Professional Documents
Culture Documents
5 DESEMBER 2009
Supervisor : dr. Edi Prasetyo Wibowo, SpOG
Medical Student:
Syarif
Winda
Helmiati
Halia
Cases resume :
1
Normal labor
Name/adress
: Mrs. S/ Narmada
Age
28years old
Time
14.30
Subject
Admitted
to
Hospital
5 desember 2009
14.30 wita
Object
Examinaton at Mataram GH:
General condition: good
GCS : CM
BP :130/90 mmHg
PR : 80 bpm
RR : 24 tmp
Temp : 37 C
An +/+, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :32cm
EFW : 3255 gr
FHR : 152 bpm
UC :3x10-40
VT :CD complete, AM (-), green, head
palpable, caput (+), denom fontanella
minor anterior, descend HIII, small part
and umbilical cord wasnt palpable.
Lab. Examination :
Hb : 11,8 gr%
Leko : 22.800 mm3
Trombo : 247.000 mm3
Hct : 32,8 gr%
HBsAg : -
Assesment
Planning
G2P1A0L1 A/S/L/IU
with neglected 2nd
stage of labor.
Time
Subject
Object
Assesment
Planning
10.00
Patient want to bear
FHR : 124 bpm
VT: CD complete, eff 100%, AM (-), descend
H
10.30
Conduct to bear until 11.30,but nothing
progress
13.00
Reffered to mataram GH
Therapy:
D5
Motivated to eat n drink
Motivated to left side
ANC 8 x,at polindes, last 17 nov 2009
Obstetric history
1. aterm, male,9 th, midwife, normal, 3600 g
2.This pregnant
Contraception history: IUD 7 years, inject 3
month 2 x
Contraception planing: inject 3 month
17.00
19.00
EV begun
Time
06.00
Subject
Object
-General condition: good
-BP : 120/80 mmHg
-PR : 84 x/mnt
-RR : 22 x/mnt
-T : 37 C
-UFH :2 finger under umbilicus
-UC : good
-Lokea (+)
-Wound of epis : good
Assesment
Planning
Name/adress
Age
Time
Address
21.30
: Mrs. N / Sweta
Admitted
to Hospital
22 years old
4 Des 2009
21.30 wita
Subject
Narmada
Object
Assesment
Planning
Examinaton at VK :
General condition: good
GCS : CM
BP :110/70 mmHg
PR : 84 x/
RR : 20x/
Temp : 36,7C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :30 cm
EFW : 2945 gram
FHR : 12-12-12
UC : VT : CD 1 cm, eff 10%, AM (-), clear,
head
palpable,
descend
H1+,
denominator unclear, unpalpable small
part of fetal and umbilical cord
Lab. Examination :
Hb : 10,7 gr%
Leko : 12.600 mm3
Trombo : 266.000 mm3
Hct : 31,5 gr%
HBsAg : Pelvic evaluation:
Promontorium not prominent
Spina ischiadica not prominent
Archus pubis >90
Os coccygeus mobile
PS:?????????????????????
G1P0A0L0 A/S/L/IU
head presentation
with PRoM >12
hours
Time
Subject
Object
Lab. Examination :
Hb : 10,7 gr%
Leko : 12.600 mm3
Trombo : 266.000 mm3
Hct : 31,5 gr%
HBsAg : Pelvic evaluation:
Promontorium not palpable
Spina ischiadica not prominent
Archus pubis >90
Os coccygeus mobile
PS: 5
Cervic dilatation: 1 1
Panjang cervic: 2 1
Station: H1 1
Konsistensi: mild 1
Potition: mid 1
Assesment
Planning
Time
05.00
Subject
Abdominal pain>
0%
Object
Assesment
Planning
BP :120/80 mmHg
PR : 84x/
RR : 24x/
Temp : 36,5C
UC : 1x10/10
FHR:11-12-12
CTG base line: 140x/mnt
05.30
Abdominal pain>
UC: 1x10/10
FHR:12-12-12
06.00
Abdominal pain>
UC: 1x10/10
FHR:12-12-13
06.30
Abdominal pain>
UC: 1x10/10
FHR:12-12-13
07.00
Abdominal pain>>
UC: 2x10/20
FHR:12-12-13
07.30
Abdominal pain>>
UC: 2x10/20
FHR:13-12-12
08.00
Abdominal pain>>
UC: 2x10/30
FHR:12-12-12
Temp:36,8C
08.30
Abdominal pain>>
UC: 2x10/30
FHR:12-12-12
09.00
Abdominal pain>>
UC: 3x10/30
FHR:12-12-12
09.30
Abdominal pain>>
UC: 3x10/30
FHR:12-12-13
10.00
Abdominal pain>>>
UC: x10/30
FHR:12-12-13
Time
Subject
10.30
Abdominal pain>>>
11.00
Object
Assesment
Planning
UC: 3x10/30
FHR:12-12-11
Abdominal pain>>>
UC: 3x10/30
FHR:13-12-12
Temp:36,7C
11.30
Abdominal pain>>>
UC: 3x10/30
FHR:12-12-13
12.00
Abdominal pain>>>>
UC: 3x10/45
FHR:12-12-12
12.30
Abdominal pain>>>>
UC: 3x10/45
FHR:13-12-13
13.00
Abdominal pain>>>>
UC: 3x10/45
FHR:12-13-13
13.30
Abdominal pain>>>>
UC: 4x10/45
FHR:12-13-13
14.00
Abdominal pain>>>>
UC: 4x10/45
FHR:12-13-13
Temp:36,7C
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-), clear,
head palpable, descend HIII,
denominator fontanella minor
right anterior, unpalpable small
part of fetal and umbilical
Stage 2 of labor
16.00
Abdominal pain>>>>
UC: 2-3x10/35
FHR:12-13-13
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-), clear,
head palpable, descend HIII,
caput
(+),
denominator
fontanella minor right anterior,
unpalpable small part of fetal
and umbilical
0%
Time
16.30
Subject
Object
Assesment
Planning
EV begun
0%
18.30
Abdominal pain>>>>
UC: 4x10/45
FHR:13-12-13
19.00
Abdominal pain>>>>
UC: 4x10/45
FHR:12-12-13
19.30
Abdominal pain>>>>
UC: 4x10/45
FHR:12-13-13
20.00
Abdominal pain>>>>
UC: 4x10/45
FHR:12-13-13
20.30
Abdominal pain>>>>
UC: 4x10/45
FHR:12-13-13
21.00
UC: 4x10/45
FHR:12-14-13
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-), clear,
head palpable, descend HIII,
denominator fontanella minor
right anterior, unpalpable small
part of fetal and umbilical cord
21.15
FHR: 13-12-12
Doran teknus perjol vulka
Time
Subject
Object
18.00
Assesment
Stage 2 of labor
Stage 3 of labor
Planning
Baby female was born,
3000 g, A-S 7-9
Amniotic fluid clear
Placenta was born 10
minutes later
20.00
BP :110/70 mmHg
PR : 80x/
RR : 20x/
Temp : 36,8C
UC : good
UFH : 2 finger below
umbilicus
Active vaginal bleeding (-)
Motivated mother to
breastfeeding for the baby
Referred mother and baby
to melati room
07.00
BP :110/80 mmHg
PR : 84 x/
RR : 20x/
Temp : 36,5
UC: good
FUH:
2
finger
below
umbilicus
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm
Active vaginal bleeding (-)
Motivated mother to
breastfeeding for the baby