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Supervisor : dr. I Made P. Mahayase, Sp.

OG
Medical Students: Dian, Ita, Tomi, Lili, Ika, Elin

G1P0A0H0 38-39 weeks/G/L-L/IU Breech presentation and Head Presentation with active phase 1 st stage of labor with severe preeclamsia + history ruptur of membran

Name Age Address


Time

: Mrs. R : 25 years old : Kr. Jasi, Lingsar

CTH

: September 11th, 2011 at . 22.10 Wita

Subject
Patient reffered from Gerung GH with G1P0A0H0 39 weeks/G/L-L/IU Breech-Head Presentation with active phase 1st stage of labor and severe preeclamsia. Abdominal pain (+). Bloody slim (+). History rupture of membrane (+). FM (+). History of DM (-), HT (-), Astma (-). LMP : 14-12-2010 EDD : 21-09-2011 History of ANC : > 4x, posyandu Last ANC : History of family planning : Next family planning : IUD Obstetrical history : I. This. Chronologis at Kediri PHC: 11/09/2011 19.00 Patient come to Kediri PHC with 9 month pregnancy, and Gemeli (USG, 20-06-2011). Confessed abdominal pain, History ruptur of membran since 10/09/2011, at 14.00 WITA. FM (+), epigastric pain (-), dizzines (), bllured vision (-) GC : Well GCS ; E4V5M6

Object

11/09 2011 22.10

GC : Well GCS ; E4V5M6 BP : 160/85 mmHg PR : 104 bpm T : 37,C RR : 22 tpm General status : Eye : an (-), icteric (-) Thorax : C ; S1/S2 single reguler, murmur (-), gallop (-). P ; ves (+/+), wh (-), rh (-) A: : scar (-), striae (+) Extremity : edema +/+ Obstetrical Status : UFH: 35 cm, Breech presentation, head presentation UC : 3 x 10 35 FHR : 1. 140 bpm 2. 144 bpm VT 5 cms, eff 50%, amnion (-) clearly, foot palpable HII, unpalpable umbilical cord

Assesment
G1P0A0H0 39 weeks/G/L-L/IU Head Presentation + breech presentation with active phase 1st stage of labor, severe preeclamsia and history rupture of membrane

Planning
Obs. mother and fetal well being Lab : DL, HbsAg Coass co GP: pro SC GP co to supervisor pro Sc ACC

Lab ; (-) WBC : 14.500 RBC : 4,31 HCT : 36,7% PLT : 277.000 HGB 10,7 g/dL Protein : +2 HbsAg : (+)

Time Contd

Subject
A : G1P0A0 39 weeks/G/L-L/IU head presentation with active phase 1st stage of labor and stage of labor and severe preeclamsia P: -Nipedifin 3x10 mg -Bolus and drip MgSO4 -Obs mother and fetal well being By anamnesis Chronologist at GH of Gerung Cont therapy from Kediri PHC mother and fetal well being KIE family, DC Patient sent to GH of NTB

Object

Assesment

Planning

00.45

SC began Female, 3200 gr, AS 79, congenital anomali (), anus (+). Female, 1950, AS 5-7, congenital anomali (+), anus (+) Amnion clear. Placenta was born manual. Bleeding 200cc GC : well cons : E4V5M6 BP : 130/70 mmHg PR : 100 x/minute RR : 20 x/minute T : 37 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 600 cc GC : well cons : E4V5M6 BP : 130/80 mmHg PR : 100 x/minute RR : 20 x/minute T : 37 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) 2 hours post SC Obs mother and baby

02.45

07.00 (12-92011)

1st day post SC

Obs mother and baby