No. 1.

Case Resume : Case

Total 1

Pathology Delivery G1P0A0L0 36-37 weeks /S/L/IU

Normal Delivery

G1P0A0L0 36-37 weeks /S/L/IU

Name Age Address Admitted No. RM

: Mrs. W : 19 years old : Lingsar, West Lombok :14th December 2013 : 52-87-26

G1P0A0L0 36-37 weeks /S/L/IU

Time 14/12 2013

Subject Patient refferred from Lingsar PHC, with G1P0A0H0 36-37 weeks /S/L/IU, fetal and mother well being with PROM. Patient confussed water leakage from her womb at 07.00 WITA (1312-2013). abdominal pain (+) Since 07.00 Wita (13-12-2013). . Bloody slim(+) and Fetal Movement (+). No history of DM, HT, asthma. No history of allergic reaction to medicine or food. LMP : 01-4-2013 EDD: 08-01-2014 History of ANC : 4x at Posy History of USG : Never

Object Examination ER VK General condition : Well GCS : E4V5M6 BP: 120/80mmHg PR : 80 x / m RR : 20x/m Temp : 36,9 C General Status Eyes : an-/-,ict -/Cor : s1s2 single (+), m -, g Pulmo : Ves +/+, rh -/-, whz -/Abdomen : striae gravidaum (+), linea nigra (+) Ext : Oedem - - warm + + + +

Assesment

Planning

11.30 WITA

G1P0A0L0 Obs mother and 36-37 weeks fetal well being /S/L/IU head Cek lab DL HbsAg presentation DM cie patient for eat and drink

Time

Subject History Family Planning : Next Family Planning : injection 3 months History of obstetry: 1. This

Object Status Obstetric L1 : Breech L2 : back on the left side L3 : breech L4 : 4/5 UFH : 28 cm EFW : 2635 gram FHR: 11-12-11 (136 bpm) UC : 2x/10~20 VT : 1 cm, eff 10%, amnion (+), Head presentation, HI, denom unclear, unpalpable small part of fetal/ umbilical cord PE : Promontorium unpalpable Spina ischiadica not prominent Os cooccygeus mobile Arcus pubis >90

Assesment

Planning

Time

Subject

Object Pelvic Score: 6 (induction with oxytocin) -Cervix dilatation : 1 cm (1) -Effacement : 10% (2) -Cervix constitency: average (1) -Cervix Position : mild (1) -Station : -2 (1) Laboratorium Result : WBC : 15,6 .103/uL Hb : 11,7 .103/uL HcT : 35,1% PLT : 242 106/uL HBsAg : (-)

Assesment

Planning

Time

Subject Chronologist at PHC Meninting 3/12/2013 ( 08.00 WITA ) S: Patient came to PHC said that she pregnant for 8 months, she confessed that she have water leakage from her womb and abdominal pain at 00.00, Bloody slim (-). LMP : 01-04-2013 EDD : 08-01-2014 O : General condition : Well GCS : E4V5M6 BP: 110/70mmHg PR : 80x / min RR : 20 x / min Temp : 36,3 C Obstetric Status UFH : 27 cm EFW : 2480 gr UC : 2x/10-20 FHR : (11-12-11) 136 x / minutes L1 : Breech L2 : back on the left side L3 : Head L4 : 4/5

Object

Assesment

Planning

Time

Subject

Object

Assesment

Planning

VT : (-). A: G1P0A0L0 36-37 weeks /S/L/IU, with ROM, mother and fetal well being P: Infus RL 28 bpm Ampicillin 1 gr/IV

Time

Subject

Object FHR: 12-11-12 (140 bpm) UC : 2x/10~25 VT : 3 cm, eff 10%, amnion (+), Head presentation, HI, denom unclear, unpalpable small part of fetal/ umbilical cord

Assesment G1P0A0L0 3637 weeks /S/L/IU head presentation laten phase 1st of labor

Planning Obs mother and fetal well being CIE eat and drink

18.00 Patient confused more frequently

22.00 -

FHR: 12-11-12 (140 bpm) UC : 3x/10~30 VT : 3 cm, eff 25%, amnion (+), Head presentation, HI, denom unclear, unpalpable small part of fetal/ umbilical cord FHR: 12-11-12 (140 bpm) UC : 2x/10~25 VT : 4 cm, eff 25%, amnion (+), Head presentation, HI, denom unclear, unpalpable small part of fetal/ umbilical cord G1P0A0L0 3637 weeks /S/L/IU head presentation 1st of labor active phase Obs mother and fetal well being Obsr.with partograf CIE eat and drink

02.00 1512-13 -

Time 06.00

Subject

Object FHR: 12-12-12 (144 bpm) UC : 3x/10~35 VT : 6 cm, eff 50%, amnion (-) Clear, Head presentation, HI, denom unclear, unpalpable small part of fetal/ umbilical cord

Assesment G1P0A0L0 3637 weeks /S/L/IU head presentation 1st of labor prolong active phase

Planning Obs mother and fetal well being CIE eat and drink CTG DM Co to GP result CTG (reactive ) pro termination result Rehidration and CTG after rehidration CTG result reactive and drip oxy CIE family for termination Drip Began 8 tpm Oxy

07.00 -

Rehidration Began

09.45

Co SPV CTG Post rehidration

10.00

FHR: 12-11-12 (140 bpm) UC : 4x/10~40 VT : 9 cm, eff 90%, amnion (-), Head palpable, HII, unpalpable small part of fetal/ umbilical cord

Time 10.30 WITA 11.00 WITA -

Subject

Object FHR : 12-11-12 (140 bpm) UC : 3x/10~35 FHR : 13-12-13 UC : 3x/10~35

Assesment

Planning Drip Oxytocin 12 dpm Drip Oxytocin 14 dpm

11.30 WITA

FHR : 12-11-12 (140 bpm) UC : 4x/10~40

Drip Oxytocin 20 dpm

Time

Subject

Object

Assesme nt

Planning

12.00 WITA

Abdominal pain

FHR : 13-13-13 (156 bpm) Second Conduct labor UC : 4x/10~40 stage of Inspection : Head on labor vulva. Doran, teknus perjol, vulka
Baby was born , Spontan, A-S : 7-9, BW : 2700 gram, Body length : 51 cm, anus (+), anomaly congenital (-). Placenta was born, 500 gr, complete, bleeding 300 cc.

12.05

Time

Subject

Object

Assesme nt

Planning

14.00 WITA

GC: Well GCS : E4V5M6 BP : 110/70 mmHg PR : 82 x / m RR : 18x/m Temp : 37C UC : + well UFH : 2 finger bellow umbilical Lochea : + Baby Rooming
GC: Well GCS : E4V5M6 BP : 120/70 mmHg PR : 83 x / m RR : 18x/m Temp : 36.9C UC : + well UFH : 2 finger bellow umbilical Lochea : (+) Rubra

2 hour Post Partum

- Obs mother well being - CIE for breastfeeding - Suggest mother to eat n drink

07.00

2 day post - Obs mother well being Partum - CIE for breastfeeding - Suggest mother to eat n drink - Mobilitation

BABY Rooming

Ny. Wasiah 15/ 12 / 2013

19 yo 02.00

X X X O O

X
Baby was born , Spontan, A-S : 7-9, BW : 2700 gram, Body length : 51 cm, anus (+), anomaly congenital (-). at 12.05 WITA

O O

02.00 03.00 04.00 05.00 06.00 07.00 08.00 09.00 10.00 11.00 12.00

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