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DELIVERY TEAM REPORT

Wednesday, September 5th 2018

Supervisor :
dr. Edwin Martin Asroel, M.Ked(OG), SpOG

Residents :
1. dr. Sofyan Andri
2. dr. Jonathan T L Tobing
3. dr. Willy Kurnia Almon

Department of Obstetric and Gynecology


Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2018
Wednesday, September 5th 2018 at 08.00 am
S -

O Presens state
Sens : CM
BP : 110/70 mmHg
P : 82 x/min
RR : 20 x/min
T : 36,70C
Obstetrical state
Abdomen : Aymmetrically Enlarged
Fundal Height : 3 fingers below processus xyphoideus
Tension Part : Right Back
Lowest Part : Head
Fetal Movement : (+)
Uterine contraction : (-)
FHR : 128 x/ minutes, Regular
VT : Cx undilated, Blood slime (-), Amniotic fluid (-)
A Hepatitis B + PG + IUP (37-38) wga + Head Presentation + Alive Fetus
P - Oxygen 4L/i via nasal canule
- IVFD Ringer Lactate 20 dpm

Plan Reposted to Fetomaternal Supervisor  dr. Edwin Martin Asroel, M.Ked(OG), SpOG
Monitoring vital sign, fetal well being with CTG
Laboratory check  HbeAg
Follow Up
Time BP Pulse RR Temp HIS FHR Exp

08.30 110/70 89 20 36.7 - 128 -

09.00 110/60 82 22 36.5 - 126 -

09.30 110/70 90 20 36.7 - 128 -

10.00 110/70 93 20 36.8 - 115 HbeAg results: Non


reactive
HST results
Intrauterine
resuscitation
10.15 100/70 87 20 36.5 - 103 C-Section emergency
Laboratory results
• PT : > 80s N: 14 s
• APTT : > 120 s N: 33.7 s
• TT : > 80 s N: 21.0 s
• INR : 6.0
• HbeAg : non reactive
CTG
CTG
Wednesday, September 5th 2018 at 10.15 am
S -

O Presens state
Sens : CM
BP : 100/70 mmHg
P : 87 x/min
RR : 20 x/min
T : 36,60C
Obstetrical state
Abdomen : Aymmetrically Enlarged
Fundal Height : 3 fingers below xyphoid process
Tension Part : Right Back
Lowest Part : Head
Fetal Movement : (+)
Uterine contraction : (-)
FHR : 108 x/ minutes, Regular
A Fetal Bradicardia + Hep B + PG + IUP (37-38) wga + Head Presentation + Alive fetus

P - Oxygen 10L/i via face mask


- IVFD Ringer Lactate rapid drips 40 dpm
- Left Lateral Decubitus
- Inj Cefazoline 2 gr IV
Plan Monitoring vital sign, fetal well being with CTG
C-Section emergency
Consult to Anaesthesiology Dept about prolonged HST  Approved with FFP preparation
Consult to Perinatology Dept
Reported to Delivery ward Supervisor  dr. Edwin Martin Asroel, Mked(OG), SpOG approved
Advise: Preparation PRC 2 packs@175 cc & FFP 3 packs @250 cc  Blood Sample admitted
Time BP Pulse RR Temp HIS FHR Exp

10.30 110/70 89 20 36.7 - 105 -

10.45 110/60 82 22 36.5 - 103 Anesthesiologi consult


answered

11.00 110/70 90 20 36.7 - 86 Perinatology consult


answered

11.15 110/70 93 20 36.8 - 82

11.30 100/70 87 20 36.5 - 86 Patient transferred to


Operation theatre

11.45 110/70 90 22 36.7 - 69

12.05 100/70 92 20 36.5 - Operation Started


C-Section d/t Fetal Bradicardia
At 12.10 pm Born baby girl, BW 3200 gr, BL 48 cm, A/S 0/0 anal (+)

• 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 GA-ETT anesthesia, Pfannenstiel incision was made in the
abdomen, through to the underlying layer of fascia. The fascia was incised
in the midline and extended laterally using scissor. Superior aspect of the
fascia was elevated using Kocher, and the underlying rectus muscles were
separated.
• 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.
• Seen ascites, volume ± 500 cc, yellow-ish
• The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium penetrated
and widened bluntly.
• By luxating head, born baby girl with BW 3200 gr, BL 48 cm, AS
0/0, anus (+). Evaluation of amniotic fluid  unclear
• Seen umbilical cord loop on the neck, three times. Amniotic fluid
was green
• 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
• Identification of both tubal and ovarium, seen in normal condition.
• 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 cutis
was sutured with subcuticuler suture
• Surgical wound was closed with sofratulle, sterile gauze and
hypafix
• Mother was stable the after the operation
• Estimated blood loss : ± 500 cc
Therapy
• IVFD RL + Oxytocine 10 IU  20 dpm
• Inj. Ceftriaxone 1 gr/12 hrs
• Inj. Ketorolac 30 mg/8 hrs
• Inj Ranitidine 50 mg/12 hour
• Misoprostol per rectal 400 mcg
• Inj. Tranexamic Acid 500 mg/8 hours
• Inj Fitomenadion 4 mg/ 12 hours

Plan:
1. Observe VS, contraction, bleeding, and UOP
2. FFP Transfusion post operative 3packs @250 cc.
Follow Up
BP Pulse RR Temp Contraction Exp
Time
13.00 110/70 89 16 36.7 Adequate Vaginal Bleeding (-)
FFP wasnt ready yet

