mr minggu 11012015

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Duty Report RSUDZASunday, January 11th 2015

Supervisor:

dr. Tg. !uspa De"i, #$gyn

Resident:

%arrah

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Reporting

2 &esarean Se'tion

1 (agina) De)iveries

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1. Spontaneous Delivery

Farrah/dr.Puspa, Obgyn

Mrs. M, 38 yoMR 13!"8!#"

*+!2 ter pregnan'y,sing)eton )ive headpresentation, !R#- 1 dayA%/ , unripe 'ervi !S1

Process:

CTG reassuring Inductionwith modality misoprostol 4x50mcg po after 1stmisoprostolrippened 'ervi acceleration with oxytocyn5iu/R 500 cc titration o$s. 2

hours acti!e phase of la"or #$cm% o"s& ' hours'ndphase ofla"or

$%&: Re3erred $y #$gyn

4orn a)e $a$y 200, 67 ', AS89104S +7;60 "ga

&)ear s'anty anioti'

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#. &esareanSe'tion

/&D 10 and 8

#72.1

Z+.0

#62.0

Z+0.0

/&D 8

6.1


Doe to $ree'h presentation!riigravida

Mrs. DM, #) yo$RM* 13!"8!+#

*1 ter pregnan'y, $ree'hpresentation !R#- hours,

#)igohydranios, in )a$or

$%&* Re3erred $y #$gyn

4orn 3ea)e $a$y 2500, 67 ', AS8910

4S +7;60 "g

%! : /UD transesarean

-other and $a$y are in good'ondition, Rooing in

Pro'edures

&ase Out'o(e

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Pro'edure &ase Out'o(e

3. &esareanSe'tion


Mrs. $, 38 yo$RM* 13!3"!"

*+!1A1 60;61 "ga,sing)eton )ive headpresentation, !revious &;Se'tion 1 /DT 7 years,=atent phase o3 )a$orProcess:

CTG reassuring > + 'o"ser!ation $ hours > + ',"ater $roe o"ser!ation( hours > + ', his 29109+0?3ai)ed o3 (4A& de'ided'esarean se'tion

$%&* &ae $y her o"n "i))

#@ !R#&SS . . .

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han- ou

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Mrs. M, 38 yo

*+!2 ter pregnan'y, sing)eton )ive head presentation, !R#- 1 dayA%/ , unripe 'ervi !S1

11/1/#1", .

&hie3 'op)aint : Bater $roe sin'e 1 day $e3ore adissionCistory : Aditted 8 onths pregnan'y. =-! 3orget. A@& regu)ar)y at id"i3e,

US eaination ;. The patient 'op)aint "ater $roe sin'e 1 day $e3oreadission. &ontar'tion ;, $)oody sho" ;. %uor a)$us ;, 'aries dentis ;.A'tive 3eta) oveent.

%ai)y !revious Cistory o3 /))ness * Astha, Cypertension, heart disase, D-,A))ergy denied-enstrua) history : enar'he 1+ yo, regu)ar)y, days, + pads9day,disenorrhea ;-arried history: 1, 22 yo

%! history: D-!A

#$stetri' history :

1. 4oy,15 yo, +200 gra, nora) de)ivery, $orn at id"i3e, no" hea)thy

2. *ir), 8 yo, +600 gra, nora) de)ivery, $orn at id"i3e, no" hea)thy

+. This pregnan'y

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Physi'al 0a(ination *3u))y a)ert, 4! 110970 Cg ! : 77 R : 17 T : +,60&1+ '97 g 4-/ 25,

2eneral Status *yes : no anei' 'onEungtive, no i'teri' s')era

Ceart : S1;S2 regu)er, no urur, no ga))op

!u)o : vesi'u)ar, no rai)s, no "heeFing

A$doen : Gua) to pregnan'y

treity: "ar, no edea

Obstetri'al Status *

%C +2 ', %B 2865 gra, right $a', head presentation, 595, %CR 165dp. C/S /rregu)ar

/ : (9U "n)

/o : Sooth portio, open #U,

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aboratory*

C$ : 11,2 gra9d) 12;16 gra9d)

=eu'o'yte : 10.009u) 6100;10500 9u)

Tro$o'yte : 2+0.000 9u) 150000;600000 9u)

Ct : ++ L 60;55 L

Rando $)ood g)u'ose : 87 g9d)

