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OBSTETRIC AND GINECOLOGY DEPARTEMENTBUDHI JAYA MOTHER AND CHILD HOSPITALJL. Dr. Sahardjo No. 120 Jakarta Selatan 12960Telp. (021) 8292672, 8311722, 8312378Fax. 8301901

No. MR

OPERATION REPORT

Nama : Mrs. Reine Sex : Female Age : 26 YearsOperator Prof. Dr. H.I.O Marsis, SpOG Anesthetic dr. Widodo, Sp AnAssistant 1 Melati Pratiwi Instrumentator Zr. LatifahAssistant 2 dr. Benhur Sibuea Observer Daniel MatiusPre-operation Diagnose : Antiphospholipid Syndrome at 38 t

weeks of gestation in G 1P0A0 Post-operation Diagnose : Antiphospholipid Syndrome Date of operation : July 12 t 2013

Duration of operation : 1 hours 15minutes

Tehnique of operation :1. Sectio caesarea trans peritoneal profunda2. -3. -

Type of operation Emergency Poliklinik

Elektif

Minor Medium

Mayor

Operation Procedures:

I. Patient slept in supine position with spinal anastesia on operation table

II. Applied 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. Pfanenstiel incision was made around fibritio tissue 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 2 curavors were put inside the right and left abdomen cavity for

seperating the uterine and the other organ.

VI. Opened plica vesico uterine and continued incision to left and right lateral and put

aside to lower.

VII. 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 amniimembran, liquor amnii was clear and we could saw babys head .

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VIII. Then the b abys head was pulled out by forceps extraction and with mild pressure on

the fundus uterine by assistance. Then the deliver step by step from head, front

shoulder, back shoulder, backward trochanter anterior, trochanter posterior, breech

and extremitas inferior was delivered with a sort umbilical cord coil attached to the

baby.

IX. The baby was crying, umbilical cord was clamped 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

perinatology.

X. The new born baby was delivered at 6.05 am, with female gender, body weight birth

2800 gr, length birth 48 cm, Apgar Score 9/10, anal (+) and didnt saw major

congenital disorder

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

residual plasenta tissue. Bleeding was controlled. After that the uterine tissue was

sewed and over hecting with chromic cat gut no 2.

XII. Suture was done on lower segmen of uterine at two pole with Chromic cat gut no. 1

and then the miometrium tissue was suture by continue and overhecting

- First slice of miometrium tissue with Chromic cat gut no. 2 by continue

- Second slice of miometrium 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.

XIII. The abdomen cavity was cleaned and 2 curavors was pulled out from the abdomen

cavity.

XIV. Before the abdomen cavity sewed, it was giving cortisone asetat 25 mg/10ml into

peritoneal cavity.

XV. After sure its no bleeding, abdomen cavity was objed slice by slicea. 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

c. Fascia was sutured with vicryl no. 1 by simpl suture

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

e. Cutis was sutured with Chromic cat gut no. 3.0 by sub cuticuler

XVI. Bleeding approximately 300 cc

XVII. Cavum uterine was cleaned pervaginam


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XVIII. 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

XIX. The operation finished

The condition of patient post operation:

General condition : Look mild sick

Blood pressure : 120/70 mmHg

Pulse rate : 72 x/minute

Respiration : 24 x/minute

Temperature : 36,3 oC

Tissue to Pathology of Anatomy :

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

No

Operator,

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

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