CASE REPORT

G6P5A0, gravid 40
WEEKS, INPARTU
STAGE II OLD BABY
WITH LARGE AND
Suspect KPD

Celsi Vitara Saputri

406171003
Identity patient

Name: Ny. P
Age : 37 year
Ethnicity: Sundanese
address: Kp, Babakan
Islam
Education: Elementary
Occupation: Housewife
anamnesis

Taken from autoanamnesis, 20 January 2018, at 16.40 pm

Main complaint : Patient say opening no advanced
hospital sheet now: Patients present with Exit waters since pk 10.00. speechlessar
blood and patients also complain the mules increasingly long increasingly great,
Denied blurred vision, nausea, vomiting denied, heartburn denied. Active fetal
movement. pregnancy tosix, no there is history of miscarriage. Irregular
menstruation, HPHT25 June 2017, never used birth control, ANC to midwife 7x visit
hospital sheet first: Hypertension (-), DM (-), asthma (-), drug allergies (-), food allergies
(-)
hospital sheet family: Hypertension (-), DM (-), asthma (-), drug allergies (-), food
allergies (-)
History menstruation : menarche at the age of 14 year, cycle 28 day, the
duration of 7 days, HPHT 25 June 2017, the gestational age of 40 weeks
marriage history : first marriage
History gestation Pregnancy tosix, child first until the fifth child born pps
History KB : Never use Contraseption
History ANC : To midwife 7x visits
Examination Physical

General appearance: Looks moderate pain

awareness: compos mentis
vital signs
Blood pressure: 120 /80 mmHg
Pulse : 90 x /mnt
RR : 20 x /mnt
Temperature : 36,50C
Examination Systematic
head: Normocephali
Eyes: Conjunctiva anemis - / -, sclera jaundice - / -
Nose: septal deviation -, secretions - / -
Ears: ear Liang field, cerumen - / -, intact tympanic
membrane + / +
Mouth: Oral hygiene well, dental caries -
Throat: Tonsils T1 / T1, hyperemia - / -
Neck lymph nodes and thyroid gland was not enlarged
Breast: Symmetrical, inverted nipple -
Lung: Inspection: chest movement symmetrical in still
and moving
palpation: No palpable masses, stem fremitus right
and left equally strong
percussion: Sonor throughout the lung fields
auscultation: BJ I and II regular, murmur -, gallop -
Abdomen: Inspection: Buncit, striae gravidarum +
palpation: Supple, tenderness -
percussion: Timpani
auscultation: + Normal bowel sounds
Genitalia: The vulva and vagina there is no
abnormality, edema -, blood -, mucus -
extremities: akral warm, CRT <2 seconds, reflex
patellar + / +, Edema -/- the extremities under
Examination obstetric

Leopold I: Buttocks, TFU 43 cm, palpable part less rounded, soft, bouncy
Leopold II: The Prisoner abdomen right backs (Puka). DJJ 137x / min, his 2-3x / 10
minutes, more or less duration> 40 seconds
Leopold III: Head, palpable part of a round, hard, bouncy
Leopold IV: PAP
External examination: vulva and vagina there is no abnormality, edema -, slime +,
blood +
Examination in: opening complete, amniotic (-), portio thin soft, head Presentation
Hodge 1
Examination Laboratory

Hematology
Hb: 13.0 g/dL
Hematocrit: 39.6%
Leukocytes: 12.700 /ul
Platelets: 194,000 /ul
cloting time : 11'00 "
Bleeding time: 2'30 "
Blood group : A
rhesus : Positive
GDS: 109 mg/dL
protein urine :-
resume

Has examined a woman 37 years coming with complaints Exit water - water since pk 10:00. Out
blood and pasien too complain the mules increasingly long increasingly great, Headache (-),
Blurred vision (-), nausea (-),vomiting (-), heartburn (-). Active fetal movement,no there is history
of miscarriage during her first pregnancy until the fifth pregnancy, irregular menstruation, HPHT
25 June 2017, the ANC in midwife 7x. History of hypertension (-), DM (-), asthma (-), food and
drug allergies (-).
Physical examination of the general state look ill being, consciousness compos mentis, TD 120 /80
mmHg, pulse 90x / min, RR 20x / minute, a temperature of 36,50C, lower extremity edema + / +
Examination obstetric Leopold I buttocks, Leopold II Puka, Leopold III head, Leopold IV PAP.
Outside of vulvar and vaginal examination no abnormalities, edema (-), blood (+), Mucus (+)
Examination of the vulva and vagina there is no abnormality, the ostium open, amniotic (-), portio
thin soft
Laboratory tests Hb 13,0 g/dL, Ht 39.6%, Leukocytes 12.700 /ul, Platelets 194,000 /ul, protein
urine -, GDS 109mg /dL, CT 11'00 ", BT 2'30"
diagnosis Work

mother : G6P5A0, gravid 40 weeks, inpartu prolonged second stage + suspected big
baby + KPD
Children: single fetus (+), intrauterine, presentations head
Management

Non Medical: Hospitalization in hospitals VK Ciawi, Observation TTV, his and

progress of labor, FHR observations, confinement plan sectio caesarea
medical: - IVFD 20tpm 500cc RL.
- cefadroxil 2 x 500 mg
- drip oxy 5 IU