II OBSTETRIC INPATIENT REPORT

Friday, August 17th 2018 – Thursday, August 20th 2018

Chief on Duty :
Dr. Syafali Prima
Dr. Ali Ridho

Supervisor:
Dr. H. Nuswil Bernolian. OBGYN (C). MARS

RECAPITULATION OF OBSTETRIC PATIENTS

Physiological Patients : 6 Patients

Pathological patients : 47 Patients
Total : 53 Patients
Patient was discharged : 39 Patients
Patient was stable inward : 18 Patients

RECAPITULATION OF OBSTETRIC PATIENTS

PROCEDURAL AMOUNT %

Aterm
5 9.4
No Induction
4 7.5
Spontaneous Delivery With Induction
1 1.9
Preterm
1 1.9
Breech
Vaginal delivery
Forcipal Extraction
Vacuum Extraction 0 0
Assited Vaginal Delivery Partial Extraction 0 0
4 7.6

Abdominal Delivery 25 47.2

Conservative Management 9 16.9

Expectative Management 3 5.7

Suturing laseration 0 0

Brandt Andrew Manuever 1 1.9

Curretage 0 0
TOTAL 53 100

RECAPITULATION OF OBSTETRIC PATIENTS

Day/ Date Old patients New patients Discharged patients Total Patients

OBF 3 1 3 1

OBP 12 4 2 14
Friday/
August 17th,
2018 Gestosis 2 0 1 1

Post Op 12 4 4 12

OBF 1 1 1 1

Saturday/ OBP 14 3 4 13
August 18th,
2018
Gestosis 1 1 1 1

Post Op 12 4 4 12

OBF 1 2 1 2

OBP 13 8 7 14
Sunday/
August 19th,
2018 Gestosis 1 0 0 1

Post Op 12 2 5 9
 Old
Day/ Date New patients Discharged patients Total Patients
patients

OBF 2 2 2 2

OBP 14 4 8 10
Monday/
August 20th,
2018
Gestosis 1 0 1 0

Post Op 9 2 5 6

OBF 2 1 2 1

OBP 10 3 6 7
Tuesday/
August 21st, 2018
Gestosis 0 0 0 0

Post Op 6 3 2 7

OBF 1 1 1 1

OBP 7 4 3 8
Wednesday/
August 22nd,
2018
Gestosis 0 1 0 1

Post Op 7 4 3 8

OBF 1 2 1 2

Thursday/
August 23rd, OBP 8 0 2 6
2018

Gestosis 1 0 0 1
 Post Op 8 1 2 7

Obstetrical Patients Friday, August 17TH 2018

Identity Diagnosis ICD 10 Previous Procedure ICD Last Diagnosis Recent Resident/
9 Procedure Consultant

1. Mrs. G2P1A0 38 O14.13 • Intrauterine resuscitaion 74.0 P2A0 post Discharge ICA
SIT weeks O76 • LSCS LSCS oi fetal SPM
26/RA gestational age distress with AT
in labor 1st stage severe
latent phase with preeclampsia
severe
preeclampsia
SLF cephalic
presentation +
fetal distress
2. Mrs. G5P2A2 32 O60 • Conservative 659.8 G5P2A2 32 Discharge ALI
NYA weeks of O34.21 management weeks KY
39/UA gestational with • Plan for US gestational age
threatened Confirmation with threatened
preterm labor + preterm labor +
prior CS 2x SLF prior CS 2x
cephalic SLF cephalic
presentation presentation
3. Mrs. G2P1A0 37 O33.9 • LSCS 74.0 P2A0 post Discharge ICA
NUR weeks O34.21 LSCS oi CPD SPM
34/UA gestational age + prior CS AF
in labor 1st stage
latent phase with
CPD + prior CS
1x (oi CPD)
SLF cephalic
presentation