13.30 110/60 82 22 36.5 Adequate Vaginal Bleeding (-)


FFP wasnt ready yet

14.00 80/60 98 20 36.7 Inadequate Vaginal Bleeding (+)


Inj Methylergometrine
200 mcg
Misoprostol 600 mcg p/r
Bimanual compression
14.30 90/70 110 20 36.8 Inadequate Relaparotomy
Wednesday, September 5th 2018 at 02.30 pm

S -

O Presens state
Sens : Under narcose
BP : 80/50 mmHg
P : 109 x/min
RR : 16 x/min via ventilator
T : 36,60C
Obstetrical state
Abdomen : Distension, peristalic low
Fundal Height : 2 fingers above navel level, inadequate contraction
Vaginal Bleeding : (+), curved vaginal canal  Vaginal bleeding ± 2000cc , actively
Micturition : (+) 100 cc, yellow-ish

A PPH ec Uterine atony + Hipocoagulation state + Post C-Section d/t Fetal Bradicardia + PD0

P - RL+ oxytocine 20 IU + HES double line  rapid drips 40 dpm


- Inj Methylegometrine 200 mcg
- Misoporostol 600 mcg p/r

Plan Relaparotomy Emergency – Hysterectomi consideration


Blood Preparation 4 PRC @175 cc & 4 FFP @250cc
Consult to Anaesthesiology
Post B-lynch suture Surabaya modification d/t PPH ec Uterine
Atony + Hypocoagulation state at 03.15 pm
• 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 GA-ETT anesthesia, Pfannenstiel incision was made in the
abdomen, through to the underlying layer of fascia. The fascia was incised
in the midline and extended laterally using scissor. Superior aspect of the
fascia was elevated using Kocher, and the underlying rectus muscles were
separated.
• 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.
• Seen blood volume on the whole abdominal cavity, volume ± 1000 cc
• Cavum abdomen was cleaned, evaluation uterus  inadequate
contraction and source of bleeding  from uterus suture.
• B-lynch suture Surabaya modification was performed.
• Evaluation Uterus  Bleeding controlled from suture and
form vaginal canal.
• Peritoneum sutured continuously, muscle approximation
using simple suture and fascial closure using continous
suture.
• Subcutaneous layer was sutured with simple suture and cutis
was sutured with subcuticuler suture
• Surgical wound was closed with sofratulle, sterile gauze and
hypafix
• Mother was stable the after the operation
• Estimated blood loss : ± 1500 cc
• During surgery  PRC transfusion 2 packs @175 cc & 3 FFP
transfusion @250 cc.
Therapy
• IVFD RL + Oxytocine 10 IU  20 dpm
• Inj. Ceftriaxone 1 gr/12 hrs
• Inj. Ketorolac 30 mg/8 hrs
• Inj Ranitidine 50 mg/12 hour
• Misoprostol per rectal 400 mcg
• Inj. Tranexamic Acid 500 mg/8 hours
• Inj Fitomenadion 4 mg/ 12 hours

Plan:
1. Observe VS, contraction, bleeding, and UOP
2. PRC transfusion 4 packs @175 cc & FFP 4 packs @250 cc
Wednesday, September 5th 2018 at 06.00 pm

S -

O Presens state
Sens : Under narcose
BP : 75/45 mmHg
P : 109 x/min
RR : 16 x/min via ventilator
T : 36,60C
Obstetrical state
Abdomen : laxed, peristalic low
Fundal Height : 2 fingers below navel level, adequate contraction
Vaginal Bleeding : (+) didnt active
Micturition : (+) 50 cc, yellow-ish

A Post Laparotomy – B lynch suture surabaya modification d/t PPH ec Uterine Atony + Hypocoagulation
state + Hep B + Post C-Section d/t Fetal Bradycardia
P - IVFD Ringer Lactate rapid drips
- Inj Ceftriaxone 1 gr/ 12 h
- Inj Ketorolac 30 mg/ 8 h
- Inj Tranexamic Acid 500 mg/ 8 h
- PRC transfusion 4 packs @175 cc & FFP transfusion 4 packs @250 cc
Plan Laboratory check CBC, BloodGLucose adR, Blood Gas Analyse, RFT & LFT
Evaluation of vital sign, vaginal bleeding, contraction & UOP
Wednesday, September 5th 2018 at 08.00 pm

S -

O Presens state
Sens : Under narcose
BP : 115/65 mmHg
P : 89 x/min
RR : 16 x/min via ventilator
T : 36,60C
Obstetrical state
Abdomen : laxed, peristalic low
Fundal Height : 2 fingers below navel level, adequate contraction
Vaginal Bleeding : (+) didnt active
Micturition : (+) 100 cc, yellow-ish

A Post Laparotomy – B lynch suture surabaya modification d/t PPH ec Uterine Atony + Hypocoagulation
state + Hep B + Post C-Section d/t Fetal Bradycardia
P - IVFD Ringer Lactate rapid drips
- Inj Ceftriaxone 1 gr/ 12 h
- Inj Ketorolac 30 mg/ 8 h
- Inj Tranexamic Acid 500 mg/ 8 h
- PRC transfusion 4 packs @175 cc & FFP transfusion 4 packs @250 cc  done
Plan Laboratory check CBC, BloodGLucose adR, Blood Gas Analyse, RFT & LFT
Evaluation of vital sign, vaginal bleeding, contraction & UOP