Case Report

Name : Mrs. MRM : 062334Age : 20 years oldAddress : Batu Penyu, Batu LayarAdmitted : October 22th 2012

TIME SUBJECTIVE OBJECTIVE ASSESSMENT

PLANNING

22/10/2012

13.00

Patient referred from Policlinic NTB GH with G4P1A2L1 42-43 weeks S/L/IU head presentation with mother & fetal well. Patient confessed > 9 mounth pregnancy. History rupture of membrane(-).Blood slim (-). Abdominal pain (-). FM (+).No history of DM, HT, asthma.

LMP : 01/01/2012EDD : 08/10/2012

History of ANC : > 4x at Posyandu, PHC.Last ANC : 20/10/2012History of USG : 1xResult :

History of family planning : Injection 3 monthsNext family planning : Injection 3 months

Obstetrical History :I.Abortus II.♂, spontan, midwife, 3800 g, live, 6 years old.III.AbortusIV.This

General Status :GC : wellBP : 120/60 mmHgPR : 80 bpmRR : 20 bpm T : 36,5oCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesiculer (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).

Obstetrical Status :L1 : breechL2 : back on the left sideL3 : headL4 : 5/5UFH : 30 cm EFW : 2945 gramUC : (-)FHB : 12-12-11 (140 bpm)VT : Ø (-), head palpable at the fornix

G4P1A2L1 42-43 weeks

S/L/IU head presentation with mother & fetal well

• Observation mother & fetal well being.• RL 500 cc, 28 tpm• DM co GP pro CTG, advice : ACC CTG → reactive, termination• If PS < 5, termination with Misoprostol 25 mcg/8 hours• If PS > 5, termination with Oxytosin Drip

TIME SUBJECTIVE OBJECTIVE ASSESSMENT

PLANNING

Chronologist :-

PS : 5Cervix dilatation 1 cm : 1Cervix length 1 cm : 1Cervix consistency moderate : 1Cervix position posterior : 0Station H I : 1

Lab Examination (05/06/2012) :HB : 9,4 g/dl RBC : 4,21 x 106/µL HCT : 31,5 % WBC : 8,9x 103/µLPLT : 338 x 103/µLHbSAg : (-)

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.00

UC : (-)FHB : 12-12-12 (148 bpm)

Misoprostol 25 mcg/6 hours

20.00

UC : (-)FHB : 12-12-11 (140 bpm)

Misoprostol 25 mcg/6 hours

23/10/2012

04.00

UC (-)FHB : 11-12-11 (136 bpm)

Misoprostol 25 mcg/6 hours

07.00

UC : (-)FHB : 12-12-12 (140 bpm)VT : Ø 1 cm, eff 25%, amnion (+), head palpable ↓HI, denominator unclear, impalpable small part and umbilical cord.

SPV Visit:Advice:

CTGDrip oxytocin

10.30

UC : 1 x 10’ ~ 15”FHB : 12-12-11 (140 bpm)

Coo GP result CTG CTG reactive

Acc Drip Oxytocin

11.00

UC : 2 x 10’ ~ 15”FHB : 11-11-11 (132 bpm)

Flash IDrip oxytocin began

8 tpm

11.30

Abdominal pain came and relieved

UC : 2 x 10’ ~ 20”FHB : 11-12-11 (136 bpm)

Drip oxytocin 12 tpm

12.00

Abdominal pain came and relieved

UC : 2 x 10’ ~ 20”FHB : 11-12-11 (136 bpm)

Drip oxytocin 16 tpm

12.30

Abdominal pain came and relieved

UC : 2 x 10’ ~ 20”FHB : 12-12-11 (140 bpm)

Drip oxytocin 20 tpm

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

13.00

Abdominal pain came and relieved

UC : 3 x 10’ ~ 35”FHB : 11-12-11 (136 bpm)VT : Ø 2 cm, eff 30%, amnion (+), head palpable ↓HI, denominator unclear, impalpable small part and umbilical cord.

G4P1A2L1 42-43 weeks S/L/IU head presentation with Latence phase 1st

stage of labor

Drip oxytocin 24 tpm

13.30

Abdominal pain came and relieved

UC : 3 x 10’ ~ 35”FHB : 11-12-12 (140 bpm)

Drip oxytocin 28 tpm

14.00

Abdominal pain came and relieved

UC : 3 x 10’ ~ 35”FHB : 12-12-12 (146 bpm)

Drip oxytocin 32 tpm

14.30

Abdominal pain came and relieved

UC : 3 x 10’ ~ 35”FHB : 11-11-11 (132 bpm)

Drip oxytocin 36 tpm

15.00

Abdominal pain came and relieved

UC : 3 x 10’ ~ 40”FHB : 12-12-11 (140 bpm)

Drip oxytocin 40 tpm

15.30

Abdominal pain came and relieved

UC : 4 x 10’ ~ 40”FHB : 11-11-11 (132 bpm)

Drip oxytocin 40 tpmMaintenance

16.00

Abdominal pain came and relieved, Rupture of

membrane

UC : 4 x 10’ ~ 40”FHB : 11-12-11 (136 bpm)VT : Ø 5 cm, effacement 50%, amnion (-), head palpable ↓HII, denominator unclear, impalpable small part and umbilical cord.

G4P1A2L1 42-43 weeks S/L/IU head presentation with

c

Drip oxytocin 40 tpm

Maintenance

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

16.30

16.40

Abdominal pain +++Mother wants to bearing down

UC : 4 x 10’ ~ 40”FHB : 12-12-13 Doran teknus perjol vulka

2nd stage of labor • Drip oxytocin 40 tpm• Conduct mother to bearing down :

Baby was born :female, AS 7-9, 2500 gram, 51 cm. Anus (+), congenital anomaly (-).

Placenta was born spontaneous, complete, bleeding ±150 cc.

UFH : 2 fingers below umbilicus.

19.00

- GC : wellBP : 110/70 PR : 84 bpmRR : 20 bpm T : 36,1oCUFH : 2 fingers below umbilicusUC : (+)Lochea rubra : (+)

2 hours post partum

•Observed mother and baby well being•Observed bleeding & VS mother•Suggest mother to mobilisation, eat & drink.

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

24/10/2012

07.00

- GC : wellBP : 120/60 PR : 88 bpmRR : 20 bpm T : 36,4oCUFH : 2 fingers below umbilicusUC : (+) Lochea rubra : (+)

Baby rooming in :PR : 140 bpmRR : 44 bpmT : 36,6oC

One day post partum

•Observed mother and baby well being•Suggest mother to mobilisation, eat, and drink, medication.•Breast feeding