Supervisor: dr.

Agus Thoriq, SpOG

DM: Akbar

Case Resume :
No.
1.
2.

Case
Pathology Delivery
G4P2A1L2 41 weeks head presentation
with hypertension gestasional + IUGR
G2P1A0L1
40-41
weeks
head
presentation with protracted active
phase 1st stage of labor
Normal Delivery

Total
2

CASE 1
IDENTITY
Name
Age
Address
No. RM

: Mrs. S
: 26 yo
: Monjok
: 538430

Hozpitalised on 12.15 WITA, 11th May 2014

G4P2A1L2 41 weeks head

presentation with Hypertension
gestasional + IUGR

TIME

SUBJECTIVE

11/05/
14

Patient came to VK IRD

confessed abdominal pain
since
06.00
WITA
at
11/05/14, water came out
from her vagina (-), bloody
slim (-), fetal movement (+),.

12.15
WITA

No history of DM, history of,

asthma (+), history of HT (+).
History of food allergic (+).
LMP : 30-07-2013
EDD : 06-05-2014
History of ANC : 3 x in
Posyandu
Last ANC: 20/03/2014, result:
BP: 130/80 mmHg, FHB (+),
head presentation,
History of USG: 1 x
Male, S/L/, 26-27 weeks,
plasenta in corpus posterior
(14/02/2014)

OBJECTIVE
General status:
GC: well
GCS: E4V5M6
BP: 150/100 mmHg
PR: 84 bpm
RR: 22 rpm
T: 370 C
Eye : anemis (-), icteric (-)
Thorax :
Cor : S1S2 single reguler,
murmur (-), gallop (-)
Pulmo : vesikuler (+/+),
wheezing (-/-), Ronkhi (-/-).
Abdomen : scar (-), striae
livida (+), linea nigra (+),
Extremity : edema (-/-), warm
acral (-/-)
Nutrition status :
Body Height : 134 cm
Body weight : 48 kg
Obstetrical status:
L1: breech
L2: back on the right side
L3: head
L4: 4/5
UFH: 25 cm
EFW: 2170
UC: 2x10~20
FHB: 12-12-12 (144x/min)

ASSESTMENT

PLANNING

G4P2A1L2 41
weeks head
presentation
with 1st stage
latent phase
Hypertension
gestasional +
IUGR

Obs mother &

fetal well being
Obs. Progress of
labor

TIME

SUBJECTIVE

OBJECTIVE

History of Family Planning:

injection
Next Family Planning: History of obstetry:
1.Aterm,
spontan,
traditional birth attendan,
3300 gram female, 14 yo
2.Aterm , spontan, 3300
gram, female 9 yo
3.Abortus
4.This

VT : 2 cm , eff 15%, amnion

(+), head presentation, denom
unclear, HI, unpalpable small
part of fetal

Chronologist: (-)

Lab Result
Hb : 11,7 x 106/ L
WBC : 13,23 x 103/ L
PLT : 376x 103/ L
HCT : 34,1 %
HBsAg : (-) non reactive
Proteinuria : (-)

ASSESTMENT

PLANNING

TIME
12.45
WITA

SUBJECTIVE
Abdominal pain +

13.15 Abdominal pain +

WITA

OBJECTIVE

ASSESTMENT

PLANNING

UC: 2x10~20
FHB : 12-12-12 (144)

G4P2A1L2 41
weeks head
presentation
with 1st stage
latent phase
Hypertension
gestasional +
IUGR

Obs mother & fetal

well being
Obs. Progress of
labor

UC: 3x10~35
FHB:13-12-13 (160)

G4P2A1L2 41
weeks head
presentation
with 1st stage
latent phase
Hypertension
gestasional +
IUGR

Dm pro ctg, GP
advice CTG, consult
result of ctg to GP,
GP advice
recutitation
intrauterine

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

14.00

Abdominal pain ++
Mothers confessed, water
leaked out from her vagina

UC: 3x10~45
FHB : 12-12-12 ( 144)
VT: 5cm , amnion (-),
head presentation,
denom unclear, HII,
unpalpable small part of
fetal

G4P2A1L2 41
weeks head
presentation
active phase
first stage of
labor with
Hypertension
gestasional +
IUGR

Observation
progress of labor

14.30

Abdominal pain ++

UC: 3x10~45
FHB : 12-12-11 ( 140)

G4P2A1L2 41
weeks head
presentation
active phase
first stage of
labor with
Hypertension
gestasional +
IUGR

Observation
progress of labor

15.00

Abdominal pain ++

UC: 3x10~45
FHB : 12-12-11 ( 140)