4T : 2? 1;M

&T : M 5;15M

&on')ution : "ithin nora) )iit

&T* :4ase)ine : 165$p(aria$i)ity : 5;25 $pA''e)eration : H

2910?De'e)eration : ;Cis : ;%eta) oveent : H&T* &ategory 1

US :4!D : 78 %B : 2700graA& : +10 %CR : H

%= : 6 A%/ : !)a'enta at anrerior 'orpus&on')ution: Ter pregnan'y, )ivehead sing)eton $a$y, diinishedanioti'

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A: *+!2 ter pregnan'y, sing)eton )ive head presentation, !R#- 1day A%/ , unripe 'ervi !S1

! : R. D9 #$servation o3 vita) sign, 'ontra'tion,%CR9hour?

#$servation 3or 'ord 'opression

R. Th9 !)an to vagina) de)ivery/nitia) p)an repenned 'ervi indu'tion "ith 'ervi'a)rippening "ith isoprosto) 650 'g po A4 proN)ais: /nE 'e3triaon 2 gr926 Ea

Informed consent

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A: *+!2 ter pregnan'y, sing)eton )ive head presentation, !R#- 1day A%/ , unripe 'ervi !S1

Diagnosti' !)an

#$servation o3 vita) sign, 'ontra'tion,%CR9hour

#$servasion 'ord 'opression and intrauterin in3e'tion

Therapy!)an

!)an to vagina) de)ivery/nitia) p)an repenned 'ervi indu'tion "ith'ervi'a) rippening "ith isoprosto) 650 'gpo A4 proN)ais: /nE 'e3triaon 2 gr926 Ea

du'ation !)an

p)aining a$out patient 'ondition and p)an o3diagnosis and p)an o3 therapy 3or patients and3ai)y

4reast i) and 'ontra'eption otivation

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January 11th2015

1. 4ib

Repenned 'erviindu'tion "ithisoprosto) / 50 'g po.Reeva)uate hours )ater07.00

07.00 wib

S/Contraction continuously (+), fetal

movement (+),

O/

GC : good, CM, B : !!"/#" mm$g,

% : &&'/mnt, %% : '/mnt, em* :

-C,

General status : .nl

Ostetric status :

0$% !1" *m, contraction '/!"2/"34: normal 5/65: soft *ortio, a'ial, effacement 7"8, cm, amnion memranes (9), ead$ 4944

;/

*+!2 ter pregnan'y, sing)eton)ive head presentation, !R#- 1day A%/ , unripe 'ervi !S1,

ripened 'ervi/

lan to vagianl delivery

o'ytocin 7 46 in 7"" cc %< egin at

&m46/mnt titrated 1m46/mnt every "2

until ade=uate contraction

%eevaluate ours after ade=uate

contraction

).3 4ib

Rea'h adeGuate 'ontra'tion6910?960O at 12 drop9ntReeva)uate in + hours

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January 11th2015

+. 4ib

S9&ontra'tion ore regu)arH, 3eta) oveent H,#9*& : good, &-, 4! : 11090Cg, !R : 79nt, RR :209nt, Tep : +.5&,*enera) status : "n)#$stetri' status :

%CR 1+5 $p, 'ontra'tion6910?960O/: nora) (9U(T: thin portio, anterior,eIa'eent 5L, 7 ',anion e$ranes ;,sa)) 3ontane) in rightanterior, head C //;///A9

*+!2 ter pregnan'y,sing)eton )ive headpresentation, a'tive phaseo3 )a$or!9!)an 3or vagina) de)iveryReeva)uate 2 hours )ater22.00

11. 4ib

S9-other "ants to $ear do"n,3eta) oveent H,#9*& : good, &-, 4! : 11090Cg, !R : 779nt, RR :229nt, Tep : +.+&,*enera) status : "n)#$stetri' status :

%CR 150 $p, 'ontra'tion6910?950O/: nora) (9U(T: 'op)ete 'ervi'a) di)atation ,e$rane ;, ')ear anioti'

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Su((ary/!+ !ost (agina) De)ivery

"ith /ndu'tionAppropriate 3orgestationa) age

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!artogra3

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han- ou

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Mrs. DM, #) yo*1 ter pregnan'y, $ree'h presentation !R#- hours, #)igohydranios, in)a$or

11/1/#1" 1+.3 p(

&hie3 'op)ain : &ontra'tion sin'e 6 hours $e3ore adissionR!S : !atient aditted 8 onth pregnan'y, =-! Apri) 2016 ter pregnan'y.

