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8/13/2019 MR 231013 Negelegted
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8/13/2019 MR 231013 Negelegted
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Case Resume :
No. Case Total
Pathology Delivery 1
1. G1P0A0L0 38-39 weeksS/L/IU with neglected active
phase 1ststage of labor
Normal Delivery 0
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Name : Mrs. E
Age : 21 years old
Address : Gegelang, LingsarAdmitted : 23rd Oct 2013
No. RM : 091711
G1P0A0L0 38-39 weeks S/L/IU with neglected active
phase 1ststage of labor
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s
Time Subject Object Assesment Planning
23/10/
2013
10.30
WITA
Patient referred from Narmada PHC
with G1P0A0L0 38-39 weeks S/L/IU
with latent phase 1 stage of labor pro
USG.Mother confessed abdominal pain
spread to flank since 07.00 (22/10/2013),
bloody slim (-), history of water leakage
(-), Fetal Movement (+). Nausea (-),
vomiting (-), headache (-), visual
diturbance (-).
No history of DM, HT, asthma. No
history of allergic reaction to medicine or
food.
LMP : 24 - 1 - 13
EDD: 1 11 - 13
History of ANC : 8x at Posyandu andPHC
Last ANC : 13-10-2013
History of USG : -
Last USG :
History of Family Planning : -
Next Family Planning : IUD
History of obstetry:1. This
Examination at VK Teratai Room:
General condition : Well
GCS : E4V5M6BP : 120/80 mmHg
PR : 88x/
RR : 20x/
Temp : 37,7C
General Status
Eyes : an-/-, ict -/-
Cor : s1s2single, m -, g
Pulmo : Ves +/+, rh -/-, whz -/-
Abdomen : striae gravidaum (+),
linea nigra (+)
Ext : oedem-/-, warm +/+
Status Obstetric
L1 : breech
L2 : back on the right side
L3 : head, in pelvic inlet
L4 : 4/5
UFH : 32 cm
EFW : 3.255 gram
FHR:20-21-19,reguler (160bpm)(FHR takicardi)
UC : 2 x /10~20
VT : 6 cm, eff 50%, Amnion (+),
head palpable HI, denominator
unclear, small part of
fetal/umbilical cord unpalpable
G1P0A0L0 38-39
weeks S/L/IU with
neglected active phase
1ststage of labor
Observation mother
and fetal well being
Lab. Check (CBC,
HBsAg, and Complete
Urine)
CTG
DM Co. to SPV, pro :
Inj. ceftriaxon 1g
Resusitation
intrauterin (RL :
D5% = 2 : 1)
SC
SPV Adv :
SPV Acc for SC,
Inj ceftriaxon 2g
Inj xilomidon 2cc
CIE patient and family
Pre OP SC
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Time Subject Object Assesment Planning
Chronology at Narmada PHC
22 /10/2013 at 00.30 WITA
S: Patient confessed abdominal pain
spread to flank since 07.00 (2/10/2013)
LMP : 24- 1- 2013
EDD: 1- 11- 2013
O:
General status :
GC well, con. CM, BP 130/80mmHg,
PR 80 x/minute, RR 20 x/minute, T 36.0
C. Oedema extremeties -/-.
Obstetric status:
L1: breech TFU: 30 cm
EFW: 2790 gram
L2 : back on the rightL3 : head
L4 : 4/5
UC : 2 x 10~ 35
FHR : 12- 11 -11 (140x/mnt)
VT : 1 cm, eff. 25 %, Amnion (+)
clear, head palpableHI, , denominator
unclear, impalpable small part of fetal &
umbilical cord.
G1P0A0L0 38-39
weeks S/L/IU with
latent phase 1 stage
of labor.
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Time Subject Object Assesment Planning
22/10/2013 at 07.30 WITA
S : -
O:
Obstetric status:
UC : 2-3 x 10~ 35-40
VT : : 2 cm, eff. 25 %, Amnion (+)
clear, head palpableHI, , denominatorunclear, impalpable small part of fetal &
umbilical cord
A: -
P: -
22/10/2013 at 01.00 WITA
S: -
O:
General status :
-.
Obstetric status:
UC : 3 x 10~ 35
FHR : -
VT : 2 cm, eff. 25 %, Amnion (+)
clear, head palpableHI, , denominator
unclear, impalpable small part of fetal &umbilical cord
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Time Subjective Object Assesment Planning
23/10/2013 at 07.00 WITA
S: -
O:
General status :
-.Obstetric status:
UC : 2 x 10~ 35
FHR : -
VT : 2 cm, eff. 25 %, Amnion
(+) clear, head palpableHI, ,
denominator unclear, impalpable
small part of fetal & umbilical cord
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FHR > 160 bpm
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12.00
wita
Patient moved to OK Room - G1P0A0L0 38-39
weeks S/L/IU with
neglected active phase
1ststage of labor
Time Subject Object Assesment Planning
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13.05
WITA
- G1P0A0L0 38-39
weeks S/L/IU with
neglected active phase
1ststage of labor
SC Begin
13. 35
WITA
- - - Baby was born, male,
birth weight 3.300 g,
birth lenght 48 cm,
anus (+), congenitalanomaly (-), Apgar
Score 7-9
Amnion clear
Move Baby to NICU
15.35 Patient confessed dizzy (+) General StatusGeneral condition : Well
GCS : E4V5M6BP : 120/80 mmHg
PR : 79x/
RR : 18x/
Temp : 36,8C
UC : +
UFH : 2 fingers below umbilicalUO : 500 ml
2 hours post SC
Observation patientgeneral condition,
urine output and vital
sign
Observation SC
wound
Move patient to Melati
room
Time Subject Object Assesment Planning
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24/10/13
07.30
Patient confessed dizzy (+) General Status
General condition : Well
GCS : E4V5M6BP : 120/80 mmHg
PR : 88x/
RR : 22x/
Temp : 36,7C
UC : +
UFH : 2 fingers below umbilical
UO : 400 ml
Baby in NICU ;
PR: 144 bpm
RR: 42 x/m
Temp :36,8 C
1 day post SC Observation patient
general condition,
urine output and vital
sign
Observation SC
wound
Time Subject Object Assesment Planning
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THANK YOU...