+

LAPORAN JAGA OBGYN

Rabu, 5 Juni 2019 – Kamis, 6 Juni 2019
RSUD SANJIWANI GIANYAR
Tim jaga A: Igam, Yogi, Dindi
 RESUME KASUS JAGA
Rabu, 5 Juni 2019 – Kamis, 6 Juni 2019
(Pkl 07.00 – 07.00 WITA)
KASUS OBSTETRI
A. Kasus

1. Kasus Baru
• Fisiologis : 1 Kasus
• Patologis : 0 Kasus

2. Kasus Sisa
• Fisiologis : 0 Kasus
• Patologis : 0 Kasus

Total Kasus : 1 Kasus

B. Partus
– Partus Fisiologis : 2 Kasus
– Partus Patologis : 0 Kasus
Total Partus : 2 Kasus
Lain-Lain : 0 Kasus

Kasus Ginekologi : 1 Kasus

 KASUS GINEKOLOGI
Rabu, 5 Juni 2019 – Kamis, 6 Juni 2019
(Pkl 07.00 – 07.00 WITA)

1. SRI, 56th, 520653, Ca. ovarium std IIIB (residif) + post TAH - BSO -
omentektomi adhesiolisis (6/8/18) + pasca kemoterapi paxus
carboplatin VI seri (3/1/19) + paska kemoterapi doxorubicin
carboplatin II seri (18/5/19) + anemia ringan (9,78) —> perbaikan KU
(pro kemoterapi seri ke III di RSUP Sanglah bila KU optimal) (IGAM)
 OBSTETRIC CASE REPORT
DUTY ON : JUNE 5 th 2019 – JUNE 6th 2019
LUL, 35 th (617657) Dindi
ASSESS PLAN OF
NO DATA BASED
MENT CARE

1 Anamnesis :
Patient complained labor pain (+) since 08.00 am (05/06/19), watery
vaginal discharge (+) since 11.00 am (05/06/19), fetal movement (+)
good.

LMP : 15/09/2018
EDD : 22/06/2019
Marital status : married

Obstetric history :
1. 2009, aterm, SC, male, 3000g
2. Current pregnancy

Menarche : 14 YO
Duration : 4 DAYS
Volume : + 50 CC
 OBSTETRIC CASE REPORT
DUTY ON : JUNE 5 th 2019 – JUNE 6th 2019
LUL, 35 th (617657) Dindi
PLAN OF
NO DATA BASED ASSESSMENT
CARE

2. Physical Examination:
Weight/Height : 55 kg / 158 cm  BMI: 22,5 kg/m2
• Present state :
GCS: E4V5M6
BP : 120/70 mmHg RR : 20x/minute
HR : 80x/minute Tax : 36,50C
• General state :
Head: Eyes : Anemic (-/-)
Thorax : Cor : S1 S2 normal, regular, murmur (-)
Pulmo : Vesiculer +/+, ronchi-/-, wheezing -/-
Abdomen : ~ Obstetric state
Extremities: Warm +/+
+/+
• Obstetric state :
Abdomen :
Fundal Height 29 cm ~ EFW 2790 gram
Uterine contraction (+) 3-4x/10’~40-45’’, FHB: 148 bpm
Vagina (5/6/2019) pk 11.15 pm
Cervical dilatation complete, amniotic membrane (-)
Head palpable, left occiput anterior, Hogde III+
Small parts/umbilical cord unpalpable
 OBSTETRIC CASE REPORT
DUTY ON : JUNE 5 th 2019 – JUNE 6th 2019
LUL, 35 th (617657) Dindi
N0 DATA BASED ASSESSMENT PLAN OF CARE

3. Laboratory Result G2P1001 37 weeks 4 day, Intervention :

-WBC: 12,55 - HCT: 29,6 singletone/life, LMR 1. Expectative pervaginam
-HGB: 9,5 - PLT: 213 ( Previous SC 1x ), mild Target: Well born baby and
- BT/CT: 2’00”/8’00” anemia, 2nd stage of mother in good condition
labor

EFW: 2790 gr
SPR: 2/LRP

Lead to bear down

At 11.25 pm born baby female,

2600 g, 48 cm, AS 8-9,
congenital anomaly (-)

Active management 3rd stage of

labor at 11.30 pm born placenta
3rd stage of labor completely.
 RESUME KB

KB POST PARTUM
– IUD : 0 KASUS
– SUNTIK : 0 KASUS
– MOW : 0 KASUS
– KONDOM : 0 KASUS

JUMLAH POST PARTUM : 0 KASUS

JUMLAH POST KURETASE : 0 KASUS
THANK YOU