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No. MR

OPERATION REPORT

Nama : Mrs. Endah Sex : Female Age : 36 Years

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

Asisten 1 dr. Benhur Instrumentator Zr. Ria

Asisten 2 Melisa Silvia Sembiring Observer Putu Tara Judica WahyudyasaPre-operation Diagnose :G2P1 A0+ insufficiency plasenta +

history of small weight baby + chronic hypertension

Post-operation Diagnose : P2A0, post SCTP e.c CPD,

insufficiency plasenta + history of small weight baby +

chronic hypertension

Date of operation : December 3rd

2012

Duration of operation : 1 hours 20

minute

Tehnique of operation : Type of operation

1. Sectio caesarea trans peritoneal profunda □ Emergency □ Minor

2. - □ Poliklinik □ Medium

3. - □Elektif □ Mayor

Operation Prosedures :

I. Patient slept in supine position with spinal anastesia

II. Aplied inside the dower catheter

III. Aseptic and antiseptic on abdomen adjacent regio until 1/3 proksimal upper leg and the

operation field was limited with steril doek

IV. Pfanenstiel incision was made around fibritio tissue, 15 cm length and the skin fold in

down abdomen regio was thrown, the incision was made deeper sliece by sliece from

cutis, subcutis, fascia with sharp technique. Then musculus rectus abdominis it

separated to lateral section with dull technique, bleeding was taken care off.

V.

Peritoneum parietal was opened upside 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.

Transversal incision was made on lower segment of uterus, extend to right and left until

we can saw liquor amnii membran and then the operator brook the liquor amnii

membran, liquor amnii was clear and we could saw baby’s head

10 28 00 00

OBSTETRIC AND GINECOLOGY DEPARTEMENTCHRISTIAN UNIVERSITY OF INDONESIA HOSPITALJl. Mayjen Sutoyo no. 2, Cawang, Jakarta Timur, 13630

Tel. 021 – 8092317 ext. 108 / 205



VII. Baby’s head was pulled out with using forceps and with mild pressure on the fundus

uterine by assistant. Then delivered step by step, front shoulder, back shoulder,

backward trochanter anterior, trochanter posterior, breech, extremitas inferior.

VIII.

The baby was crying, umbilical cord was clomped on 2 place ± 5 cm and 7 cm from the

umbilical cord, then it was cut between 2 clamp and the baby was delivered to

perinatologi

IX. The new born baby was delivered at 16.30 WIB, with female gender, body weight birth

2500 gr, leght birth 45 cm, Apgar Score 8/9, anal (+) and did’t saw major congenital

disorder

X. Plasenta was completely born in manual, cavum uterine was cleaned from the residual

plasenta tissue with sharp curretase post partum until surely clean. Bleeding was

controlled. After that the uterine tissue was sewed and over hecting with “chromic cat

gut no. 2”

XI.

Suture was done on lower segmen of uterine at two pole with “chromic cat gut” no. 2

and then the miometrium tissue was suture by continue

- First slice of miometrium tissue with “Chromic cat gut” no. 2 by interlocking

- Second slice of miometrium tissue and serosum was suture by continue with

“Chromic cat gut” no. 2 XII. The abdomen cavity was cleaned and 2 curavor was pulled out from the abdomen

cavity

XIII. Before the abdomen cavity was sewed, it was giving cortisone asetat 2,5 mg into

peritoneal cavity

XIV. After sure it’s no bleeding, abdomen cavity was objed slice by slice

a. Peritoneum parietal was sutured with “chromic cat gut” no. 2.0 by continue

b. M. Rectus abdominis was sutured with “chromic cat gut” no. 1.0 by continue

c. Fascia was sutured with “vicryl” no. 1 by simple suture

d. Subcutis was sutured with “chromic cat gut” no. 2.0 by simple suture

e. Cutis was sutured with “Plain cat gut” no. 3.0 by subkuticuler

XV.

Bleeding approximately 500cc

XVI. Cavum vagina was cleaned pervaginam with cassa and bethadine

XVII. 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



XVIII. The operation finished

The condition of patient post operation:

General condition : Look mild sick

Blood pressure : 180/100 mmHg

Pulse rate : 88 x/minute

Respiration : 20 x/minute

Temperature : 37 oC

Tissue to Pathology of Anatomy :

□ Yes

□ No

Operator,

(Prof. dr. H.I.O Marsis, SpOG)

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