4. Mrs. G2P1A0 37 O99.280 • Hysterorrhaphy 69.41 P2A0 post Discharge ICA

PUT weeks O42.1 • Consult to Internal hysteroraphy ALI
27/UA gestational age O34.21 department oi complete AT
in labor 1st stage uterine rupture
latent phase with
hyperthyroid +
PROM 6 hours
+ prior CS 1x
(oi CPD) SLF
cephalic
presentation
5. Mrs. G3P2A0 33 O60 • Conservative 659.8 D/ G3P2A0 33 Discharge SPM
END weeks O30.0 management 67.51 weeks AW
36/UA gestational age • Cervical circlage gestational
with age not in
 threatened labor post
preterm cervical
laborTLF circlage TLF
cephalic cephalic
presentation - presentation -
cephalic cephalic
presentation presentation
6. Mrs. G1P0A0 41 O42.1 • Antibiotic 74.0 P1A0 post Discharge ICA
NUN weeks O33.9 • LSCS LSCS oi CPD ALI
29/RA gestational age O41.8 + AT
st
in labor 1 anhydramnios
stage latent with history
phase with of rupture
PROM 14 membrane
hours + CPD
SLF cephalic
presentation +
anhydramnions
7. Mrs. G5P4A0 27 O60 • Conservative 659.8 G5P4A0 27 Stable In HAD
NYI weeks of O20.0 management weeks of Ward SPM
33/ gestational age O34.21 • Plan for US gestational AT
UA nd confirmation age with OUI
with 2
trimester Covered by
haemorrhage + Placenta +
prior CS 2x prior CS 2x
TLF TLF
intrauterine intrauterine
8. Mrs. G3P2A0 30 O60 • Vaginal delivery 650 P3A0 post Pass ASH
PAT O99.119 vaginal Away ALI
weeks
34/RA August PB
gestational age K76.89 delivery with th
G51.0 Mariceau 20
not in labor
maneuver 2018
with SLE was with SLE was
suspected + suspected +
multiple multiple
nodule at liver nodule at
+ bell’s palsy liver + bell’s
+ IDCM right palsy +
IDCM right
mammae SLF
mammae +
cephalic observation
presentation of dypsnoe cb
bilateral
pleural
effusion +
lung oedema
+ hepar
metastase
Obstetrical Patients Saturday,August 18th 2018
Identity Diagnosis ICD Previous Procedure ICD Last Recent Resident/
10 9 Diagnosis Procedure Consultant

.1. Mrs. G2P1A0 39 O42.113 antibiotic 650 P2AO Post Discharge SPM
MAR/32/UA weeks vaginal delivery Spontaneouse NS
gestational Delivery with
age inlabor history of
first stage ROM 14
latent phase hour+Post
with PROM IUD
4 hours SLF Insertion
cephalic
presentation
2. Mrs. G4P3A0 40 O14.90 stabilisation 650 P4A0 Post Stable In ALI
EMI/33/UA weeks antihypertension Spontaneouse Ward HD
gestational vaginal delivery Delivery Enim
age inlabor With Severe 10.A
first stage Preeclampsia
latent phase
with severe
preeclampsia
SLF
cephalic
presentation
3. Mrs. G2P1A0 39 O32.1 LSCS 74.0 P2A0 Post Discharge ICA
ELY/34/UA weeks LSCS o.i SPM
gestational Feet HD
age inlabor Presentation
first stage
active phase
SLF feet
presentation

4. Mrs. G1P0A0 37 O42.113 antibiotic 650 P1A0 Post Discharge VAI

HAN/23/UA weeks vaginal delivery Spontaneouse ALI
gestational Delivery with HD
age inlabor History of
first stage ROM 17
latent phase Hour
with PROM
6 hours SLF
cephalic
presentation

N Identity Diagnosis ICD Previous Procedure ICD 9 Last Diagnosis Recent Residen
o. 10 Proced t/
ure Consult
ant
5 Mrs. G6P5A0 28 O42.11 • stabilisation 74.0 P6A0 Post Stable ICA
SUS/36/ weeks 3 • antihyperten LSCS o.i Total In SPM
UA gestationa O44.1 sion Placenta Ward HD
l age O34.21 • LSCS Previa + 2.4.6
inlabor O36.4 Severe
with O32.1 Preeclampsia+
antepartu Prior CS 1x
m
hemorrha
ge c.b
total
placenta
previa +
severe
preeclam
psia +
prior CS
1x SDF
breech
presentati
on
6 Mrs. G7P5A1 37 O44.1 • PRC 74.0 P6A1 Post Stable ICA
YAN/43/ weeks O36.4 transfusion 9 LSCS o.i Total In ALI
UA gestationa D64.9 • LSCS 9 Placenta Ward HD
l age • tubal ligation . Previa 2.5.2
inlabor 0
with
antepartu
m
hemorrha
ge c.b
total
placenta
previa+
moderate
anemia
SDF
cephalic
presentati
on
7 Mrs. G2P1A0 39 O15.9 • stabilisation 74.0 P2A0 Post Stable ICA
HAR/25 weeks • antihyperten LSCS o.i In SPM
gestationa sion antepartum Ward HD
l age • LSCS eclampsia 2.5.3
inlabor
first stage
active
phase
with
eclampsia
intrapart
um SLF
cephalic
presentati
on
8. Mrs. G0 31 O42.0 • antibiotic 659.8 G1P0A0 31 Stable ALI
ANI/23/ weeks 13 • conservative 88.7 weeks of In HD
UA gestation management gestational Ward
al age • lung age with 1 Enim
with maturation day PROM 2
PPROM • US SLF cephalic
1 day confirmation presentation
SLF
cephalic
presentat
ion

