1. Mrs.Saniti /36 y.

o/
hospitalized october 15th 2014 /11.45 WITA
G4P2012 37-38 WoP+ head presentation + chronic
hipertention superimposed severe preeclampsia+
secondary old primi + not in labor + EFW 3200 gram
chief complain : dizziness
patient was referred from policlinic Ulin Hospital with diagnosed
G4P2012 37-38 WoP+ head presentation + chronic hipertention
superimposed severe preeclampsia+secondary old primi + not
iprimn labor + EFW 3200 gram. patient told that she have
dizziness since 3 hour admission. Nausea (-), vomit (-), cloudy
eyesight (-), uterus contraction (-), watery discharge (-), bloody
show (-)
History of illness: HT (+) DM (-) Alergic (-)
History of family illness : DM (-), HT (-)
History ofmarriage : 1x,18 years
History of contraception: injection for 3 month
History of labor : 1. 1997/abortus/12 weeks
2.1998/midwife/aterm/female/3100 g/spontaneous
3. 2004/hospital/aterm/male/3300g/spontaneous

Status Present:
G C S: 4-5-6
A/I/C/D (-/-/-/-)
BP
: 160/100 mmhg,
RR
: 18x/menit
: vesikuler +/+
Rh -/Status Obstetri:
LI
LII
LIII
LIV
VT: (-)/ lowest

HR : 88 x/m
Temp : 36,7

C/P

: FH 31 cm
contraction : (-)
: punggung kanan
FHR
;11 -11-13
: letak kepala
: belum masuk PAP
part of fetus still high/PS 2

A )G4P2012 37-38 WoP+ head presentation + chronic hipertention

superimposed severe preeclampsia+ secondary old primi + not
in labor + TBJ 3200 gram

P)
O2 masker 6-8 lpm
Infus + DC
Complete laboratory check
MgSO4 regiment
Nifedipine 3x10 mg
Metil dopa 3x250 mg
NST if the result good Pro pervaginam
termination and ripening misoprostol 4x50 mg/6
hours until PS 5
If PS 5 pro OD
Fluid balance
Observation present status /VS/FHR/impending
eklampsia sign /inpartu sign

USG Policlinic october 15 th 2014

BPD: 91,8 cm ~ 36/37
AC: 340,8 ~ 39
HC : 310 ~ 36/37
Plac. Corpus anterior/III/enough
EFW: 3270 gram
Visite dr.Renny Sp.oG
Pkl. 12.00 WITA
Advise:
Informed consent to family
Protap PEB
Terminasi-Repening misoprostol
Evaluation 6 hours
Observation status present/VS/FHR/tanda2 impending/tanda2
inpartu

Complete blood test october 15th

2014 (11:14)
examination

result

unit

Hemoglobin

11,1

g/dl

Leucocyte

14,5

ribu/ul

Eritroscyte

4.30

juta/ul

34

vol%

Trombocyte

335

ribu/ul

MCV

79,3

MCH

25,8

pg

MCHC

32,6

9,5/27,2/0,84

detik

BSN

102

Mg/dL

Urid acid

5,3

mg/dl

27/15/300

U/I

138/4,1/102,5

mmol

Hematokcrite

PT/APTT/INR

SGOT/SGPT/LDH
Na/K/Cl

Pemeriksaan
15-10-2014 (11:14)

Warna-kekeruhan

Hasil
Kuning muda-jernih

BJ

1.000

pH

7.5

Keton

Negatif

Protein-albumin

Negatif

Glukosa

Negatif

Bilirubin

Negatif

Darah samar

Negatif

Nitrit

Negatif

Urobilinogen

0.2

URINALISA (SEDIMEN)
Leukosit

0-2

Eritrosit

0-1

Selinder

Negatif

Epitel

1+

Bakteri

Negatif

Kristal

Negatif

Lain-lain

Negatif

17.00
PS 2 misoprostol 1 50mcg/vag/6 hours
Next evaluation : 23.00
23.00
PS 3 misoprostol 2 50mcg/vag/6 hours
05.00
PS 3 misoprostol (-)

october 16th 2014, 06.00

S: (-)
O: GCS 456 A- I- C- DBP: 150/90 HR: 88
RR: 20
C/P: normal
STO : contraction (-) 2 x 20/10

T: 36.9

FHR: 12-12-11

A) G4P2012 37-38 WoP+ head presentation +

chronic hipertention superimposed severe
preeclampsia+ Primitua sekunder + not in
labor + TBJ 3200 gram on termination
ripening misoprostol

11.15
Patient sent to operating room
11.40
Cesarian sectio was begun
11.50
Baby was born
Gender : female, weight 2450 gr,
length 48 ,AS 4 6 7 , anus (+),
congenital anomaly (-)

P)
O2 masker 6-8 lpm
MgSO4 regiment
Nifedipine 3x10 mg
Metil dopa 3x250 mg
Konsul ulang kemajuan persalinan
Balans cairan
Pro percepat kala II bila inpartu
Mo: KU/TV/DJJ/tanda2
impending/tanda2 inpartu

Surgery report

Informed consent and antibiotic prophylaxis

Patient was lied on supine position under spinal anesthetic
Performed disinfection of operating area & drapped operating area
Performed incision on middle abdomen, axplorating of cavum
abdomen
1. Gravid aterm uterine
2. Normal PA d et s
. Performed LSCS
1. Performed bladder fap
2. Performed low segment uterine incition (2 cm), widened to lateral
bluntly
3. Teared amniotic membrangt
4. Baby was born (female/ 2450 g/48 cm/AS 4-6-7)
5. Placenta was born completely
6. Performed evaluation of bleeding
. Suture the surgical wound layer by layer

 13.10
Post operation
S) Active bleeding (-), pain (-)
O) BP= 150/90 HR =88
RR= 22 T =37,0
FH~ umbilicus
Contraction (+)
A) P3013 post cesarian section
P)
laboratory check post cesarian section,if Hb < 8 tranfution PRC until HB
>8 IVFD RD5 1000 cc/24 jam
oxytocin drip 2 amp 20 dpm till 24 hours post op
MgSo4 drip 40% , 20 g until 24 hours post SC
inj alinamin F 3x1
inj ketorolac 3x1
inj vit c 3x1
inj ceftriaxon 2x1
inj transamin 3x500 mg
fuiid balance
nifedipin 3x10 mg if BP > 140/90
observation VS/fuxux/uterus contraction