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CASE RESUME
NORMAL LABOR -
24/04/ Patient reffered from Lingsar PHC w/ General status G1P0A0L0 39-40 w DM plan:
17 G1P0A0L0 36 weeks S/L/IU breech GC/cons: well/E4V5M6 S/L/IU head Tell mother about the
19.15 presentation laten phase of labor. She BP : 110/70 mmHg presentation with examination result
confessed abdominal pain spread to the PR: 78 tpm HbsAg positive Tell mother about the
flank since 15.00 (24/4/2017). Bloody RR: 19 tpm procedure and risk of
slime (+), water leaked out from her womb Tax: 37,0 C the next planning
(-), fetal movement (+). Demam (-) Obs mother and fetal
Localis status well being
History of DM (-), HT (-), asthma (-), Eye : an (-), ict (-) Obs progress of labor
allergic (-) Pulmo ves (+/+), rh (-/-), wh (-/-) Ask mother to eat and
Cor : S1S2 single regular, murmur drink
LMP: 20/07/2017 (-), gallop(-) Ask mother to back to
EDD: 27/04/2017 Abdomen: the left side
Scar (-), striae gravidarum (+), linea
History of ANC: 7x @midwife of PHC, 7x nigra (+) DM co to GP, GP acc
@RSUP NTB Extremity: oedema (-/-) warm acral
Last ANC: 22/04/17 (+/+)
Result: BP 110/80 mmHg, BW 62kg, 38-
39 w, UFH 29 cm, head presentation, back Obs status:
to the left side, FHB (+) , HbsAg (+) L1 : Breech
L2 : back to the left side
History of USG: 3x L3 : Head
Last USG : 22/4/17 L4 : 4/5
S/L/IU head presentation BPD :36 w, AC UFH: 29 cm
34 w, FL 32 w, EFW 2378 +/- 356 grm EFW : 2790 gr
Placento on corpus anterior FHB : 11-11-12
UC : 1x10~35
History of family plan: injection (2006- VT : 4 cm, eff 50%, amnion (+),
2009), Oral KB 3 months (2009) breech palpable (+), sacrum
Next family planning: inj 3 months transverse, HI, not palpable small
Obstetrical history: part & umbilical cord
1. This
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
P/ refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
09.05 Mother want to bearing down Vulva opened, pressure of Conduct of labor
anus, perineum bulging
9.00 am Abdominal pain spread to GC: well G1P0A0L0 35-36 Prepare of labor
the flank (+) more GCS: E4V5M6 weeks S/L/IU breech
frequent, water leak out BP: 180/100 mmHg presentation 2nd phase of
from her womb (+) greeny, PR: 95 tpm labor
odorless, RR: 27 tpm
Tax: 36.6 C
UC: 4x10~45
FHB: -
Urine: 300 cc
VT: 10cm, eff 100%, foot
palpable (+), not palpable small
part & umbilical cord
09.05 mother want to bearing Vulva opened, pressure of anus, Conduct of labor
am down perineum bulging