Name : ADRIA ROZA

Age : 24 years old

MR No. : 56 07 14
Address : Jl. Raya Indarung, Simpang Gadu
Date : September 30th, 2007

Anamnesis :
A 24 years old patient was admitted to the Delivery Room of Dr. M. Djamil
Central General Hospital on September 30th, 2007 at 01.20 am with chief complain fluid
leakage from the vagina since 2 ½ hours ago.

Present Illness History :

 Fluid leakage from the vagina since 2 ½ hours ago, about a half glass of water,
greenish colour, smelly odor.
 Feeling of pain from waist to region which referred to the groin was absent.
 Bloody show from the vagina was absent.
 No massive vaginal bleeding.
 Amenorrhea since 9 months ago.
 First date of last menstrual period was on December 31st, 2006
Estimation date of delivery was on October 7th, 2007
 Fetal movement was felt since 4 months ago.
 No complain of nausea, vomitting and vaginal bleeding neither during early
pregnancy nor late pregnancy.
 Prenatal care to a midwife.
 Menstruation History : menarche at 13 years old, regular cycle, every month which
last for about 1 week each cycle with the amount of 2-3 times pad change/day
without menstrual pain.

Previous Illness History :

There wasn’t previous history of heart, lung, liver, kidney, DM and hypertension.

Family Illness History :

There wasn’t history of hereditary disease, contagious and physicological illness in the
family.

Marriage history : once in 2006

History of pregnancy/abortion/delivery : 1/0/0
I. Present
History of family planning : (-)
History of immunization : (-)

Physical Examination :
GA Cons BP PR RR T
Mdt CMC 120/70 82 20 af

Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric

Neck : JVP 5-2 cmH2O, tyroid gland no enlargement
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
Obstetric Record :
Face : Chloasma gravidarum was positive
Breast : Both enlarge, areola/nipple hyperpigmentaton, colostrum (+)
Abdoment :
I : Enlarge equal to term pregnancy, median line hyperpigmentation, striae (+),
cicatrix (-)
Pa : L1 : Uterine fundal was palpable 3 finger above symphisis pubic
A large nodular mass was palpated
L2 : A hard and resistance structure was felt on the left side
Numerous small, irregular were felt on the right side
L3 : A hard mass was palpable and fixed
L4 : The lowest part of the fetal body has entered the inlet
Uterine Fundal Height : 39 cm Estimated fetal body weight : 4030 gr
Uterine contraction : (-)
Pe : Tympani
Au : Peristaltic sound normal Fetal Heart Sound : 12-11-12, regularly

Genitalia :I V/U normal

Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (+), there’s greenish fluid, concentrate at
posterior fornix, LT (+)
Portio : NP, size equal to an adultfoot toe, tumor (-), laceration (-), fluxus (+)
There was greenish fluid leakage from cervical canal, OUE was closed,
LT (+)
VT  1 finger
Portio thick, 1 ½ cm, posterior, soft
Amnionic sac (-), greenish colour
Head palpable at HI
Pelvic Inlet : Promontory : can’t be reached
Inominate line : palpated 1/3 – 1/3
Sacrum bone : concave
Pelvic side wall : straight
Ischiadic spine : no protruded
Coccygeus bone : moveable
Arc of pubic : > 90
Pelvic Outlet : Inter tuberous distance could be passed through by normal adult fist
(>10,5 cm)
Impression : No contracted pelvic

Diagnose :
G1P0A0L0 term pregnancy (39-40 weeks) + 2 ½ hours PROM + susp, large baby
Fetal alive, singleton, intra uterine, head presentation HI

Management :
Control GA, VS, FHS, delivery sign
Check routine blood labor
Antibiotic (skin test first)
Observe 3 ½ hours later (04.50 am)

Plan :
Vaginal Delivery
Laboratory :
Hb : 12.6 gr%
Leucocyte : 12,100/mm
Hematocrit : 36%
Trombocyte : 256,000/mm3

At 04.50 am :
A/ Feeling of pain from waist to region which referred to the groin (+)
Fetal movement (+)
PE/ GA Cons BP PR RR T Uterine Contr. FHS
Mdt CMC 120/70 84 20 af (-) 134

Genitali : I V/U normal

VT  1 finger
Portio thick 1 ½ cm, posterior, soft
Amnionic sac (-), greenish colour
Head palpable at HI
D/ G1P0A0L0 term pregnancy (39-40 weeks) + 6 hours PROM + susp, large baby
Fetal alive, singleton, intra uterine, head presentation HI
M/ Control GA, VS, FHS
Prepare for CS
Prepare WB 500 cc
Report to operation room & consult anesthesiologist
P/ CS

At 07.30 am : TPPCS was perfomed

At 08.30 am : Finished TPPCS
A female baby was born by TPPCS with 4032 gr in weight, 49 cm in
height and APGAR score was 8/9.
Placenta was born with a little pull on umibilical cord.
Size was 20 x 18 x 3 cm, weight approximately 600 gr.
Umbilical cord was approximately 50 cm in length with paracentral
insertion.
Bleeding during operation approximately 200 cc.
D/ P1A0L1 post TPPCS on indication of partus kasep
Mother – Child was good
A/ Observe after operation