Case report

Identity
Name : Mrs. R
Age : 27 years old
No. RM : 98 07 15
Date : June 07th, 2017

Husban Identity
Name : Mr. W
Age : 30 years old
Occupation: Private

Addres : Surau Gadang, Padang

Anamnesis :

A 27 years old patient admitted to the Emergency

Delivery Room of Dr. M. Djamil General Hospital
Padang on June 7th, 2017 at 17.45 AM, with chief
complain Feeling of pain from waist to region since 6
hours ago
Present Illness History
Feeling of pain from waist to region since 6 hours ago
Bloody show from the vagina since 6 hours ago
Fluid leakage from the vagina since 1 hours ago , wetting
2 pieces of panties , fishy odor and clear residue
Massif bleeding from the vagina was absent
Amenorrhea since 9 months ago
LMP was forgotten EDD : difficult to estimated
Fetal movement was identified since 5 months ago.
No complain of nausea, vomiting, and vaginal bleeding
neither during early pregnancy nor late pregnancy.
Prenatal care to Midwife 4x ( 2,5,8,9 month ) of pregnancy
Menstruation history: menarche at 12 years old, irregular
cycle, once in 28-35 days which last for 5 to 7 days each
cycle with the amount of 2-3 times pad change/day without
menstrual pain
Previous Illness History :
There wasnt previous history of heart, lung, liver,
kidney, DM, hypertension, and allergy

Family Illness History :

There wasnt history of hereditary disease, contagious
and physicological illness in the family
Marriage history : once at 2008
History of pregnancy/abortion/delivery: 2/0/1
1. 2009,male,3100gr, CS oi Contracted Pelvic, Doctor, Alive
2. Present

History of family planning : IUD

History of immunization : (-)
Graduate : Junior high school
Occupation : housewife
Physical Examination

GA : moderate
consiousness : CMC
BP : 120/80 mmHg
HR : 96 x/min
RR : 21 x/min
Temperatur : 37,1 C
Body height : 142 cm LILA : 25 cm
Body weight : 50 kg
BMI : 24,79 kg/m2 (normoweight)
 Eyes : conjunctiva wasnt anemic,
sclera wasnt icteric
Neck : JVP 5-2 cmH2O, tyroid gland
no enlargement
Chest : H/L normal
Abdoment : obstetric record
Genitalia : obstetric record
Extremity : oedem -/-, RF +/+, RP -/-
Obstetric record
Abdoment
Inspection : Abdomen seem enlarge according to term
pregnancy, sicatrix (+) Pfanensteal
Palpation

L1: Uterine fundal height was 3 fingers below

xiphoideus processus.
A large, soft, nodular mass was palpable
L2: Greatest resistance was palpable on the left side.
Numerous small, irregular structure were felt on
the right side
L3 : A hard, round, mass was palpable, fixated
L4 : Convergen
 UFH: 30 cm; EBW: 2945 gr; His: 3-4x/45/S
Auscultation : Fetal heart sound :130-140x/m
Genitalia
Inspection : V/U normal, vaginal bleeding (-)

VT : 8-9cm
Amnionic sac (-) clear residue
Caput was palpated at HI-II size 4x3x2cm
Pelvic Inlet
Promontory cant bereached

Inominate line difficult to exam

Sacrum bone : concave

Pelvic side wall : straight

Ischiadic spine : protude

Coccygeus bone : not moveable

Arc of pubic : < 90

Pelvic Outlet :
Inter tuberous distance can be passed through by
normal adult fist (>10.5 cm)
Impression : contracted pelvic
CTG
CTG
Base Line : 140-150
Variability : 5-20
Aceleration : (+)
Deseleration : (-)

Impresion : Reative CTG

USG
ULTRASOUND
Fetal alive singleton intrauterine head presentation
Fetus movement was good

Biometric : BPD 93,0 mm EFW 2900-3000 gr

AC 311 mm
FL 71,1 mm
AFI was enough

Placental implanted at anterior corpus gr II-III

Impression : term pregnancy, fetal alive

Laboratorium
Hb : 10,5 gr/dl (12-14)
Leukocyte : 13.130/mm3 (5-10)
Hematocryte : 32 % (37-43)
Trombocyte : 280,000/mm3 (150-400)
PT : 10,2 (10,0-13,6)
APTT : 31,5 ( 29,2-39,40)
Diagnose :
G2P1A0L1 term parturient active phase of first stage +
arrest of descent due to CPD + one previous CS
Fetal alive singleton intrauterine head presentation with
caput palpated at HII

Management :
Control GA, VS, His, FHS
Informed consent
Inj Ceftriaxone 2x1gr IV
Consult Perinatologi
Consult Annasestesiologist

Plan :
CS
07/06/2017 ( 18.40 PM )
TPPCS was performed
A female baby was born by TPPCS :
FW : 3000gr
FL : 49 cm
A/S : 8/9
Placenta was delivered by small traction, complete, 17x 15x 2,5 cm
in size,500 gr in weight, umbilical cords length 55 cm, insertion
paracentralis.
Blood loss during operation 250 cc

Diagnosis :
P2 A0 L2 post TPPCS oi arrest of descentdue to CPD + previous CS
Mother-child were in care
Plan :
Control GA, VS, Contraction, Vaginal Bleading
IVFD RL ( Oxitocyn + Methergine ) 20dpm
Inj Ceftriaxone 2x1gr IV
Pronalges Spp If Need
Routine Blood test 6hours Post Operation