G4P2A1L2 41
weeks head
presentation
active phase
first stage of
labor with
Hypertension
gestasional +
IUGR

Observation
progress of labor

TIME
15.25
WITA

15.30
WITA

SUBJECTIVE
Mothers want to bearing down

OBJECTIVE
UC: 3x10~45
FHB : 12-12-12 ( 144)
Inspeksi : Bulging of
perineum, opening
vulva (diameter of head
5cm), anus pressure,

ASSESMENT
2nd stage of
labor

PLANNING
Conduct of labor

Baby was
born
spontaneously,
male, AS: 6-8,
BW/BL = 2000 gr/46
cm,
anus
+,
anomaly kongenital
-

TIME
15.30

17.30

SUBJECTIVE
Patient confessed abdominal
pain

OBJECTIVE

ASSESTMENT

PLANNING

UC (+)

3rd stage of
labor

Management
active of 3rd stage
Placenta was born
spontan, complete,
weight 400 gr,
bleeding 150 cc

GC: well
GCS: E4V5M6
BP: 120/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C

2 hours post
partum

Obs. Mother well

being
Suggest mother to
eat and drink

UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)

Baby in NICU

TIME
07.00
(12/05
/14)

SUBJECTIVE

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 150/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)
Lochea rubra (+)
Baby in NICU
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2C

ASSESTMENT
1 day post
partum

PLANNING
Obs. Mother
well being
Suggest mother
to eat and drink

Baby

3
3
3
3
3
2
17

3
3
4
3
3
3

19

Conclusion:
Baby aterm (38-40)
Baby IUGR because < 10 Percentil
Risk Factor:
hypertension

CASE 2
IDENTITY
Name
Age
Address

: Mrs. M
: 26 yo
: Batu layar

Hozpitalised on 17.30 WITA, 11th May 2014

G2P1A0L1 40-41 weeks head

presentation with protracted active
phase 1st stage of labor

Time

Subjective

11/05/2
014

Patient referred from

Meninting PHC with
G2P1A0L1
40-41
weeks S/L/IU head
presentation
with
protracted
active
phase 1st stage of
labor.
Patient
confessed abdominal
pain since 07.00 WITA
(11/05/2014),
water
came out from her
vagina since 07.00
WITA, bloody slim (+),
fetal movement (+)
No history of DM, HT,
asthma.
No history of allergic
reaction to medicine
or food.

17.30
WITA

LMP : 01/08/2013
EDD: 07/05/2014

Objective
Examination:
General condition : Well
GCS : E4V5M6
BP : 110/90 mmHg
PR : 90 x/m
RR : 21 x/m
Temp : 36,8 C
General Status
Eyes : an-/-, ict -/Cor : s1s2 single, m -, g
Pulmo : Ves +/+, rh -/-,
whz -/Abdomen : scar (-),
striae gravidaum (+),
linea nigra (+)
Ext : oedem-/-, warm +/+
Status Obstetric
L1 : breech
L2 : back on the right
side
L3 : head
L4 : 4/5

Assesment

Planning

G2P1A0L1 4041
weeks
S/L/IU
head
presentation
with protracted
active
phase
1st stage of
labor

Observation mother well

being
CIE mother and family
IVFD RL 20 tpm
DM co to GP pro obs.
Sign
of
labor,inj
ceftriaxon 1 gr/iv and
ctg, GP advice obs. Sign
of labor , inj ceftriaxon
1gr /iv and ctg

Time

Subjective

Objective

History of ANC : 5 x
at PHC
Last
ANC:
10/05/2014,
result:
BP: 110/80 mmHg,
UFH : 31cm, head
presentation,40-41
weeks, FHB (+)

UFH : 30 cm
EFW : 2945 gram
FHR: 13-13-13 (154)
UC : 3x10~30
VT : 4 cm, eff 50%,
amnion (-),clear, head
palpable HII, denom
unclear,
unpalpable
small part of fetus

History of USG : History

of
Family
Planning: Next Family Planning:
injection
History of obstetry:
1.Male,
spontan,
midwife, aterm, 2800
gram, 5 yo
2.This

Lab Result
Hb : 10,7 x 106/ L
WBC : 22,65 x 103/ L
PLT : 252 x 103/ L
HCT : 33,5 %
HBsAg : (-) non reactive

Assesment

Planning

Time

Subjective

11/05/2
014
(07.30)

Chronologist at Meninting PHC

S: Patient pregnant 9 month come
to Meninting PHC confessed
abdominal pain and water leak
from her vagina since 07.00 wita
(11/05/2014)
O:
GC : Well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 x/m
Temp : 36,5 C
UFH : 31 cm
FHB: 12-12-11( 136)
UC : 2x10~25
VT: 2 cm, eff. 25 %, amnion (+)
clear,
head
palpable
HI,
denominator unclear, unpalpable
small part of fetal & umbilical cord.

