Resident : 1. dr. Ria Suci Nurlianti2. dr. Vivi Yovita3. dr. Ormias Pratama

Obstetri Emergency Team Duty Report Tuesday, February 20th 2015

Supervisor :dr. Riza Hendrawan Nasution, Mked(OG), Sp.OG

Department of Obstetric and GynecologyMedical Faculty of Universitas Sumatera Utara

Pringadi General Hospital2015

Prior patient : - patientNew patient : 1 patient

1. 6 Mrs. I, 33 yo, G3P1A1Diagnosis : Secundigravida + Intra Uterine Pregnancy (36-38) WGA + Head Presentation + Alive Fetus + in labor

Planning : monitoring vital sign, uterine contraction and Fetal heart rate Monitoring labor progress → spontaneus vaginal delivery

1. Mrs. I, 33yo, G3P1A1, Bataknese, Christian, Senior high school, housewife, married to Mr. D, 35 yo, Bataknese, Christian, Senior high school Enterpreneur. The patient was arrived in Pringadi Hospital ER, on february 20th 2015 at 9.00 am:

CC : Uterine contractionH : it was felt by the mother since 05.00 am (20/2/2015), history of bloody show (-),

history of rupture of amniotic fluid leakage (-). Micturition (+) and Defecation (+) in normal limit

Previous illness : (-)Previous medical history : (-)

LMP : 25- 5 - 2014EDD : 2 – 3 - 2015 ANC : Midwife 8x

History of labor1.boy, aterm, 2800gr, SVD, Midwife, clinic, exitus in 1 yo2.This pregnancy

Present StateConsc : compos mentis Anemic : (-)BP : 110/70 mmHg Icteric : (-)HR : 80 x/i Cyanotic : (-)RR : 20 x/i Dypsnoe : (-)Temp : 36,5°C Oedema : (-)

General State

Head : Conj Palpebra inferior anemic(-)/(-), sclera icteric (-)/(-)

Neck : in normal limit

Thorax : Lung : Respiratory sound: Vesiculer (+)/ (+)

Additional sound: Wheezing(-)/(-), Rales (-)

Cor : S1/S2 reguler, murmur (-), gallop (-)

Extremity : oedema (-)/(-) pretibial, KPR (+)/(+) N

Obtetrical State

Abdomen : Symmetrically enlarged

Fundal Height : 3 fingers above Proc. Xypoideus

Tense part : Left

Lowest part : head

FM : (+)

Uterine cont. : 2 x 10”/10’

FHR : 144 x/I

EFW : 2600- 2800 gr

USG TAS

USG TAS

USG TAS• Singleton, Head presentation, Alive• FM (+), FHR (+)• BPD : 9.03 cm• FL : 7.38• AC : 33.7 cm• Amniotic fluid within normal limit• Placenta corpus anterior Conclusion : IUP (36-38)wga + Head presentation + Alive

LABORATORY FINDINGS

Hb : 9,3 N: 12-14 gr/dLLeucocyte : 15.800 N: 4000-11000/uLHematocrit : 29,30 N: 36,0-42,0/%Platelet : 279.000 N:150.000-400.000/uL

PT : 12 C: 14,1INR : 0,95 C :1-1,3APTT : 40,5 C : 32,7

Dx : Secundigravida _+ IUP (36-38)wga + Head Presentation + Alive + Inlabor

Therapy :- IVFD RL 20 dpm

Planning : • monitoring vital sign, uterine contraction and Fetal heart rate• Monitoring labor progress → spontaneus vaginal delivery

Partograf

Spontaneous Vaginal Delivery with EV report

• Mother laid in ginecology table with i.v. line installed properly,• in an adequate contraction the head was forward and backward in vaginal

inlet. And then persist. (Media lateral episiotomi was done)• Vakum cup was installed as closed as posible to the fontanella, vakum cup

evaluation : no mother part was squeezed by vacum• Vacum pressure was increased, started from 0.2, 0.4, 0.6 kg/ cm2, evaluation of

the birth canal squeezed• In the next adequate contraction, controlled traction was done, in the same

direction with the birth canal and then born baby head, the cup was open and born all the body. And then born baby boy, BW : 2800 gr, BL :47 cm, AS 8/9, anal (+).

• With PTT, plasenta was born, impression complete.• Explore vaginal canal found second grade laceration and repaired.• Mother condition after vaginal delivery is stabil.

• Th/ - IVFD RL → 20 bpm• Inj. Ceftriaxone 1 gr/12 hours• Metronidazol drip 500 mg/ 8 hours

Laboratory finding after SVD with EV

Hb : 9,9 N: 12-14 gr/dLLeucocyte : 30.600 N: 4000-11000/uLHematocrit : 31,10 N: 36,0-42,0/%Platelet : 281.000 N:150.000-400.000/uL

THANK YOU