OBSTETRICS & GYNECOLOGY DEPARTMENT

MORNING REPORT (Ward)

Thursday, December 23 rd 2021

Coassistent :
1. Muhammad Fadhil Ridho Rizqullah
2. Sonia Wahyuni Sagita

Department of Obstetrics and Gynecology

RSU Haji Medan
2021
New Patient

1. Mrs. D. 30 y.o, G2P1A0

Diagnosis : SG + IUP (38- 39) wga + breech location + Alive Fetus
Supervisor : dr. A Khuwailid Sp.OG
Planning : C-section

On Thursday, December 23rd 2021, by C-Section born baby boy , BW 2900 gr, BL 50
cm, A/S 8/9/10, Anus (+)
PATIENT 1
Mrs. D, 30 y.o, G2P1A0, Javanese, Moslem, Bachelor, Housewife,
married to Mr. Z, 35 y.o Javanese, Moslem, Entrepreneur, was
admitted to RSU Haji Medan on December 23rd 2021 at 10.00 am
with:

Cc : Preparation for C-section

Review: Patient was referred from Obstetrician with
diagnose SG + IUP (38- 39) wga + breech location + Alive
Fetus and was planed for c-section. History of labor
contraction (+).History of bloodyshow (-). History of
amniotic fluid leakage (-). Micturition and defecation (-).
History of Previous illness :-
History of Medication :-
History of Surgery :-
LMP : 05-4-2021
EDD : 12-1-2022
ANC : Obstetrician 4 times

History of pregnancy :
1. Baby girl, aterm, 3000 gr, normal, midwife, clinic , 29 y.o, healthy
2. Current pregnancy
Present state
Cons: composmentis Anemic : (+)
BP : 110/70 mmHg Icteric : (-)
Pulse : 84x/i Cyanosis : (-)
RR : 20x/i Dypsnoe : (-)
Temp : 36,7°C Edema : (-)

General state : Good

Nutritional state : Obese (BW: 76 kg, BL: 159 cm)
Illness State : Moderate
Generelize State
• Head : Inferior palpebra conj anemic (+), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
• Abdomen: Hepar and Lien not palpable
• Extremities sup/inf : Edema (-), Cyanosis : (-)
 Obstetrical State
• Abdomen : Asymetrically enlarged
• Leopold 1 : 3 fingers below xyphoid processus (34cm)
• Leopold 2 : left
• Leopold 3 : butt
• Fetal movement : (+)
• Fetal Heartrate : 147 x/i, regular
• EFW : 2500-3000 gr
• Uterine Contraction : 1x15”/20’

Gynecological State
Vaginal examination : not performed
 LABORATORY FINDINGS on December 23rd 2021
PEMERIKSAAN HASIL NILAI RUJUKAN
HEMATOLOGI
Darah Lengkap
- Hemoglobin 9.4 11.7 – 15.5 g/dL
- Hematokrit 29.8 37 – 45 %
- Lekosit 12.50 4 – 11 ribu/mm3
- Trombosit 301 150 – 440 ribu/mm3
- Eritrosit 3.96 4.00 – 5.00 juta/uL
- PDW 15.6 9.0 – 13.0 fL
- RDW-CV 16.6 11.5 – 14.5 %
- MPV 8.7 7.2 – 11.1 fL
- PCT 0.263 0.150 – 0.400 %
Indeks Eritrosit
- MCV 75 80 – 100 fL
- MCH 24 26 – 34 pg
- MCHC 32 32 – 36 g/dL
Hitung Jenis Lekosit
- Basofil 0 0–1%
- Eosinofil 7 1–3%
- Neutrofil Segmen 74 50 – 70 %
- Limfosit 14 20 – 45 %
- Monosit 5 4–8%
 LABORATORY FINDINGS on December 23rd 2021

PEMERIKSAAN HASIL NILAI RUJUKAN

Jumlah Total Sel
- Total Lymphosit 1.74 0.58 – 4.47 ribu/uL
- Total Basofil 0.01 0 - 0.1 ribu/uL
- Total Monosit 0.60 0.17 – 1.22 ribu/uL
- Total Eosinofil 0.93 0 - 0.61 ribu/uL
- Total Neutrofil 9.2 1.88 – 7.82 ribu/uL
HEMOSTASIS
- Masa Pembekuan (CT) 5 2 – 6 menit
KIMIA KLINIK
Karbohidrat
- Glukosa Darah Adrandom 85 <200 mg/dL

IMUNOSEROLOGI
Hepatitis Marker
- HBsAg Negatif Negatif
Non reaktif Non reaktif
Transabdominal Sonography
 TAS
- Single fetus, breech location, alive fetus
- Fetal movement (+)
- BPD : 9,76 cm
- AC : 32,9 cm

Conclusion : IUP (38-39) wga + breech location +

Alive Fetus
Diagnosis:
SG + IUP (38-39) wga + breech location + Alive Fetus

Therapy:
• IVFD RL  20 dpm

Planning:
• C-section
• Consult to Anesthesiology Dept.
• Consult to Perinatology Dept.
THANK YOU
 Report of C-section
Born baby boy , BW 2900 gr, BL 50 cm, A/S 8/9/10, Anus (+)

• The patient was laid on the operating table, with IV line and urinary catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine on the abdomen,
and then draped leaving the surgical field exposed.
• Under spinal anesthesia, a Pfanennstiel incision was made, by remove previous scar
continue to cutis, subcuticular and through to the underlying layer of fascia. The fascia was
incised and extended laterally bluntly, and the underlying rectus muscles were dissected.
• Peritoneum was identified. The peritoneum was elevated using clamp and entered using
Metzenbaum scissor with care for the underlying organ, and extended superiorly and
anteriorly with careful visualization of the bladder.
• The lower uterine segment was identified. A low cervical incision in the uterus performed
until sub endometrium layer. Endometrium penetrated and widened bluntly.
• By luxating the head, born baby boy, BW 2900 gr, BL 50 cm, A/S 8/9/10, Anus (+). The umbilical
cord was clamped in two places and cut in between. The placenta was born with fundal pressure
and traction on the umbilical cord.
• Uterine cavity was cleaned with gauze.
• Uterus was sutured by continuous interlocking stitches in two layer.
• Both Tuba and Ovarian was within no abnormality
• Bleeding was controlled
• Abdominal cavity was cleaned from blood and stoll cell.
• Peritoneum sutured continuously, muscle approximation using simple suture and fascial closure
using continous suture.
• Subcutaneous layer was sutured with simple suture and skin was sutured with subcuticular
suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Mother was stable the after the operation.
• Estimated blood loss ± 200 cc.
Therapy:
• IVFD RL 30 dpm
• Ketorolac inj 1 amp/8 hours IV
• Cefriaxone 1 g/8 jam IV

Plan :
• Monitoring vital sign, uterine contraction and vaginal bleeding
THANK YOU