A@& regu)ar)y to id"i3e and #4*P@, )ast u)trasound 1 "ee ago "ithresu)t $a$y in good 'ondition, $ree'h presentation. &ontra'tion sin'e 6hour $e3ore adission. Bater $roe danied, and $)oody dis'harge H.)eu'orrhea H, se))y ;, it'hy ;. A'tive 3eta) oveent.

%ai)y previous i))nes : Astha, Cypertension, heart disease, D-, A))ergydenied

-enstrua) diary: enar'he 12 yo, regu)ar)y, day, disenorrhea denied-arried history: 1 , 2 yo%! history: ;

#$stetri' history:1. &urrent pregnan'y

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Physi'al ea(ination

*enera) 'ondition: *ood, &- "eight: 0 g height: 155 ' 4-/ : 25

4! 120970 Cg, !u)se 77 $p. RR 20 9inute, Tep. +,6Q &

2eneral status *ye : @o Anei' 'onEun'tiva, no i'teri' s')era

Ceart : /;// regu)er nora) heart sound, no urur, no ga))op

=ung : vesiu)er )e3tright, no "heeFing, no rai)s

A$doen : Gua) to pregnan'y

treity : "ar etreity, edea ;

Obstetri' status *

%C: +0 ', %B: 25 gr, 'ontra'tion 2910?9+5O, %CR 165 $p

/ : v9u 'a), no a'tive $)eeding

/o : sooth )ivid portio, open ostiu,

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aboratory*

C$ : 12,+ gra9d) 12;16 gra9d)

=eu'o'yte : 8.2009u) 6100;10500 9u)

Tro$o'yte : 220.000 9u) 150000;600000 9u) Ct : +6 L 60;55 L


4T : 2? 1;M

&T : M 5;15M

&on'lution * 5$

&2 *4ase)ine : 165$p(aria$i)ity : 5;25 $pA''e)eration : H

2910?De'e)eration : ;Cis : H 2910%eta) oveent : H&2 'ategory 1

6S2 *%CR H, sing)e, $ree'hpresentation4!D : 80 %B : 2700graA& : +20 A%/ : 10%= : 6!)a'enta on anterior 'orpus7sses(ent * sing)eton )ive$ree'h presentation

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A: *1 ter pregnan'y, $ree'h presentation !R#- hours,#)igohydranios, in )a$or

Diagnosti' !)an

#$servation vita) sign, 'ontra'tion and%CR9hour

#$servation o3 'ord 'opression sign andintrauterin in3e'tion

Therapy!)an

ergen'y &;se'tion/n3ored 'onsent&onsu)t to Anastesio)ogist&onsu)t to !erinato)ogy departent

du'ation !)an

p)aining a$out patient 'ondition and p)an o3diagnosis and p)an o3 therapy 3or patients and3ai)y

4reast i) and 'ontra'eption otivation

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#peration reportJanuary, 11th2015, 21.00;22.00&esarean Se'tion due to $ree'h presentation on priigravida,

1. !atient "as "ithin supine position in spina) anesthesia

2. Asepti' and antisepti' on surgery part "ith povidon iodine

+. !3annenstie) in'ision around the o)d s'ar

6. A$doina) "a)) "as opened )ayer $y )ayer, no adhesion

5. A3ter peritoneu "as opened, there "as a gravid uterus ter pregnan'y

. /dentiN'ation )o"er uterine segent. =US "as in'ised sharp)y, penetrated

$)unt)y, etended sharp)y. 4y )uated the $ree'h, $orn 3ea)e $a$y 4B +500 gra, 50 ', AS 8910

7. Anioti'

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Su((ary/!1 !ost &esarean Se'tiondoe to $ree'h presentation

on priigravidaAppropriate 3or gestationa)age

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han- ou

M $ 38

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Mrs. $, 38 yo*+!1A1 60;61 "ga, sing)eton )ive head presentation, !revious &;Se'tion 1/DT 7 years, =atent phase o3 )a$or11/1/#1" pu-ul 1). 4ib

&hie3 'op)ain : 'ontra'tion sin'e 5 hours $e3ore adission 'ae a)oneR!S : !atient aditted 8 onth pregnan'y, =-! 0+90692016 60;61 "ga .A@& regu)ar)y to id"i3e, #$gyn. U)trasound +. =ast US + "ee ago said the$a$y is good 'ondition. !atients 'op)aint 'ontra'tion sin'e 5 hours $e3oreadission. Bater $roe denied, $)oody dis'harge H. A'tive 3eta) oveentH.

