Supervisor : dr. Made Juliawan, Sp.OG.

Medical Student : Ita, Uyunk, Adit, Tya, Dinmas, Arif, Dian Physiologies labor Phatologies case :0 :1

CASE I
G4P3A0L2 A/S/L/IU active phase first stage of labor with compound presentation

NAME/AGE : Mrs. Sumiati/ 35 Years old ADDRESS : Lingsar Time

14July -2011 10.00

Admitted: 14 JuLy /2011 at 10.00

S
Patient reffered from Sigerongan PHC with G4P3A0L2 A/S/L/IU active phase first stage of labor, came directly to VK confessed rupture of membrane since 08.00 (14/07/2011), abdominal pain (+) & bloodyslim (+) since 04.00 (14/07/2011), FM (+). DM (-), HT (-), asthma (-). LMP : Forgot EDD : History of ANC : >4x, Polindes Last ANC : 8/06/2011 History of USG : History of family planning : 3 month inj Next family planning : 3 month inj. Obstetrical history : I. Female, TBA, spontan, 8 month (dead) II. Male, TBA, spontan, 13 years old III. Male, midwife, 2700 gr, spontan, 7 years old IV. this Chronologis: S : Patient came to Segerongan PHC at 08.30 (14 Juli 2011) confessed rupture of membrane at 08.00 (14 Juli 2011) and abdominal pain, bloody slim (+).

O
General status : General condition: good, BP: 120/80mmHg RR: 18x/mnt Pulse :88 x/mnt T: 36,5 C Eyes : an(-) ikt (-) Cor : S1 S2 tunggal regular m(-), g(-) pulmo : versikuler (+/+), Rh /-, whz -/Obstetric status : L1 : breech , UFH : 32 cm EFW : 3255 gr L2 : right back L3 : head presentation L4 : 4/5 UC : 3x10 ~ 35 FHR :160 bpm
VT: CD 5 cm, eff 50 %, amn (-), head and hand palpable in H I, denominator unclear. Lab result : Hb = 9,1 g/dl Leu = 8.600 Plt = 225.000 Hct = 30,6 % HbsAg (-)

A
G4P3A0L2 A/ S/L/IU first stage active phase of labor with compound presentation + Mild Anemia 1. 2. 3.

P
obs. Mother and fetal well being Injection ampicillin 2 gr IV Consult to dr.Juliawan (pro SC) Advice: ACC SC

Time

S
O: General status : BP : 110/70 mmHg RR: 18 x/mnt T : 36,5 UFH : 33 cm EFW : 3250 gram FHR : 136x/ mnt UC : 3.10 ~ 40 VT : 6 cm, eff 50 %, amn (-), head and hand palpable, H1, unpalpable umbilical cord A: G4P3A0L2 A/S/L/IU active phase first stage of labor with compound presentation P: Sent to GH of NTB

11.10 WITA 11.15 WITA

SC began Baby was born. Male, 3400 grams, BL: 48 cm. AS 7-9. Anus (+), kongenital anomali (-) Baby was sent to NICU

11.20 WITA

Plasenta was born manually, complete, 500 gr Bleeding 350 cc SC Finished

11.30

Time
11.45

S
Mother confessed weakness

O
Mother GC : well BP ; 110/70mmHg PR : 88 bpm RR : 18 x T : 36,5 C UC (+) hard palpable 3 finger above umbilical. Active bleeding (-) UO : 150 cc Mother GC : well BP ; 110/70mmHg PR : 88 bpm RR : 18 x T : 36,5 C UC (+) hard palpable 3 finger above umbilical. Active bleeding (-) UO : 150 cc Mother GC : well BP ; 110/70mmHg PR : 88 bpm RR : 18 x T : 36,5 C UC (+) hard palpable 2 finger above umbilical. Active bleeding (-) UO : 150 cc

A
15 minute post SC

P
Obs vital sign and active bleeding

12.00

Mother confessed weakness

30 minute post SC

Obs vital sign and active bleeding

12.15

Mother confessed weakness

45 minute post SC

Obs vital sign and active bleeding

Time
12.30

S
Mother confessed weakness

O
Mother GC : well BP ; 110/70mmHg PR : 88 bpm RR : 18 x T : 36,5 C UC (+) hard palpable 2 finger above umbilical. Active bleeding (-) UO : 175 cc Mother GC : well BP ; 110/70mmHg PR : 88 bpm RR : 18 x T : 36,5 C UC (+) hard palpable 2 finger at umbilical. Active bleeding (-) UO : 175 cc Mother GC : well BP ; 110/60 mmHg PR : 88 bpm RR : 18 x T : 36,5 C UC (+) hard palpable at umbilical. Active bleeding (-) UO : 200 cc

A
1 hour post SC

P
Obs vital sign and active bleeding

13.00

Mother confessed weakness

1 hour 30 minute post SC

Obs vital sign and active bleeding

13.30 WITA

Mother confessed wound pain

2 hours post SC

Obs mother and baby well being Obs vital sign and active bleeding

Time
15 July 2011 07.00 WITA

S
Mother GC : well BP : mmHg PR : bpm RR : x T: 36,5

A
First Day post SC

P
Obs mother and baby well being Obs vital sign and active bleeding