Obstetrical Patients Sunday,August 19th 2018

No. Identity Diagnosis ICD Previous ICD Last Diagnosis Recent Resident/
10 Procedure 9 Procedure Consultant

1 Mrs EVI/ G3P2A0 24 O11.5 Expectative 88.0 G3P2A0 24 Stable In ALI

40yo/UA weeks O34.21 Management weeks Ward FB
gestational age Lung gestational age VK
with 2nd Maturation with
trimester US superimposed
haemorrhage + confirmation preeclampsia +
superimposed Prior CS 1x
preeclampsia on (o.i severe
chronic preeclampsia)
hypertension + SLF
prior CS 1x SLF intrauterine +
cephalic retroplacenta
presentation haematoma
2 Mrs. SOL G2P1A0 30 O46.90 Expectative 88.0 G2P0A0 30 Stable In SPM
/26yo/RA weeks Management weeks Ward FB
gestational age Lung gestational age VK
not inlabor with maturation not in labor
PPROM 4 hours Us with PPROM 2
SLF cephalic Confirmation days SLF
presentation+ cephalic
anhydramnios presentation +
anhydramnions
3 Mrs G1P0A0 26 G40.909 Medicinalis 88.0 G1P0A0 26 Stable In MUT
YUN/23yo/UA weeks Neurologist weeks Ward ALI
gestational age Assessment gestational age 2.2.1 FB
not inlabor with US not inlabor
Epilepsi was Confirmation with Epilepsi
suspected SLF was suspected
intrauterine SLF
intrauterine
4 Mrs MAR/ G4P3A0 32 O11.5 Labor 73.4 P4A0 Post Discharge SPM
35yo/UA weeks O34.21 induction 650 partial FB
gestational age P/ Vaginal extraction
not inlabor SDF Delivery
breech
presentation
No. Identity Diagnosis ICD Previous ICD Last Recent Resident/
10 Procedure 9 Diagnosis Procedure Consultant

5 Mrs.APR/32yo/RA G3P2A0 33 O60.00 Conservative 493 G3P2A0 33 Stable In MUT

weeks E.04.9 Management 88.0 weeks Ward ALI
gestational age Lung gestational 2.2. 4 FB
with threatened Maturation age with
preterm labor + US threatened
Struma nodusa confirmation preterm labor
non toxic was Internal dept + Struma
suspected SLF and surgery nodusa non
cephalic Assessment toxic was
presentation suspected
SLF cephalic
presentation
6 Mrs SEP/31yo/UA G2P1A0 38 B19.10 Vaginal 650 P2A0 Post Discharge SPM
weeks delivery spontaneous IS
gestational age P/ IUD delivery with
inlabor 1st insertion HbSAg(+)
stage active
phase with
HbSAg (+)
SLF cephalic
presentation
7 Mrs ELI/ 25yo/UA G2P1A0 41 O11.5 LSCS 74.1 P2A0 Post Discharge ICA
weeks O34.21 IUD LSCS o.i ALI
gestational age insertion breech FB
inlabor 1st presentation +
stage latent anhydramnion
Phase SLF
breech
presentation +
anhydramnion

No. Identity Diagnosis ICD Previous ICD Last Diagnosis Recent Resident/
10 Procedure 9 Procedure Consultant