%ai)y previous i))ness : Astha, Cypertension, heart disease, D-, A))ergy"as denied

-enstruasi diary: enar'he 1+ yo, regu)ar)y, day, disenorrhea denied-arried history: 1, 27 yo%! history: pi))

#$stetri' history:1. 4oy, 7 y, +800 gra, S& e' 3ai)ed indu'tion, RSUD ZA hospita)2. -es'arriage, 2 ont pregnan'y, 'urretage histiry ;+. &urrent pregnan'y

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Physi'hal ea(ination

U: *ood, &- B: 70 g C : 15 ' 4-/ +2,8

4! 110970 Cg, CR 70 9-inute. RR 20 9-inute, T +,6Q &

2eneralis Status *ye : @o aneis , no iteri

&or : 4J /;// regu)ar, no urur, no ga))op

!u)o : (esiu)er right)e3t, no "heeFing, no ra)es

A$doen : n)argent eGua) "ith pregnan'y, appear operation

s'artreity : "ar a'ra), no oedea

Obstetri' state*

%unda) height +6 ', )e3t $a', head presentation, %B: +255 gr,'ontra'tion H 2910?9+0O, %CR 150 dp,

/ : (9U "n), a'tive $)eeding ;

(T : so3t portio, aia), eI 50, + ', anion e$ranes H, head C /;//

&lini'al pelvi(etri*

!roontoriu no pa)pa$)e, D/ 8.5 ', )inea innoinata 19+;19+,Sa'ru ona3, Spina proinent, A! 80K adeGuate pe)vi'

&T*

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aboratory*

C$ : 11,2 gra9d) 12;16 gra9d)

=eu'o'yte : 12.2009u) 6100;10500 9u)

Tro$o'yte : 215.000 9u) 150000;600000 9u)

Ct : +1 L 60;55 L


4T : +? 1;M

&T : 7M 5;15M

Assesent : "ithin nora) )iit

&T* :4ase)ine : 150$p(aria$i)ity : 5;25 $pA''e)eration : H

2910?De'e)eration : ;Cis : H 2910?%eta) oveent : H&T* 'ategory 1

US* :4!D : 86 %CR HA%/ : 10 %B : +600graA& : +65%= : 5!)a'enta on 3unda)7sses(ent * sing)eton )ive$ree'h presentation

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A9 *+!1A1 60;61 "ga, sing)eton )ive head presentation, !revious &;Se'tion 1 /DT 7 years, =atent phase o3 )a$or

!9 R. D9 #$servation o3 vita) sign, 'ontra'tion,%CR9hours

#$servation RU/ sign

R. Th9 /nitia) p)an 3or vagina) de)ivery "ith (4A& Reeva)uate 7 hours )ater 05.00

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January 12th2015

1. 4ib

S9 Bater $roe H, &ontra'tionH, 3eta) oveent H#9*& : good, &-, 4! : 120970Cg, !R : 779nt, RR :229nt, Tep : +.5&,*enera) status : "n)#$stetri' status :%CR 160 $p, 'ontra'tion

+910?960O/: nora) (9U(T: so3t portio, aia), eI 50, +', anion e$ranes ;, headC /;//A9*+!1A1 60;61 "ga, sing)eton)ive head presentation, !revious&;Se'tion 1 /DT 7 years,

=atent phase o3 )a$or!9#$servation o3 vita) sign,

'ontra'tion,%CR#$servation RU/ sign!)an vagina) de)ivery "ith (4A&,Reeva)uate hours )ater 1.00

). 4ib

S9 -oS9 Bater $roe H, &ontra'tionH, 3eta) oveent H#9*& : good, &-, 4! : 11090Cg, !R :869nt, RR :229nt, Tep : +.5&,*enera) status : "n)#$stetri' status :

%CR 166 $p, 'ontra'tion6910?965;50O/: nora) (9U(T: (T: so3t portio, aia), eI 50,+ ', anion e$ranes;, head C /;//A9*+!1A1 60;61 "ga, sing)eton)ive head presentation, !revious

&;Se'tion 1 /DT 7 years,=atent phase o3 )a$or, 3ai)ed(4A&!9!resarean se'tion

#@ !R#&SS..

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han- ou

mr minggu 11012015

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