Nama : .

D
Umur : 32
MR : 96 17 89
Alamat : Padang
 A 32 years old patient was referred to M.Djamil General hospital on
May 31th 2017 at 01.15 from Private Hospital whit diagnose Placental
retensio
01.15 Blood preasue 80/60 airways : paten
Consius breathing : O2 4L
Pulse hard to difine Circulation : IV line 2jalur
monitor was apply Resisitaion
BP : 100/7O
D/ Syok hypovolemic due to retensio plasenta Hr : 112
 01.30 BP: 100/70 airways : claer
Consius breathing : O2 4L via nasal canul
Pulse:112x/menit Circulation : 2 Line IV line IVFD RL
saturation : 99%

D/ resolved Syok hypovolemic due to retensio plasenta

previously patient was labour at midwife 2 hours ago, spotaneus
labour, whit wheigt 3100 gr , Body Lenght 50 cm, A/s 8/9.
but after baby born, placental wast spontan born, pasien was refferd
to Private Hospital , Cause massive bleding pastinet referred to
M.Djamil General Hospital.
This is second labour, fist son was normal labour 3 years ago.
Previous Illness History
There wasnt previous history diseases of heart, lung, liver, kidney,
and DM before pregnancy No history of alergic

Family Illness History

There wasnt history of hereditary disease, contagious and
physiological illness in the family
Marriage history: once at 2013
History of pregnancy/abortion/delivery : 1/0/0
1. 2014,3100gr,Male,Spontan,Midwife,Life
History of family planning :-
History of immunization : -
GA Cons BP PR RR T
Moderet CMC 100/70 112 24 37

BW BH BMI Patella rf urine

60/72kg 158 cm 24 normoweight +/+ N 50cc at the
time

Eyes: conjunctiva anemic,

sclera wasnt icteric
Neck: JVP 5-2 cmH2O,
no enlargement of thyroid gland
Chest: heart within normal limit
lung : rhonci -/-, wheezing -/-
Abdomen
Inspection :
Tampak sedikit membuncit
Palpation :
Uterine Fundal was palple 2 finger above umbilical,
Uterine contraction was good
 Au : Normal Peristaltic sound

Genitalia :
I : V/U within normal limit
Umbilical Cord was looked at vulva
Diagnose
Resolved Hypovolemic Shock due to placental retensio
on P2A0L2 Post Spotaneus Labour from other institision
Management
Control GA, VS, FHR, liquid balance, urine volume
Informed consent
O2 14lt/mnt via nasal canul
Routine blood test

Plan :
Manual Placental
Laboratory
Parameter Result Reference Value
Hb 8,4 12 15 g/dL
Ht 26 40 48 %
Leucocyte 19,340 5,9 - 16,9.103 /mm3
Trombocyte 238.000 146 - 429.103 /mm3
aPTT 35,4 22.6 35.0 Sec
PT 11,3 9.6 12.9 Sec
Manual Placenta was perform
Placenta was born with manual placenta with size 17 x 15 x 2,5 cm and
weight 500 gr. Umbilical cord Insetion P/C.
Perineal laseration hectinged and treated
Diagnose :
P2A0L2 Post Manual Placenta oi Placenta Retensio from other
institution + Mild Anemia (8,4gr/dl)
Management
Control GA, VS, liquid balance, urine volume
IVFD RL ( 2amp Ocitosin + 1amp Methergine) 8hours/kolf
Inj Cefrtiaxone 2x1gr
Mefemanic Acid 3x500mg
SF 2x1
Vit C 2x1
2 unit PRC transfusion
 31-05-2017 08.00 am
A/: Fever -, vaginal bleeding -
PF/: GA COns BP HR RR T Urine

Moderate CM 120/80 84 x/m 24 x/m afebris 100cc /

mmHg 1 jam
Abdomen : FUT 3 fingers under umbilical
contraction was good,
Genital : Inspection: Vulva and urethra were normal
D/: P2A0L2 Post Manual Placenta oi Placenta Retensio from other institution + Mil
d Anemia (8,4gr/dl)
Plan :
Control GA, VS, liquid balance, urine volume
IVFD RL ( 2amp Ocitosin + 1amp Methergine) 8hours/kolf
Inj Cefrtiaxone 2x1gr
Mefemanic Acid 3x500mg
SF 2x1
Vit C 2x1
2 unit PRC transfusion
 01-06-2017 08.00 am
A/: Fever -, vaginal bleeding -
PF/: GA COns BP HR RR T Urine

Moderate CM 120/80 84 x/m 24 x/m afebris 100cc /

mmHg 1 jam
Abdomen : FUT 3 fingers under umbilical
contraction was good,
Genital : Inspection: Vulva and urethra were normal
D/: P2A0L2 Post Manual Placenta oi Placenta Retensio from other institution +
Mild Anemia on tretment
Plan :
Control GA, VS, liquid balance, urine volume
IVFD RL ( 2amp Ocitosin + 1amp Methergine) 8hours/kolf
Inj Cefrtiaxone 2x1gr
Mefemanic Acid 3x500mg
SF 2x1
Vit C 2x1
2 unit PRC transfusion
 02-06-2017 08.00 am
A/: Fever -, vaginal bleeding -
PF/: GA COns BP HR RR T Urine

Moderate CM 120/80 84 x/m 24 x/m afebris 100cc /

mmHg 1 jam
Abdomen : FUT 3 fingers under umbilical
contraction was good,
Genital : Inspection: Vulva and urethra were normal
D/: P2A0L2 Post Manual Placenta oi Placenta Retensio from other institution +
Mild Anemia on treatmet
Plan :
Control GA, VS, liquid balance, urine volume
IVFD RL ( 2amp Ocitosin + 1amp Methergine) 8hours/kolf
Inj Cefrtiaxone 2x1gr
Mefemanic Acid 3x500mg
SF 2x1
Vit C 2x1
2 unit PRC transfusion