CASE NO

Identity
Patient Husband
Name : Mrs. G Name : Mr. S
Age : 29 years old Age : 31 years old
MR No : 01056033 Education : S1
Education : S1 Occupation : Employee
Occupation : Employee Address : Limau Manis
Address : Limau Manis
Admission Date : 08/02/2021
Admission
Origin Preparation for surgery Diagnosis Plan
date
Mrs. G, 29 years old, MR 01056033

Date : Pulmonologist Consultation : • G2P0A1L0 38-39 week of Emergency CS

08/02/2021 Referral from : A/ susp covid 19 term parturient latent
Polyclinic RSUP M Djamil P/ phase of first stage + LBP
Time : Tcm isotermal 1x —> waiting the due to HNP lumbalis
12.57 Diagnose : result —> cito lscs • Fetal alive, singleton, head
Acc admission in yellow zone for presentation
DPJP : G2P0A1L0 38-39 week swab pcr 1x
HSA of term parturient latent Azitromycin 1x500 mg
phase of first stage + Vit C 2x250 mg
LBP due to HNP lumbalis Zinc 2x20 mg
N acetyl cistein 2x200 mg

Perinatology Consultation :
P/ will accompany during the
operation
 Anamnese Examination ADDITIONAL EXAMINATION
Anamnese GA Cons BP HR RR T Ultrasound
Patient reffered from Polyclinic M djamil General Hospital with diagnose G2P0A1L0 Mdt CM 127/88 88 20 36.9 •38-39weeks of pregnancy according to fetal
38-39 week of term parturient latent phase of first stage + LBP due to HNP biometrics
lumbalis. Patient was diagnosed with lumbar HNP since 2019. A complaint of Body height : 150 cm •Fetal alive, singleton, head presentation
back stiffness that has been felt since 2007. patients did not routinely Body weight : 70 kg (before pregnant : 55 kg)
control to ortophaedic. Patient Patient felt pain from the waist to the groin BMI : 24,4 kg/m2 (normoweight) •CTG: 1st Catgory
UAC : 26 cm
at polyclinic then referred to PONEK. Eye : Conjunctival wasn‘t anemic, sclera wasn’t icteric •Ro Thorax:
•Pain from the waist to the groin (+) since 2 hours ago Thorax : Cor and pulmo in normal limit •Pneumonia
•Bloody show from the vagina (+) since 2 hours ago
•Fluid leakage from the vagina was (-) Abdomen Laboratory 08/02/2021 :
•Massive bleeding from the vagina was (-) Inspection : Hb: 11,2
•Amenorrhea since 9 months ago Abdomen seems accordance to term pregnancy. Leu : 9.030
•LMP: 16-5-2020 EDD : 23-2-2021 Hyperpigmentation (+), striae gravidarum (+), cicatrix (-) Tromb: 189.000
•Fetal movement was felt since 4 months ago Palpation : Ht: 33
•Prenatal care to obstetrician 7th, on 2,3,4,5,6,7,8 month pregnancy Leopold Erit: 3,95
•No. complain of nausea, vomiting, and vaginal bleeding during early pregnancy L1: Uterine fundal palpated 3 fingers below proc xyphoideus. Diff Count : 0/1/-/76/16/7/-
•No. complain of nausea, vomiting, and vaginal bleeding during late pregnancy A big soft nodular mass was palpated PT : 9.2
•Menstruation history : menarche at 14 years old, irregular cycle, once every L2: Large and resistance structure was palpated on the left APTT : 24.4
month, which last for 5-7 days each cycle, with the amount of 3-4 times pad side. Numerous small structure were palpated on the right INR : 0.86
change/day, without menstrual pain side. D dimer : 2905
•low back pain radiating to the legs (+), difficulty walking (+) L3: A round hard mass was palpated, fixated Total protein : 6.1
• The patient is known to have had lumbar HNP since 2019, a complaint of back L4: convergent Albumin : 3.3
stiffness that has been felt since 2007 UFH : 37 cm ; UC : 1-2x/10-15’/moderate ; EFW: Globulin : 2.8
•Fever (-), cough, cold (-), sore throat (-), shortness of breath (-), Auscultation : FHR : 143-153x/I Bilirubin total : 0.2
•History of travel from or to other city (-) History of contact to COVID Bilirubin direk : 0.1
confirmed patient (-) Genitalia : Bilirubin indirek : 0.1
V/U within normal limit, vaginal bleeding (-) SGOT : 14
Hystory of marriage : once, 2019 SGPT : 8
History of Pregnancy/Abortion/Delivery : 2/0/1 VT: 1-2cm opening, posterior portio, 90% effacement, Kalsium : 8.8
•1. 2020 (April) miscarriage at 3 months of gestation, not curettage palpable sagittal suture transversely in hodge I-II Ureum : 10
•2. Present Creatinin : 0.6
inner pelvic size ​ GDS : 95
Promontorium cannot identified​ Na/K/Cl : 140/3.6/110
Inominate cannot identified ​ HbsAg : NR
Anti HIV : NR
Pelvic Sidewalls was straight​​
Sacral bone was smooth and well curved​​
Ischial spines was not protrude​​
Sacrococcygeal bone was mobile​​
Pubic arch > 90˚​​
​
Outer pelvic size: ​
 DATE DIAGNOSIS OUTCOME

