Laporan OK English
3
No. MR Name : Mrs. Diyah ayu utami Sex : Female Age : 27 Years Operator Prof. Dr. H.I.O Marsis, SpOG Anestheti c Dr. Veronica, SpAn Assitant 1 Dr. Benhur Sibuea Instrumen tator Zr. Franco Assitant 2 Medianto T Sinabutar Observer Gabriel Hutabarat Pre-surgical Diagnose : Breech labour at 37 th weeks in gestation with G2P0A1 Post-surgical Diagnose : Breech labour at 37 th weeks in gestation with G2P0A1 Surgery Date : May 5 th 2014 Duration time of surgery : 2 hours 10 minutes (7.30-9.40) Tehnique of operation : Type of surgery 1. Transperitoneal Cesarean Section □ Emergency □ Minor 2. □ Policlinic □ Medium 3. □ Elective □ Major Operation Procedures: I. Patient slept in supine position with spinal anastesia II. Aplied inside the dower catether III. Aseptic and antiseptic on abdomen adjacent regio until 1/3 proximal upper leg and the operation field was limited with steril doek IV. The abdomen was prepped and draped and tested for analgesia. When found to be adequate, a Pfannenstiel incision was made around fibritio tissue and the skin fold in down abdomen regio was thrown, the incision was made deeper slice by slice from cutis, subcutis, fascia with sharp technique. Then rectus abdominis muscles were separated to lateral with dull technique, bleeding was taken care off. V. Peritoneum parietal was opened tipside and downside so we can see uterine gravidarum, and the 2 curavor were put inside the right and left abdomen cavity for sperating the uterine and the other organ VI. Plica vesicouterine was opened and incision was made to left and right. 42 40 04 RUMAH SAKIT UMUM UKI SMF OBSTETRI GINEKOLOGI Jl. Mayjen Sutoyo no. 2, Cawang, Jakarta Timur, 13630 Tel. 021 – 8092317 ext. 108 / 205
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laporan operasi sectio cesaria. ufhjhfjehfhejkfelkfjlejlkejlrj bahasa inggris
Transcript of Laporan OK English
No. MR
SURGERY REPORT
Name : Mrs. Diyah ayu utami Sex : Female Age : 27 YearsOperator Prof. Dr. H.I.O Marsis, SpOG Anesthetic Dr. Veronica, SpAnAssitant 1 Dr. Benhur Sibuea Instrumentator Zr. FrancoAssitant 2 Medianto T Sinabutar Observer Gabriel HutabaratPre-surgical Diagnose : Breech labour at 37th weeks in gestation with G2P0A1
Post-surgical Diagnose : Breech labour at 37th weeks in gestation with G2P0A1
Surgery Date : May 5th 2014Duration time of surgery : 2 hours 10 minutes (7.30-9.40)
Tehnique of operation : Type of surgery1. Transperitoneal Cesarean Section □ Emergency □ Minor2. □ Policlinic □ Medium3. □ Elective □ Major
Operation Procedures:
I. Patient slept in supine position with spinal anastesia
II. Aplied inside the dower catether
III. Aseptic and antiseptic on abdomen adjacent regio until 1/3 proximal upper leg and the operation field
was limited with steril doek
IV. The abdomen was prepped and draped and tested for analgesia. When found to be adequate, a
Pfannenstiel incision was made around fibritio tissue and the skin fold in down abdomen regio was
thrown, the incision was made deeper slice by slice from cutis, subcutis, fascia with sharp technique.
Then rectus abdominis muscles were separated to lateral with dull technique, bleeding was taken care off.
V. Peritoneum parietal was opened tipside and downside so we can see uterine gravidarum, and the 2
curavor were put inside the right and left abdomen cavity for sperating the uterine and the other organ
VI. Plica vesicouterine was opened and incision was made to left and right.
VII. Transversal incision was made on lower segment of uterus. Once incision was opened, the incision was
extended by cutting laterally and slightly upward with bandage scissors.
VIII. Once incision was made, the fetal membrane was broken and amniotic fluid flowed. Fluid was cleaned
by suctioning, the infant wasn’t still showed.
IX. The operator step into the uterus and we could see the baby’s hand and we continued the incision from
left to right lateral. The operator pulled back the baby’s hand into uterus and then looking for baby’s feet.
After that the operator was give mild pressure on the fundus uterine. Then delivered step by step
extremitas inferior, breech, trochanter posterior, trochanter anterior, back shoulder, front shoulder.
X. Placenta was removed manually and the uterine cavity was cleaned from shred of membranes, vernix,
clots, and other debris. Bleeding was taken care off.
42 40 04
RUMAH SAKIT UMUM UKISMF OBSTETRI GINEKOLOGIJl. Mayjen Sutoyo no. 2, Cawang, Jakarta Timur, 13630Tel. 021 – 8092317 ext. 108 / 205
XI. After that the uterine tissue was sewed and over hecting:
- Suture was done on lower segmen of uterine at two pole with “Vicryl” no. 2 and then the
myometrium tissue was sutured by running-locked suture.
- First slice of myometrium tissue with “Chromic cat gut” no. 2 by continuous suture.
- Second slice of myometrium tissue and serosum was sutured with “Chromic cat” no. 2 by
continuous suture.
- Plica vesicauterine was sutured with “chromic cat gut” no. 2.0 by continuous suture.
XII. After there was no bleeding abdomen cavity was sutured slice by slice
- Parietoperitoneum was sutured with “plain cat gut” no 2.0 by continous suture
- Rectus abdominis muscles were sutured with “chromic plain gut” no 2.0 by continous suture
- Fascia was sutured with “vicryl” no 2 by continous suture
- Subcutis was sutured with “plain cat gut” no 0 by simple suture
- Cutis was sutured with" chromic cat gut " no . 3.0 by subcuticuler.
- Bleeding was approximately 800cc .
XIII. 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.
XIV. The operation finished.
The condition of patient post operation:
General condition : Look mild sick
Consciouness : Compos Mentis
Blood pressure : 100/70 mmHg
Pulse rate : 74 x/minute
Respiration : 22 x/minute
Temperature : 36,3 oC
Tissue to Pathology of Anatomy :
□ Yes : Type of tissue ..........................................
□ No
Operator,
(Prof. dr. H.I.O Marsis, SpOG)