Objective

Assesment

Planning

Time

Subjective

A: G2P1A0L1 40-411 weeks S/L/IU

head presentation with inpartu latent
phase 1st stage of labor + history of
ROM
P:
Obs. Mother and fetal well being
Obs. Progress of labor

11.30
Wita
(11-052014)

S: abdominal pain more frequently

O:
GC : well
BP:100/80
PR : 88 bpm
RR : 20 x/m
Temp : 36,5C
His : 3x10~30
FHB: 12-12-12 (144)
VT : 5 cm, eff. 50 %, amnion (+)
clear,
head
palpable
HII,
denominator unclear, unpalpable
small part of fetal & umbilical cord

Objective

Assesment

Planning

Time

Subjective
A: inpartu active phase first
stage of labor
P: continue observation

15.30

S: O:
GC : well
BP:100/80
PR : 88 bpm
RR : 20 x/m
Temp : 36,5C
His : 3x10~35
FHB: 12-12-12 (144)
VT : 6 cm, eff. 50 %,
amnion (+) clear, head
palpable HII, denominator
unclear, unpalpable small
part of fetal & umbilical
cord
A: inpartu protracted first
stage labor
P: inj ampicilin, infus RL,
prepare for referred to NTB
GH

Objective

Assesment

Planning

Time
16.30

Subjective
S:O: GC : well
BP:100/80
PR : 88 bpm
RR : 20 x/m
Temp : 36,5C
His : 4x10~35
FHB: 12-12-12 (144)
A: Inpartu protracted
1st stage of labor
P: change infus RL
with D5

Objective

Assesment

Planning

Time

Subjective

18.00
WITA

Abdominal pain +

Objective
UC : 3x10 ~35
FHB : 12-12-12 (144)

Assesment
G2P1A0L1 4041
weeks
S/L/IU
head
presentation
with protracted
active phase 1st
stage of labor

Planning
Obs. Sign of labor
Consult result of ctg,GP
advice continue
observation

Time

Subjective

Objective

Assesment

Planning

18.30
WITA

Abdominal pain +

UC : 3x10 ~35
FHB : 12-12-12 (144)

G2P1A0L1 4041 weeks

S/L/IU head
presentation
with protracted
active phase 1st
stage of labor

Obs. Progress of labor

19.00
WITA

Abdominal pain +

UC : 3x10 ~35
FHB : 12-12-12 (144)

G2P1A0L1 4041 weeks

S/L/IU head
presentation
with protracted
active phase 1st
stage of labor

Obs. Progress of labor

19.30
WITA

Abdominal pain ++

UC : 3x10 ~40
FHB : 12-12-12 (144)

G2P1A0L1 4041 weeks

S/L/IU head
presentation
with protracted
active phase 1st
stage of labor

Obs. Progress of labor

Time

Subjective

19.40
WITA

Mothers want to
bearing down

19.45
WITA

Objective

Assesment

Inspection:
Bulging of perineum,
opening
vulva,
anus presure

G2P1A0L1 4041 weeks S/L/IU

head
presentation with
2nd stage of labor

Planning
Conduct labor

Baby was born , male, AS:

5-7, BW/BL = 3550gr/50
cm, anus +, anomaly
kongenital -

Time

Subjective

Objective

Assesment

Planning

19.45

UC +

3rd stage of labor

Management active of 3rd

stage

20.00

UC +

3rd stage of labor

Placenta was not born

Injection 2nd oxytocin
Cateter urine

20.15

UC +

Retensio
plasenta

Placenta was born manual,

uncomplete,
300 gram.
Bleeding 500cc,
Pro usg on Monday
(12/05/2014)

Time
22.30
WITA

Subjective

Objective
GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)

Assesment
2 hours post
partum with rest
plasenta

Planning
Obs. Mother well being
Suggest mother to eat and
drink
Pro USG
Baby in NICU

Time
07.00
WITA
(12-052014)

Subjective

Objective
GC: well
GCS: E4V5M6
BP: 90/60 mmHg
PR: 90 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)
Lochea rubra (+)
Baby in NICU
GC : well
PR : 134 bpm
RR : 44 bpm
T : 36,2C
Use O2, IVFD D10%

Assesment
One day post
partum

Planning
Obs. Mother well being
Suggest mother to eat and
drink
Pro kuretase if USG (+)
rest plasenta

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