08/02/2021 Preoperative Diagnosis : Female baby was born by LSCS at 16.15

•G2P0A1L0 38-39 week of term parturient latent phase of BW : 3500 gram
Operation: first stage + LBP due to HNP lumbalis BL : 49 cm
LSCS •Fetal alive, singleton, head presentation A/S : 8/9

Time : Plan •Placenta was born with mild traction on the umbilical cord, placenta size 16 x
16.00 WIB LSCS 15 x 2,5 cm, weight 450 gram
•Bleeding during operation approximately 200 cc
DPJP : Instruction
HSA Control VS, UC, FHR, delivery sign Postoperative Diagnosis
IVFD RL 20 dpm P1A1L1 post LSCS oi LBP due to HNP lumbalis
Mother and baby were in care
Process
G2P0A1L0 38-39 week of term parturient latent phase of first Plan
stage + LBP due to HNP lumbalis —> LSCS Post operative treatment

Instructions
•Control GA, VS, contraction, vaginal bleeding
•IVFD RL drip Oxytocin 10 IU : Methylergometrin 0,2 mg 28 dpm
•Inj. Ceftriaxone 2 x1 gram
•Pronalges supp (if needed)
•Blood laboratory check up 6 hours post operation
•Admission in yellow zone
•Swab PCR
Admission Letter
USG PONEK
USG PONEK
Fetal alive singleton intra uterine, head presentation
Fetal movement and activity was good
BPD : 9,4 cm AC : 34,1 cm
FL : 74,33 cm HC : 35,4cm
EFW : 3446 gram AFI : 11,2 cm
FHR : 157 bpm
Placenta was implanted in anterior corpus maturation grade II-III

Impression :
• Gravid 38-39 weeks based on biometry
• Fetal alive singleton intra uterine, head presentation
CTG PONEK

Baseline : 140 bpm

Variability : 5-20 bpm
Acceleration : (+)
Deceleration : (-)
Fetal movement : (+)
Contraction : (-)
Impression : 1st Category
Laboratory
Ro Thorax
Impression : Pneumonia
Pulmonologist Consultation :
A/ susp covid 19
P/
Tcm isotermal 1x —> waiting the result —> cito lscs
Acc admission in yellow zone for swab pcr 1x
Azitromycin 1x500 mg
Vit C 2x250 mg
Zinc 2x20 mg
N acetyl cistein 2x200 mg
Perinatology Consultation :
P/ will accompany during the operation
Operation Report
Operation Report
• Patient on supine position under spinal anaesthesia
• Antiseptic and septic procedure was performed
• Pfannenstiel incision was performed, layer by layer was opened until peritoneal
• Semilunar incision on uterine low segment was performed
• Female baby was born by head extraction , BW : 3500 gram, BL : 49 cm, A/S : 8/9
• Placenta was born with mild traction on the umbilical cord, placenta size 16 x 15 x 2,5 cm, weight
450 gram
• Double layer closure then performed
• Abdomen was closed layer by layer
• Skin closed by subcuticular closure
• Bleeding during operation approximately 200 cc
Lubchenko Curve
 Follow up 2 Hours Post Op – 08/02/2021 at 19.30 WIB
S/ Post operative pain (+) Fever (-) Vaginal bleeding (-)

O/
GA Cons BP HR RR T
Mdt CM 110/70 82 20 36.8

Abd : Operation wound closed by verband. Uterine fundal palpated 2 fingers below umbilical, contraction (+)
Genitalia : V/U normal. Vaginal bleeding (-)

A/ P1A1L1 post LSCS oi LBP due to HNP lumbalis, puerperium day 1

Mother and child were in care
P/ • Control GA, VS, UC, VB
• IVFD RL + oxytocin : metergin 1: 1 -> 28 gtt
• Ceftriaxone inj 2 x 1 gram IV
• Pronalges supp II if needed
• swab PCR
• laboratory check 6 hours post op
• Admission in yellow zone
Post Operative Laboratory
Thankyou