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CASE RESUME
NORMAL LABOR
PATHOLOGY LABOR
TIME
SUBJECTIVE
28/12/
2012
05.00
OBJECTIVE
General Status
GC : well
Consciusness : Composmentis
BP : 120/90 mmHg
PR : 80 bpm
RR : 20 tpm
T : 37,0 C
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-),
G (-)
Pulmo : vesikuler (+/+),
wheezing (-/-), ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical Status
L1
L2
L3
L4
:
:
:
:
breech
back on the left side
head
4/5
UFH : 30 cm
EFW : 2790 g
UC :3x10~40
FHB : 13-14-13 (160 bpm)
VT : 4 cm, eff 50%, amnion
(-), clear head palpable H I,
denominator unclear,
impalpable small part /
umbilical cord.
ASSESSMENT
G2P1A0L1 4243 weeks S/L/IU
with inpartu
active phase 1st
stage of labour
+ HROM
PLANNING
Observe mother
and fetal well
being.
Check CBC and
HBsAG
DM pro GP to
observation
progress of labour
with partograf, GP
acc observation
progress of labour
with partograf.
TIME
SUBJECTIVE
OBJECTIVE
Lab Evaluation
HB : 11,3 g/dl
RBC : 4,63 x106/l
HCT : 35,0 %
WBC : 10,74 x103/l
PLT : 153 x103/l
HbSAg : (-)
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
Chronologist at midwife clinic :
04.00(28/12/2012)
S : Patient came confessed have 9
month pregnancy and abdominal
pain that spread to waist since
02.00 Wita and water came out
from her womb since 03.00
O : GC : well
BP : 110/70 mmHg
PR : 84 bpm
RR : 20 tpm
T : 36,3 oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 32 cm
EFW : 3100 g
FHB : (160 bpm)
LMP : 10/03/2012
EDD : 17/12/2012
VT : 5 cm, eff 50%, amnion (-),
head palpable H1
A : G2P1A0H1 42-43 wk S/L/IU head
presentation with inpartu active
phase 1st stage of labour + serotinus
P : Referred to NTB GH
OBJECTIVE
ASSESSMENT
PLANNING
TIME
09.00
SUBJECTIVE
Patient confessed abdominal pain
OBJECTIVE
GC : Well
Consciousness :
Composmentis
BP: 120/90
PR : 80 tpm
T : 37,0C
RR : 20 tpm
UC: 3x10~35
FHR: 12-13-12 (148 bpm)
VT : 6 cm, eff 75%,
amnion (-) clear, head
palpable HI, denom
LOA, impalpable small
part of fetus or umbilical
cord
ASSESTMENT
PLANNING
Observation mother
and fetal well
being
Observation
progress of labour
DM pro GP to
observation
progress of labour,
GP co to SPV, SPV
advice
acceleration if CTG
reactive
10.00
UC: 3x10~35
FHR: 12-12-12 (144 bpm)
10.30
UC: 3x10~35
FHR: 12-12-12 (144 bpm)
12 dpm
11.00
UC: 3x10~35
FHR: 12-11-12 (140 bpm)
16 dpm
11.30
UC: 3x10~35
FHR: 12-11-12 (140 bpm)
20 dpm
12.00
UC: 3x10~35
FHR: 13-12-13(152 bpm)
24 dpm
12.30
UC: 3x10~35
FHR: 12-12-12 (144 bpm)
28 dpm
TIME
13.00
SUBJECTIVE
Patient confessed abdominal pain
OBJECTIVE
GC : Well
Consciousness :
Composmentis
BP: 110/80
PR : 82tpm
T : 37,0C
RR : 20 tpm
ASSESTMENT
PLANNING
Observation mother
and fetal well
being
Observation
progress of labour
32 dpm
UC: 3x10~40
FHR: 12-11-12 (140bpm)
VT : 9 cm, eff 90%,
amnion (-) clear, head
palpable HII, caput (+),
denom LOA, impalpable
small part of fetus or
umbilical cord
13.30
UC: 4x10~40
FHR: 180 bpm
14.00
UC: 4x10~40
FHR: 13-13-14(160 bpm)
Observation mother
and fetal wellbeing
DM pro SC to GP,
GP consult SPV
(15.00): SPV
advice
Rehydration and
inj Antibiotic.
TIME
16.00
SUBJECTIVE
Patient confessed abdominal pain
OBJECTIVE
GC : Well
Consciousness :
Composmentis
BP: 110/70
PR : 82tpm
T : 37,0C
RR : 19 tpm
ASSESTMENT
PLANNING
Observation mother
and fetal well
being
Observation
progress of labour
DM pro SC to GP,
GP consult SPV:
SPV advice SC
now.
UC: 4x10~30
FHR: 12-11-12 (140bpm)
VT : complete, amnion
(-) clear, head palpable
HII, caput (+), denom
LOA, impalpable small
part of fetus or umbilical
cord
17.00
UC: 4x10~30
FHR: 12-11-12 (140bpm)
VT : complete, amnion
(-) clear, head palpable
HII, caput (+), denom
LOA, impalpable small
part of fetus or umbilical
cord
19.45
Pre Op
CIE Patient &
Family
Set DC
Inj Ampicillin 1
gr/IV
Shave pubic hair
CS began
Baby was born
(19.47), Female,
BW:3250 g/53 cm,
anus (+), AS: 7-9,
TIME
21.45
SUBJECTIVE
Patient confessed can not move her
leg
OBJECTIVE
GC: well
BP: 110/70
RR: 24 tpm
UC: +
UFH: 1 finger
umbilicus
Urine output:
Cons: CM
HR: 84 bpm
T: 36,5 C
ASSESTMENT
PLANNING
2 hours post
SC
Observed mother
and baby well
being
Observe vital sign,
sign of bleeding,
urine output.
1 day post SC
Observed mother
and baby well
being
Suggest mother to
mobilisation, eat,
and drink,
medication.
below
200 cc
Baby in NICU
PR: 135 bpm
RR: 52 tpm
T: 36,9 C
29/12/
2012
07.00
GC: well
BP: 110/80
HR: 80 bpm
RR: 20 tpm
T: 36,5 C
UC: +
UFH: 2 finger below
umbilicus
Urine output: 800 cc
Baby in NICU
PR: 126 bpm
RR: 50 tpm
T: 36,7 C