8 Mrs. SOL/ G4P3A0 37 O32.1 P/ Vaginal 650 P4A0 Post Discharge SPM
33yo/RA weeks Delivery partial FB
gestational age P/ IUD extraction +
inlabor 1st insertion IUD insertion
stage latent
phase SLF
breech
presentation
9 Mrs. G2P1A0 39 O40.3 P/ LSCS 74.1 P2A0 Post Discharge ALI
WIW/39yo/RA weeks inlabor C56.1 Tubectomy LSCS o.i FB
1st stage latent oblique
phase with presentation +
ovarian cancer ovarian cancer
stage IC stage IC
complete complete
 theraphy SLF theraphy
oblique +
polihydramnios

10 Mrs. PUS G4P1A2 39 J45.901 P/ Vaginal 650 P2A2 Post Discharge PIT
/31yo/UA weeks delivery spontaneous SPM
gestational age P/ IUD delivery with FB
inlabor 1st insertion asthma attack
stage active
phase with
asthma attack
SLF cephalic
presentation

Obstetrical Patients Monday,August 20th 2018

No. Identity Diagnosis ICD 10 Previous ICD Last Diagnosis Recent Resident/
Procedure 9 Procedure Consultant

G1P0A0 30 P1A0 Post Discharge SPM

weeks of preterm NS
gestational age spontaneous
Mrs. RIZ Vaginal
1 age in labor 1st O83.0 650 delivery
/26/UA delivery
stage latent phase
SLF cephalic
presentation
Mrs G4P3A0 32 O11.5 Cervical 73.4 P4A0 Post Discharge ALI
MAR/ weeks O34.21 ripening 650 Partial FB
35yo/UA gestational age Vaginal Extraction SDF
2 not inlabor SDF Delivery
breech
presentation

Mrs. G3P2A0 37 O44.13 LSCS 669.7 P3A0 Post Stable In ICA

MAR / weeks of O77.9 IUD LSCS o.i total Ward SPM
35 yo gestational age in insertion placenta previa 222 NS
/UA labor with + prior CS 1x
antepartum
3
hemorrhage cb
total placenta
previa + prior CS
1x SLF breech
presentation
Mrs. G3P2A0 37 LSCS 669.7 P3AO Post Stable In ICA
MAR / weeks of LSCS o.i not Ward ALI
35 yo/ gestational age in fulfilled 256 FY
UA labor with vaginally
4 prolonged second
stage (outside)
not fulfilled
vaginally SLF
cephalic
 presentation

No. Identity Diagnosis ICD Previous ICD Last Diagnosis Recent Resident/
10 Procedure 9 Procedure Consultant

Mrs G4P2A1 37 weeks O11.5 P/LSCS 669.7 G4P2A1 37 weeks Stable In SPM
JUL/38 of gestational age O77.9 of gestational age Ward KY
yo/ UA not in labor with not in labor with
5 prior CS 2x SLF prior CS 2x SLF
cephalic cephalic
presentation presentation

G2P1A0 37 weeks P2A0 Post Stable In PIT

of gestational age in Spontaneous Ward ALI
PRC
Mrs. labor first stage Delivery With IZ
transfusion
6 FIT/28 active phase with O83.0 650 Intermediate
P/ Vaginal
yo/UA moderate anemia Anemia
delivery
SLF cephalic
presentation

Obstetrical Patients Tuesday,August 21st 2018

No. Identity Diagnosis ICD Previous ICD Last Diagnosis Recent Resident/
10 Procedure 9 Procedure Consultant

Mrs. G4P2A1 39 Z34.3 Cervical ripening 73.4 P3A1 Post Stable In SPM
HAR/ weeks 032.1 Vaginal Delivery 658 Spontaneous ward AF
33yo/UA gestational age 041.0 Delivery
not inlabor with PROM 1 days
1
PROM 1 days
SLF cephalic
presentation +
Oligohydramnios
Mrs. G2P1A0 40 Z34.3 Cervical ripening 73.4 P2A0 Post Stable In ALI
FEB/ weeks 032.1 Vaginal Delivery 658 Spontaneous Ward RS
29yo/UA gestational age 041.0 Delivery
2 not inlabor SLF
cephalic
presentation +
Oligohydramnios
Mrs. G2P1A0 31 O14.13 P2A0 Post Stable In HAD
HEP/ weeks gestational Spontaneous Ward SPM
30/UA age in labor Bracht FY
3 second stage TLF Vaginal delivery 650.
breech-cephalic
presentation

