OBSTETRIC EMERGENCY ROOM

LETAK SUNGSANG
1. SUG, 29 yo
Complained labor pain (+)
since 10.00 pm
(30/08/2014) , watery
vaginal discharge (-), FM
(+) good. Known breech
pres since 08/07/2014 ~ 33
wks GA (USG at O&G).
LMP: 25/11/2013
EDD: 02/09/2014
PNC: Midwife, O&G
Obstetric History:
1. , 3500 g, SVD,
midwife, 11 yo
2. , 3500 g, SVD,
midwife, 8 yo
3. , 3500 g, SVD,
midwife, 2 yo
4.Current pregnancy
Married: 2x: I~8 yrs
II~2 yrs
Contraception: OCP ~
stop August 2013

WAW
W/H: 67/152
Present St:
BP: 120/70
P : 88

RR: 20
Tax: 36,7

General St :
Eyes
: anemic -/Thorax
cor
: S1S2 sgl, reg, m (-)
pulmo : ves +/+, rh -/-, wh -/Ext
: warm +/+ Oedem -/+/+
-/Obstetric St:
Abd: FH 38 cm , AC 97 cm
UC (+) 3x/10~40-45
FHB (+) 138 bpm
VT (SDW) 08.30 am
CD 8 cm, Eff 75%, AM (+)
Buttock palp, Sacrum Left
Anterior, H II
Unpalp small parts/umb cord

G4P3003 39-40
wks, S/L,
Breech Prest,
1st stage of
labor
EFW: 3592 g
ZA: 4

Pdx:Tx:
Exp Vaginal Delivery
IVFD RL 20 dpm
Mx:
C, VS, FHB, UC,
Progress of labor
CIE

OBSTETRIC EMERGENCY ROOM

DUTY ON : SUNDAY, AUGUST 31st 2014
1. SUG, 29 yo

WAW
LAB:
WBC: 14,6
HGB: 11,2
HCT: 40,4

PLT: 266
BT: 100
CT: 830

USG:
Fetus, S/L, breech prest, FHB (+), FM (+)
BPD: 96,0 ~ 39W6D
AVE 39W3D
AC: 348,2 ~ 39W3D
EFW: 3592 g
FL: 79,3 ~ 40W3D
EDD: 2/09/14
Placenta Fundus Corpus Anterior grd III
AFI 8,2

at 09.25 am
Patient urge to bear
down, spontaneously
ROM

Obstetric St:
Abd: UC (+) 4-5x/10~40-45
FHB (+) 142 bpm
VT (WAW) 09.25 am
CD complete, AM (-)
Buttock palp, Sacrum Transverse,
HIII+

2nd stage
of labor

Tx: Lovset Mauriceau

At 09.33 am
born baby, , 3900 g,
AS 7-8