : IUD

Outcome :
Female, BW : 3300 gr, BL : 50 cm, AS : 8/10
4. June 24th Mrs. J Pre Treatment Diagnosis :  Labor augmentation - Exclusive breast
, 2020 34 y.o G4P3A0 40 weeks 1 day of Gestational with drips Oxytocin 5 feeding for 6
LMP : Age in Active Phase 1st Stage of Labor + IU in 500 cc Ringer months
17/9/2019 Secondary uterine inertia Lactate - Family planning
MR : 389240  Spontaneous vertex counselling and
Post Treatment Diagnosis : education : IUD
delivery
Secondary uterine inertia + Term  Early breastfeeding
delivery

Outcome :
Female, BW : 3000 gr, BL : 48 cm, AS : 8/10
5. June 24th Mrs. F Pre Treatment Diagnosis :  Spontaneous vertex - Exclusive breast
, 2020 26 y.o G2P1A0 40 weeks 3 days of Gestational delivery feeding for 6
LMP : Age in Active Phase 1st Stage of Labor  Early breastfeeding months
15/9/2019  Repair of perineal - Vaginal hygiene
MR : 898817 Post Treatment Diagnosis : laceration - Family planning
Term Delivery + Second degree counselling and
perineal laceration education : IUD

Outcome :
Male, BW : 3500 gr, BL : 49 cm, AS : 8/10
6. June 23rd, Mrs.J G3P2A0  Lower segment - Exclusive
2020 33 years old 1st caesarean section on 2016 due to breech transverse caesarean breastfeeding for 6
LMP : 23/9/2019 presentation. months
section
 Labuang Baji Hospital / Waode
Radmila
Period June 21st – 24th , 2020
MR : 389420 2nd caesarean section on March 2018 due to 1  Bilateral tubectomy - Mobilization
previous caesarean section. with Pomeroy - Control for
Complaining abdominal pain with vaginal operation wound
bloody show since 12 hours before admission. modification
suture
Pre Operative Diagnosis :
G3P2A0 39 weeks 1 day in latent phase first
stage of labor + 2 previous caesarean section +
Female sterilization acceptor candidate

Post Operative Diagnosis :

2 previous caesarean section + term delivery +
female sterilization acceptor

Outcome :
Male, BW : 3600 g, BL : 49 cm, AS : 8/10
7. June 23rd, Mrs.Y G1P0A0  Oxygen 8 lpm via Non - Exclusive
2020 23 years old Headache (+), blurred vision (+) Rebreathing Mask breastfeeding for 6
LMP : 28/9/2019 BP : 170/110 mmHg months
MR : 384440 HR : 92 bpm  Drips 4 g MgSO4 40 %
RR : 20 tpm in 100 cc NaCl 0.9 % 73 - Mobilization
T : 36.8◦C dpm - Control for
 Drips 6 g MgSO4 40 % operation wound
Laboratory Results suture
Hemoglobin : 12.7 g/dl in 500 cc Ringer
- Control for
Leukocytes : 11,200/uL Lactate 28 dpm until
bloodpressure until
Trhombocytes : 321,000/uL 24 hours after delivery
ALT : 38 U/L 12 weeks after
 Urinary catheter delivery
AST : 40 U/L
Ureum : 31 mg/dl insertion - Family planning
Creatinine : 1.1 mg/dl  Nifedipine 10 mg/ 8 counselling and
Urine protein : +2 hours/ oral education : IUD
Pre Operative Diagnosis :  Lower segment - Subsequent
 Labuang Baji Hospital / Waode
Radmila
Period June 21st – 24th , 2020
G1P0A0 38 weeks 3 days in latent phase first transverse caesarean pregnancy should
stage of labor + Severe preeclampsia section be at least more
than 18 months
Post Operative Diagnosis :
Severe preeclampsia + Term delivery - ANC for subsequent
pregnancy should
Outcome : be at Obstetricians
Female, BW : 3100 g, BL : 48 cm, AS : 8/10
8. June 21st, Mrs. M P2A0  Drips 6 g MgSO4 40 % - Observation of
2020 19 years old Referred by Cahaya Medika Hospital with Post dalam 500 cc Ringer general condition,
MR : 384930 caesarean section day – 0 + Severe vital signs, uterine
Preeclampsia + partial HELLP Syndrome + Lactate 28 dpm until
Dyspnea ec lung edema suspected 24 hours after delivery contraction, and
The patient was intubated at Cahaya Medika  Drips Oxytocin 20 IU in impending signs
Hospital. 500 cc Ringer Lactate - Exclusive
History administration of MgSO4 40 % loading breastfeeding for 6
dose and maintenance dose, and urinary 28 dpm until 28 after
months
catheter insertion. delivery
- Follow up for blood
 Dexamethasone 10
GCS : E3M5VX (intubated) pressure until 12
mg/ 12 hours/ weeks later
BP : 150/100 mmHg
HR : 90 tpm intravenous (twice - Control for surgical
RR : 16 tpm (intubated) administrations), wound suture
T : 36.8oC continued with - Family planning
Dexamethasone 5 mg/ counselling and
Laboratory Results :
Hemoglobin : 9.1 g/dl 12 hours / intravenous education : IUD
Leukocytes : 17,000/uL (twice administrations) - Consult to Social
Thrombocytes : 104,000/uL  Consult to Obstetrics and
ALT : 76 U/L Anesthesiologist for Gynecology Division
AST : 15 U/L
Creatinine : 1.68 mg/dl ICU hospitalization
Ureum : 41 mg/dl  Reintubation
 Labuang Baji Hospital / Waode
Radmila
Period June 21st – 24th , 2020
Albumin : 2.32 g/dl  Drips Nicardipine 0.5
Natrium : 122 mmol/L mcg/kgBW/min
Kalium : 2.9 mmol/L
Chloride : 108 mmol/L  Drips Furosemide 1
Urine protein : +2 cc/hour/syringepump
 Transfusion of Human
Thorax X-Ray : Albumin 25 % 100 cc
Lung edema

Treatment Diagnosis :
Post Caesarean section day-0 + Severe
Preeclampsia + Partial HELLP Syndrome + Lung
edema + Hypoalbumin + Electrolyte imbalance

Total Cases :8
Vaginal delivery :5
Lower segment transverse caesarean section :2
Conservative :1
Labuang Baji Hospital / Waode
Radmila
Period June 21st – 24th , 2020

Makassar, June 25th, 2020

Known by :
Chief Resident

dr.Sulistyawan Joko Saputro

Supervisor

Dr.dr. Rina Previana, SpOG (K)