Mrs. G1P0A0 39 O14.13 Stabilization P1A0 Post Stable In ICA

SUL/ weeks gestational Antihypertension LSCS o.i Twin Ward ALI
24yo/UA age in labor 1st Labor Life Fetus + FY
659
4 stage latent phase acceleration Severe
796.3
with severe Plan for Preeclampsia
preeclampsia abdominal
TLF cephalic Delivery
 presentation-
Transverse lie

No Identity Diagnosis ICD Previous IC Last Diagnosis Recent Resident/

. 10 Procedur D9 Procedur Consultan
e e t
Mrs.YUN/31/U G3P1A1 41 Z34.8 LSCS 74.0 P2A1 Post Stable In ICA
A weeks of 3 LSCS o.i Ward SPM
gestational age 032.1 oligohydramnio NS
not inlabor with 041.0 s + Hygroma
prior CS 1x + colli with prior
5
SLF breech CS 1x
presentation +
oligohydramnio
s + Hygroma
colli
Mrs. G1P0A0 39 Z34.3 LSCS 74.0 P1A0 Post Stable In ICA
SAR/36/UA weeks of 032.1 LSCS o.i Ward ALI
gestational age 041.0 umbilical cord IS
inlabor 1st stage entenglement
active phase 1X with PROM
with PROM 10 10 hours
6
hours + SLF
cephalic
presentation +
umbilical cord
entenglement
1X

Obstetrical Patients Wednesday,August 22nd 2018

No. Identity Diagnosis ICD 10 Previous ICD Last Recent Resident/
Procedure 9 Diagnosis Procedure Consultant

1. Mrs. G1P0A0 39 O30.0 stabilisation 74.0 P1A0 Post Stable In ICA

SUL/24/UA weeks O14.13 antihypertension LSCS o.i Ward SPM
gestational O32.2 LSCS Twin Life FY
age inlabor Fetus with
first stage severe
latent phase preeclampsia
with severe
preeclampsia
TLF cephalic
presentation-
transverse lie
2. Mrs. G2P1A0 30 O42.113 antibiotic 74.0 P2A0 Post Stable In ICA
SOL/26/RA weeks O41.8X90 lung maturation LSCS o.i Ward ALI
gestational LSCS anhydramnios FB
age not with PPROM
inlabor with 3 days
PPROM 3
days SLF
cephalic
presentation +
 anhydramnios

3. Mrs. G2P1A0 30 O42.113 conservative Z39.2 G2P1A0 30 Stable In SPM

TIA/26/RA weeks management weeks Ward FY
gestational lung maturation gestational
age not US age not
inlabor with Confirmation inlabor with
PPROM 3 PPROM 17
hours SLF hours SLF
cephalic cephalic
presentation presentation
4. Mrs. G3P1A1 37 O42.013 LSCS 74.0 P2A1 Post Stable In ALI
KIF/36/UA weeks O34.21 LSCS o.i Ward AF
gestational prior CS 1x
age not with PROM 3
inlabor with hours
PROM 3
hours + prior
CS 1x SLF
cephalic
presentation

No. Identity Diagnosis ICD Previous ICD Last Diagnosis Recent Resident/
10 Procedure 9 Procedure Consultant

5. Mrs. G1P0A0 37 weeks O42.013 antibiotic 74.0 P1A0 Post LSCS Stable In AF
DES/35 of gestational age O41.0 LSCS o.i fetal distress + Ward SPM
yo/UA inlabor first stage O76 oligohydramnion
latent phase with
PROM 12 hours
SLF cephalic
presentation
+oligohydramnion
+fetal distress
6. Mrs. G2P1A0 31 weeks O60.00 tocolitic Z39.2 G2P1A0 31 Stable In AF
HAR/31 of gestational age O34.21 conservative weeks of Ward ALI
yo/UA with threatened O32.2 management gestational age
preterm labor+ lung with threatened
prior CS 1x SLF maturation preterm labor+
transverse lie US prior CS 1x SLF
Confirmation transverse lie
7. Mrs. G1P0A0 38 weeks B19.10 P/vaginal 650 G1P0A0 38 Stable in AF
KHE/20 of gestational age delivery weeks of Ward ALI
yo/UA inlabor first stage gestational age
latent phase with inlabor first stage
hepatitis B SLF latent phase with
cephalic hepatitis B SLF
presentation cephalic
presentation
Obstetrical Patient Thursday,August 23rd2018
No. Identity Diagnosis ICD Previous ICD Last Diagnosis Recent Resident/
10 Procedure 9 Procedure Consultant

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