Resume of Case August 24th, 2011

Supervisor : dr. Juliawan, SpOG MS :Tomi, Dian, Ita, Mita, Lili Phisiology : 1 Phatology: 2

Identitied
Name : Mrs. H Age : 20 years old MR : 007120 Adressed: Batu layar

Admitted to GH of NTB on August 24th, 2011 at 10.00

Time 12.30 (24/8/ 2011)

Subject Patient reffered from poli GH NTB with G1P0A0L0 41-42 weeks/S/L/IU head presentation Oligohidramnion + suspect CPD. Abdominal pain since 14-08-2011. History rupture of membrane (-), abdominal pain (+) , bloody slim (-), FM (+). History of HT (-), DM (-), Asthma (-) LMP : 7-11-2010 EDD : 14-08-2011 History of ANC : > 4 x at Polindes History of family planning : Next family planning : History of obstetric 1. This

Object General status: General condition : well Cons : CM BP : 120/70 mmHg PR : 80 bpm RR : 24 x/minute T : 36,5C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+), Rh (-/), Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 32cm L2 : back on the left L3 : head L4 : 4/5 UC :EFW : 3255 gram FHB : 12.11.12 VT : 1cm, eff 10%, amnion +, head palpable, HI unpalpable small part or umbilical cord

Assestment G1P0A0L0 41 -42 weeks/S/L/IU Oligohidramnion + Susp. CPD

Planning - Obs. Mother and fetal well being -DL and HBsAg Report to supervisor Adv : -Resusitation -Injeksi ampi 2gr/iv -SC at 16.30

Pelvic evaluation : Promontorium not palpable Sacrum : convexity normal Spina ischiadica not prominent Os coccigeous mobile Pubic arch < 90 Lab exam : WBC : 11.700 RBC : 4,36 HGB :11 PLT : 375.000 Hct : 35,9 HBsAg : -

Time 14.00wita

S -

O General condition : well Cons : CM BP : 120/70 mmHg PR : 80 bpm RR : 20 x/minute T : 36,7C UC : DJJ : +, 140x/minute

A G1P0A0L0 41 -42 weeks/S/L/IU Oligohidramnion + Susp. CPD

P SC at 16.30

16.50 wita

SC began

17.30wita

Baby was born, Female, BW ; 3500 gr, BL: 48cm, A-S ; 7-9, anus (+), congenital anomaly (-), amnion minimal and unclear bleeding 100 cc Baby was sent to NICU
Plasenta was born manually, complete, 500 gr. bleeding 100 cc GC : well BP : 120/80 mmHg PR : 80 bpm RR : 18 tpm T 36,5C TFU : 1 finger below umbilicus UC : + Active Bleeding (-)

17.45

Time 18.30

S -

O Mother GC : well BP ; 90/60mmHg PR : 108x/ bpm RR : 20 x T : 36,2C UC (+) hard, palpable 1 Finger diatas umbilical. Active bleeding (-) UO : 500 cc

A 1 hour post SC

P Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

19.30

Mother GC : well BP ; 100/60mmHg PR : 116 bpm RR : 20 x T : 36,2C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 510 cc

2 hour post SC

Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

(25-08-2011) 07.00

GC : well BP : 110/80 mmHg PR : 84 bpm RR : 20 tpm T 36,3C TFU : 1 finger below umbilicus UC : + Active Bleeding (-) Baby in NICU: RR : 36 x/minute HR : 130 bpm T : 36,5 C

1 st day post SC

Obs vital sign and active bleeding