Case Report

Name

: Mrs. M

RM
Age

: 062334
: 20 years old

Address : Batu Penyu, Batu Layar Admitted : October 22th 2012

TIME 22/10/ 2012 13.00

SUBJECTIVE 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 : 01/01/2012 EDD : 08/10/2012 History of ANC : > 4x at Posyandu, PHC. Last ANC : 20/10/2012 History of USG : 1x Result : History of family planning : Injection 3 months Next family planning : Injection 3 months Obstetrical History : I. Abortus II. , spontan, midwife, 3800 g, live, 6 years old. III. Abortus IV. This

OBJECTIVE General Status : GC : well BP : 120/60 mmHg PR : 80 bpm RR : 20 bpm T : 36,5oC Eye : anemis (-), icteric (-) Cor : S1S2 single regular, murmur (-), gallop (-). Pulmo : vesiculer (+/+), wheezing (-/-), ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+).

ASSESSMENT G4P1A2L1 4243 weeks S/L/IU head presentation with mother & fetal well

PLANNING 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

Obstetrical Status : L1 : breech L2 : back on the left side L3 : head L4 : 5/5 UFH : 30 cm EFW : 2945 gram UC : (-) FHB : 12-12-11 (140 bpm) VT : (-), head palpable at the fornix

TIME

SUBJECTIVE Chronologist : -

OBJECTIVE PS : 5 Cervix dilatation 1 cm : 1 Cervix length 1 cm : 1 Cervix consistency moderate :1 Cervix position posterior : 0 Station H I : 1 Lab Examination (05/06/2012) : HB : 9,4 g/dl RBC : 4,21 x 106/L HCT : 31,5 % WBC : 8,9x 103/L PLT : 338 x 103/L HbSAg : (-)

ASSESSMEN T

PLANNING

TIME 14.00

SUBJECTIVE

OBJECTIVE UC : (-) FHB : 12-12-12 (148 bpm) UC : (-) FHB : 12-12-11 (140 bpm) UC (-) FHB : 11-12-11 (136 bpm) UC : (-) FHB : 12-12-12 (140 bpm) VT : 1 cm, eff 25%, amnion (+), head palpable HI, denominator unclear, impalpable small part and umbilical cord.

ASSESSMENT

PLANNING Misoprostol 25 mcg/6 hours

20.00

Misoprostol 25 mcg/6 hours

23/10/2 012 04.00 07.00

Misoprostol 25 mcg/6 hours

SPV Visit: Advice: CTG Drip oxytocin

10.30

UC : 1 x 10 ~ 15 FHB : 12-12-11 (140 bpm) UC : 2 x 10 ~ 15 FHB : 11-11-11 (132 bpm) Abdominal pain came and relieved UC : 2 x 10 ~ 20 FHB : 11-12-11 (136 bpm)

Coo GP result CTG CTG reactive Acc Drip Oxytocin Flash I Drip oxytocin began 8 tpm Drip oxytocin 12 tpm

11.00

11.30

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 13.00

SUBJECTIVE Abdominal pain came and relieved

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

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

PLANNING Drip oxytocin 24 tpm

13.30

Abdominal pain came and relieved

UC : 3 x 10 ~ 35 FHB : 11-12-12 (140 bpm) UC : 3 x 10 ~ 35 FHB : 12-12-12 (146 bpm) UC : 3 x 10 ~ 35 FHB : 11-11-11 (132 bpm) UC : 3 x 10 ~ 40 FHB : 12-12-11 (140 bpm) UC : 4 x 10 ~ 40 FHB : 11-11-11 (132 bpm) UC : 4 x 10 ~ 40 FHB : 11-12-11 (136 bpm) VT : 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 28 tpm

14.00

Abdominal pain came and relieved

Drip oxytocin 32 tpm

14.30

Abdominal pain came and relieved

Drip oxytocin 36 tpm

15.00

Abdominal pain came and relieved

Drip oxytocin 40 tpm

15.30

Abdominal pain came and relieved

Drip oxytocin 40 tpm Maintenance Drip oxytocin 40 tpm Maintenance

16.00

Abdominal pain came and relieved, Rupture of membrane

TIME 16.30

SUBJECTIVE Abdominal pain +++ Mother wants to bearing down

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

ASSESSMENT 2nd stage of labor

PLANNING 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.

16.40

19.00

GC : well BP : 110/70 PR : 84 bpm RR : 20 bpm T : 36,1oC UFH : 2 fingers below umbilicus UC : (+) 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 : well BP : 120/60 PR : 88 bpm RR : 20 bpm T : 36,4oC UFH : 2 fingers below umbilicus UC : (+) Lochea rubra : (+) Baby rooming in : PR : 140 bpm RR : 44 bpm T : 36,6oC

One day post partum

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