STATUS ILMU KEBIDANAN

09890300

No. MR

OPERATION REPORTName : Mrs. Noraveri Sex : FemaleAge : 33 years

Operator Prof. Dr. H. I. O Marsis, SpOG Anesthetic dr. Veronica, Sp. An

Asistern Idr. Benhur S.InstrumentatorZr. Marintan

Asistern IIHendra Gorbi Tito ManurungObserverGasha Arya Pratama

Pre-operation Diagnose : Pregnancy 38th weeks G2P1A0 + CPD + previous cesarean delivery at P1A0

Post-operation Diagnose : CPD + prior cesarean delivery + nuchal cord with one loopDate of operation : November 10th 2014

Duration of operation : 1 hour 15 minutes

Technique of operation :

1. Sectio caesarean transperitoneal profundaType of operation

Emergency Minor

Policlinic Medium

Elective Mayor

Operation Procedures:

I. Patient slept in supine position with spinal anesthesia on the operation table.II. Applied inside the dower catheter.

III. Aseptic and antiseptic on abdomen adjacent regio until 1/3 distal upper leg and the operation field was limited with sterile doek.

IV. Pfannenstiel incision was made around the fibrous tissue and the skin fold in the lower abdomen regio, the incision was made deeper slice by slice from cutis, sub cutis, fascia with sharp technique. Then the musculus rectus abdominis was separated to lateral section with dull technique, bleeding was taken care off.

V. The peritoneum parietal was opened upside and downside so we could see the uterine gravidarum, and two sterile gaas were put inside the right and left abdomen cavity for separating the uterine and the other organ.VI. The plica vesico uterine was opened and the incision was continued to the left and right lateral and set aside.

VII. Transversal incision was made on lower segment of uterus, extend to right and left until we could see the amnion membrane and then the operator broke the amnion membrane, the liquor amnii was clear and we could saw the babys head.VIII. We saw the babys head upper from the pelvic inlet.IX. Then the babys head was pulled out by forceps and with mild pressure on the fundus uterine by assistance. There was a nuchal cord with one loop, then it was released. The delivery was done step by step from head, front shoulder, back shoulder, backward anterior trochanter, posterior trochanter, breech and inferior extremity with a sort umbilical cord coil attached to the baby.X. The baby was crying, umbilical cord was clamped on 2 places 5 cm and 7 cm from the umbilical cord, then it was cut between the 2 clamps and the baby was given to the pediatrician.

XI. The new born baby was delivered at 8.30 am, with female gender, body weight birth is 3400 gr, birth length is 48 cm, Apgar Score is 8/9, anal (+) and wasnt seen major congenital disorder.XII. Placenta was completely born in manual, cavum uterine was cleaned from the residual placenta tissue. Bleeding was controlled. XIII. After that the uterine tissue was sewed:

Suture was done on lower segment of uterine at two pole with Chromic cat gut no. 2 and then the myometrium tissue was sutured by continue and overhecting. First slice of myometrium tissue with Chromic cat gut no. 2 by continue.

Second slice of myometrium tissue and serosum was suture by continue with Chromic cat gut no. 2. Reperitonisation by sutured plica vesica uterine with chromic cat gut no. 2 by continue.XIV. The abdomen cavity was cleaned and two sterile gaas was pulled out from the abdomen cavity.

XV. Before the abdomen cavity sewed, it was given cortisone acetate 25 mg/10ml into peritoneal cavity.XVI. After ensuring that there was no bleeding, the abdomen cavity was sewed slice by slice.

a. Peritoneum parietal was sutured with Plain cat gut no. 2.0 by continue.b. M. Rectus abdominis was sutured with Chromic cat gut no. 1.0 by simple suture.c. Fascia was sutured with vicryl no. 1 by simple suture.

d. Sub cutis was sutured with Plain cat gut no. 2.0 by simple suture.

e. Cutis was sutured with Chromic cat gut no. 3.0 by subkuticuler. XVII. Bleeding approximately 200 cc.XVIII. Cavum uterine was cleaned pervaginam.

XIX. The operation wound was cleaned by cleaning stole cell from the vagina, the operation wound was cleaned with NaCl 0,9 % and then it was given antibiotic zalf and then was closed by sufratulle, sterill cassa and tegaderm.

XX. The operation finished.

The condition of patient post operation: General condition : Look mild sick Blood pressure

: 110/70 mmHgPulse rate

: 65 x/minute Respiration

: 20 x/minuteTemperature

: 37oC

Tissue to Pathology of Anatomy :

Yes: Type of tissue ..........................................

No Operator,(Prof. dr. H. I. O Marsis, SpOG)RUMAH SAKIT UMUM FKUKI

SMF OBSTETRI GINEKOLOGI

Jl. Mayjen Sutoyo no. 2, Cawang, Jakarta Timur, 13630

Tel. 021 8092317 ext. 108 / 205

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