Three times previous CS

Case 93

Patients ID
Name
Age
Address
MR
Date of admission
2013

:
:
:
:
:

Mrs. L
31 years old
Bariang Indah
18 12 55
August 23rd,

Anamnesis
A 31 years old patient was admitted to
the Delivery Room of Dr. M. Djamil
Central General Hospital on August 23rd,
2013 at 09.00 pm with chief complain
feeling of pain from waist region
intermittent was felt since 2 hours ago.

Present Illness History

Feeling of pain from waist region intermittent was felt since 2
hours ago.
Bloody show from the vagina was absent.
Fluid leakage from the vagina was absent.
There is no massive vaginal bleeding.
Amenorrhea since 9 months ago.
First date of last menstrual period was forgotten.
Estimation date of delivery cant be estimated.
Fetal movement was felt since 5 months ago.
No complain of nausea, vomitting, and vaginal bleeding neither
during early pregnancy nor late pregnancy.
Prenatal care to Rasyidin District Hospital, regular once a month
since 2 month of pregnancy age.
Menstruation history : menarche at 12 years old, irregular cycle,
once in 25-35 days which last for 5 to 7 days each cycle with the
amount of 2-3 times pad change/day without menstrual pain.

Previous Illness History

There was no history of cardiac disease, lung
disease, liver disease, renal disease, diabetes
mellitus, hypertension.
Allergic history was denied

Familial Illness History

There was no history of any hereditary, contagious,
or psychiatric disorder.

Marriage history: married once in 1999

Obstetric history : Pregnancy/Abortion/Delivery: 3/0/2
1. In 2000, female, 2800 gr, term, spontaneusly,
hospital, alive
2. In 2003, female, 2800 gr, term, CS oi no dilatation,
Private Hospital, wound healed in 7 days, alive
3. In 2005, male, 2800 gr, term, CS oi previous SC,
District Hospital, wound healed in 7 days, alive
4. In 2006, male, 2800 gr, term, CS oi previous SC,
District Hospital, wound healed in 7 days, died at
age 2 days
5. present
Educational history : Senior High School
Occupational history : housewife
History of family planning : contraception injection
every three month
Immunization
: TT 1x (7th month)

PHYSICAL EXAMINATION
GA
Cons BP
PR
RR
T
Mdt CMC 120/70
82x 20x 37
Body Height
: 150 cm
Present Body weght
: 45 kg
Before Pregnancy Body Weight
: 50 kg
BMI
: 22.3 kg/m2
Upper Arm Circumferrence
: 23 cm

PHYSICAL EXAMINATION
Eyes
: Conjunctiva wasnt anemic,
Sclera wasnt icteric
Neck
: JVP 5-2 cmH2O,
thyroid gland no enlargement
Chest
: H/L normal
Abdomen : OR (obstetric record)
Genitalia : OR (obstetric record)
Extremity : Edema -/-,
Physiological Reflex +/+,
Pathological Reflex -/-

Abdomen

Inspection : enlarged due to a term pregnancy, median line

hyperpigmentation, cicatrix (+) previous CS with median line
incision
Palpation :
L1 : uterine fundal was palpated 3 fingers below proccesus
xyphoideus,
a soft, large noduler mass was palpated
L2 : hard and resistance structure was felt on the left side,
numerous small and irregular structures were felt in the right
side
L3 : a round hard mass was palpated, not fixated
L4 : didnt performed
Uterine fundal height : 31 cm, EBW : 2790 g, uterine contraction :
(+)/S/W

Percussion
Auscultation

: tympani
: normal peristaltic sound,
FHR : 142-154 bpm

Genitalia : I : V/U normal, Vaginal bleeding (-)

Vaginal examination :
1 finger
Portio 1,5 cm in thickness, posterior, moderate
Amniotic sac (+)
Head was palpated at HI
Impression Internal and External pelvimetry : adequate pelvic

ULTRASOUND

ULTRASOUND
Fetal alive, singleton, intrauterine, head presentation
Fetal movement was good
Biometrics :
BPD : 90,2 mm
AC

: 310 mm

FL

: 71,4 mm

EFW : 2757 gr
Placenta was implanted in posterior corpus, grade IIIII
Impression : term pregnancy
fetal alive, head presentation

CTG

CARDIOGRAPH
Interpretation :
Baseline

: 140 bpm

Variability

: 5-15 bpm

Acceleration

: (+)

Deseleration

: (-)

Contraction

: (+)

Fetal Movement : (+)

Impression : Reactive CTG

Laboratory Finding
Laboratory finding

Normal value for 3rd TM

Routine blood testing

Hemoglobine

11,9 gr/dl

9,5-15,0

Leucocyte

14.800/mm3

5.916.9

Hematocrit

35 %

28.040.0

Trombocyte

210.000/mm3

146429

MCV

89 um3

8199

MCH

30,1 pg

2932

33,6 g/dl

32-36

MCHC

Diagnosis
G5P4A0L3 term pregnancy phase + 3 times
previous CS + contraction
Fetal alive, singleton, intra uterine, head
presentation at HI

Management :
Control general condition, vital sign, FHR,
uterine contraction
Routine blood test
Antibiotics (Skin test)
Informed Consent
Consult to OR and anesthesiologist

Planning :
Caesarean section

At 09.45 PM
CCS was performed
A female baby was born with :
2700 gr in weight, 47 cm in height, APGAR score 8/9
Placenta was born with a slight pull on the umbilical
cord, complete, 1 piece, with size of 17x16x3 cm,
550 g in weight, the umbilical cord length was 60
cm, with paracentral insertion.
Pomeroy Tubectomy was performed.
Bleeding during surgery was 250 cc
Diagnosis :
P5A0L4 post CCS due to 3 times previous CS + PT o.i
enough child
Mother child were in care

THANK YOU