Resume of Case September 16th, 2011

Supervisor : dr. Made Mahayase, SpOG MS :Ita, Uyunk, Lili, Atun Phisiology : Phatology:

Identitied
Name : Mrs. N Age : 21 years old MR : 254350 Adressed: Pemenang, KLU

Admitted to GH of NTB on September 16th, 2011 at 00.00

Time 00.00 (16/9/ 2011)

Subject Patient reffered from Pemenang PHC with G1P0A0L0 weeks/S/L/IU head presentation + neglected 2nd stage of labor. Abdominal pain since 20.00 WITA (14-09-2011) came to GH of NTB. History rupture of membrane (+) at 20.00 wita (14-9-2011), abdominal pain (+) , bloody slim (+), FM (+). History of HT (-), DM (-), Asthma (-) LMP : 11-12-2010 EDD : 18-09-2011 History of ANC : > 9 x at Polindes Last ANC : 15-09-2011 History of family planning : Next family planning : injection 3 month History of obstetric 1. This Chronologist : in Pemenang PHC 16-09-2011 15.00 WITA S : patient came to Pemenang PHC with Abdominal pain since 20.00 WITA (14-092011), Blood slim (+), FM (+), history ruptur of membrane (+) at 20.00 WITA (14-9-2011). History of DM (-), HT (-), Asthma (-).

Object General status: General condition : well Cons : CM BP : 120/60 mmHg PR : 108 bpm RR : 20 x/minute T : 37C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+), Rh (-/), Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 30 cm L2 : back on the right L3 : head L4 : 3/5 UC : 1x10=20 UFH : 34 cm EFW : 3565 gram FHB : 12.12.13 VT : 9 cm, eff 90%, amn (-) , head palpable, HII , caput (+) ,unpalpable small part or umbilical cord

Assestment G1P0A0L0 39-40 weeks/S/L/IU head presentation active phase 1st stage of labor

Planning - Obs. Mother and fetal well being -DL and HBsAg -Rehidration -O2 -Inj Ampisilin 1 gr/IV report to GP Adv: -Move to VK teratai -CTG -If CTG reactif Drip Oxytocin

Examination in Pemenang PHC 15/09/2011 (15.00 Wita) GC : well TD : 110/70mmHg PR : 82x/minute Temp : 366C RR : 22x/minute Abdominal palpation : UFH 29cm L1: breech L2: back on right L3: head L4: 3/5 EFW 2790 gr FHB : 11-12-11 (136x/minute) UC : 3x10=40 VT : 4 cm, amn (+), eff 75%, head palpable, HII, unpalpable small part or umbilical cord 18.00 WITA Insert infus D5 %, 20 tpm 20.00 WITA VT : complete, amn (-), head palpable, HIII unpalpable small part or umbilical cord Mothers conduct bearing down (20,0021.30 wita) A: G1P0A0L0 weeks/S/L/IU head presentation + neglected 2nd stage of labor.

Pelvic evaluation : Os coccigeous mobile Pubic arch >90 Lab exam : WBC : 18,48 RBC : 3,69 HGB :10,2 PLT : 270 Hct : 33,3 MCV: 90,2 MCHC : 27,6 HBsAg : -

Time 02.15 (16/9/2011)

S Patient move to VK teratai

O General condition : well His: 1x10=20 DJJ: 12-12-12

A G1P0A0L0 39-40 weeks/S/L/IU head presentation active phase 1st stage of labor

P CTG

02.45 (16/9/2011) 03.15 (16/9/2011) 06.45 (16/9/2011) 07.00 (16/9/2011 Drip oxy 8 tpm General condition : well His: 1-2x10=20 DJJ: 12-13-12 General condition : well His: 2x10=25 DJJ: 12-11-11 General condition : well His: 3x10=30 DJJ: 12-13-13 VT : complet, amn (-) , head palpable, HII , caput (+) ,unpalpable small part or umbilical cord General condition : weak His: 3x10=30 DJJ: 12-12-12 VT : complet, amn (-) , head palpable, HII , caput (+) ,unpalpable small part or umbilical cord G1P0A0L0 39-40 weeks/S/L/IU head presentation + prolonged 2nd stage of labor

Insert drip oxy

Drip oxy 40 tpm

Obs. Mother and fetal well being -Obs. Mother and fetal well being - Menganjurkan ibu mengedan sambil miring kiri

Drip oxy 40 tpm

09.00 (16/9/2011

Os mengatakan perut mules dan tenaga berkurang

G1P0A0L0 39-40 weeks/S/L/IU head presentation neglected 2nd stage of labor

-Co supervisor Adv : pro SC at 10.00 -Insert DC -Injection ampi 2 gr/iv -Sent patient to OK

Time 10.10 (16/9/2011 10.15 (16/9/2011

P SC began Baby was born, Male, BW ; 3550 gr, BL: 47 cm, A-S ; 5-7 anus (+), congenital anomaly (-), amnion meconeal, bleeding 350 cc Baby was sent to NICU Placenta was born manual, complete 600 gr, bleeding 350cc SC finish

10.20 (16/9/2011 10.35 (16/9/2011 10.35 (16/9/2011) Mother GC : well BP ; 100/60mmHg PR : 105bpm RR : 22 x T : 36,3C UC (+) hard, palpable in umbilical. Active bleeding (), Lochea (+) UO : 90 cc 1 hour post SC

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

Time 13.40

S -

O Mother GC : well BP ; 100/70mmHg PR : 100 bpm RR : 24 x T : 36C UC (+) hard, palpable in umbilical. Active bleeding (-), Lochea (+) UO : 90 cc

A 2 hour post SC

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

07.00

Wound operation pain (+)

Mother BP: 110/70 mmHg PR: 84x/minute RR: 20 minute T: 36 C UC: (+), well UFH: 1 finger below umbilicus UO: 400cc Vaginal active bleeding (-) Baby in NICU PR: 148/minute RR: 40/minute

1 day post SC

Obs vital sign and active bleeding S.F 1x1 Mefenamic acid 3 X 500 Amoxicilin 3x500mg