Mr Koas Fixed

8/4/2019 Mr Koas Fixed

1/15

Coass in charge:

Fara/Vicia/Yanti/

Eva/Tryas/Desi

Supervisor:

Dr. Mulyo Hadi Sungkono, Sp.OG(K)


2/15

Reg. 1124075

Mrs. S/36 y.o/ 6 y.o.e/housewifeMr. K/41 y.o/ 6 y.o.e/driver

Address : Polowijen II/452 RT1/33

Admitted at September 17th,2011, at 18.25pm

Marriage 1x 19 years

Patient came to RSSA because was referred by

midwife

Contraception: inj. 3 months, stopped 1 year ago This is the fifth pregnancy


3/15

Children:

1.

At/?/spt.B/dukun/F/17 yo/L2. At/?/spt.B/dukun/M/13 yo/L

3. At/3350 gr/spt.B/midwife/M/8 yo/L

4. At/3000 gr/spt.B/midwife/F/3 yo/L

5. This pregnancy


4/15

SUBJECTIVESeptember 17th 2011

at 10.00 am patient complained of uterine contraction

went to midwife because post date referred to

RSSA

ANC: 3x, midwife

LMP 20-11-10 EDD 27-8-11~ 43-44 wks


5/15

OBJECTIVE (07.00 PM)

GA : Good , CM

BH : 155 cm BW : 60 kg

BP : 110/70 mmHg, PR : 80 bpm, RR :20x/

Tax : 36,6C Trect : 36,8C

H/N : an -/- ict -/-

Tho : C/P wnl

Abd : FH 31 cm, longitudinal lie U , FHR

12.12.13EFW 2945 gr, uterine contraction infrequently


6/15

VT:

Dilatation 1 cm, Eff: 50 %, H I,

Amniotic Membrane (+), Head

presentation

Denominator minor fontanela

Pelvic Measurement~ wnl

Pelvic score: 6


7/15

LABORATORY

CBC : 11.900/10,4/31,6/363.000

NST : normal

baseline rate: 150 bpm

variability: 5-15 bpm

acc: (+)

dec: (-)

USG: intrauterine fetus S/L letak bujurkepala di bawah


8/15

LABORATORY (contd.)

USG: intrauterine fetus S/L letak bujurkepala di bawah

BPD: 86.5 (34 w 5 d)

AC: 313 (35 w 1 d)FL: 73.2 (37 w 3 d)

EFW: 2832

AFS: 13.5

Placental implantation on fundusMaturation grade III


9/15

ASSESSMENT

G5 P4004 Ab000 part 43-44 weeks T/H

+ post term

+ age more than 35 years


10/15

PDx: DL, admission test PTx:

Termination w/ OD 8 tpm increase 4 tpm

every 15 mnt (max. 40 tpm).

Evaluation 2 hours after adequate uterinecontraction

Pro expect pervaginam

PMo: Obs. VS, complaint, uterus contraction,

fetal heart rate, progress of labourPEd: CIE


11/15

September 17th 2011, 09.00 pm

Subjective

Uterine contraction adequate with OD 12 drops/m.

Adequate his at 07.00 PM.

Objective

GA: Good, CM

BP: 100/70, HR: 88 bpm, RR: 20 tpm

H/N: an -/-, ict -/-

Tho: c/p wnl

Abd: FH 21 cm, longitudinal lie U, FHR: 11.13.11, EFW: 2945 gram, His 10.3.35/ms

VT: 4cm, Eff. 100%, H I, amniotic (+) clear, head presentation, denominator minor

fontanela 2 oclock, pelvic measurement ~ wnl

Assesment

G5 P4004 Ab000 part 43-44 weeks T/H + First Stage Active Phase + Post term + age

more than 35 years

Planning:

Evaluated 2 hours later (11.00 pm)

Pro exp pervaginam Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour


12/15

September 17th 2011, 09.15pm

Subjective

Uterine contraction regularly (OD 12 drops/m)

Rupture of fetal membrane spontaneously

Objective

GA: Good, CM

BP: 110/70, HR: 88 bpm, RR: 20 tpm

H/N: an -/-, ict -/-

Tho: c/p wnl

Abd: FH 31 cm, longitudinal lie U, FHR: 11.12.11, EFW: 2945 gram, His 10.3.40/ms

VT: 8cm, Eff. 100%, H II, amniotic (+) clear, head presentation, denominator minorfontanela 1 oclock, pelvic measurement ~ wnl

Assesment

G5 P4004 Ab000 part 43-44 weeks T/H + First Stage Active Phase + Post term + agemore than 35 years

Planning:

Evaluated 2 hours later (11.15 pm)

Pro exp pervaginam

Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour

CIE


13/15

September 17th 2011, 09.55pm

Subjective

Mother wanted to push

Uterine contraction regularly and adequate

Objective

GA: Good, CM

BP: 100/70, HR: 88 bpm, RR: 20 tpm

H/N: an -/-, ict -/-

Tho: c/p wnl

Abd: FH 31 cm, longitudinal lie U, FHR: 12.13.12, EFW: 2945 gram, His10.3.40/ms

VT: complete, H III, amniotic (+) clear, head presentation, denominatorminor fontanela 12 oclock, pelvic measurement ~ wnl

Assesment

G5 P4004 Ab000 part 43-44 weeks T/H + Second Phase + Post term + agemore than 35 years

Planning:

Ibu dipimpin mengejan

pro exp pervaginam Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour


14/15

OUTCOME

On September 17th , 2011 at 10.00p.m

a male baby was born,3000gr / 47 cm/ AS 7-9

(Ballard score = 37 39-40 weeks)


15/15

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