Resume of Case August 24th, 2011

Supervisor : dr. Juliawan, SpOG MS :Tomi, Dian, Ita, Mita, Lili Phisiology : 1 Phatology: 1

Identitied
Name : Mrs. R Age : 23 years old MR : 005094 Adressed: Sesela, Gunung Sari

Admitted to GH of NTB on August 24th, 2011 at 11.30

Time 12.00 (24/8/ 2011)

Subject Patient reffered from Gunung Sari PHC to GH of NTB with G2P1A1L0 40 weeks/S/L/IU head presentation + macrosomia +suspect CPD. Abdominal pain since 19-08-2011. History rupture of membrane (-), abdominal pain (+) , bloody slim (+), FM (+). History of HT (-), DM (-), Asthma (-) LMP : 17-11-2010 EDD : 24-8-2011 History of ANC : > 4 x at Polindes History of family planning : Next family planning : IUD History of obstetric 1. Abortus 2. This Chronologist : 22-08-2011 S : Patient came to Gunung Sari PHC with pregnant 9 month , confesed abdominal pain since 19 -08-2011. Blood slim (+), FM (+), history ruptur of membrane (-) .History of DM (-), HT (-), Asthma (-).

Object General status: General condition : well Cons : CM BP : 130/90 mmHg PR : 80 bpm RR : 24 x/minute T : 36,7C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+), Rh (-/), Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 39cm L2 : back on the right L3 : head L4 : 4/5 UC : 3x10 lamanya 20 EFW : 4340 gram FHB : 12.11.11 VT : 2cm, eff 25%, amnion +, head palpable, HI unpalpable small part or umbilical cord USG : fetal S/L/IU with head presentation, plasenta in fundus grade III (calsification), amnion

Assestment G2P1A1L0 40 weeks/S/L/IU head presentation+ macrosomia + Susp. CPD

Planning - Obs. Mother and fetal well being -DL and HBsAg Report to supervisor Adv : -Rehidrasi -Injeksi ampi 2gr/iv -SC at 16.30

O: 09.30WITA GC : well GCS : E4V5M6 TD : 130/80 mmHg PR : 80x/minute Temp : 36,5C RR : 20x/minute Abdominal palpation : UFH 39cm, breech palpable in fundus. Right back, EFW : 4340 gram FHB (+) : 12.11.12 VT : 1 cm, amn (+), head palpable, HI unpalpable small part or umbilical cord 11.00 WITA A: G1P0A0L0 40 weeks/S/L/IU head presentation + laten phase first stage of labor with macrosomia P: Sent to GH of NTB

Pelvic evaluation : Promontorium not palpable Sacrum : convexity normal Spina ischiadica not prominent Os coccigeous mobile Pubic arch >90 Lab exam : WBC : 10.600 RBC : 4,27 HGB :13 PLT : 3756000 Hct : 40,4 HBsAg : GDS : 148

Time

O General condition : well Cons : CM BP : 130/70 mmHg PR : 84 bpm RR : 20 x/minute T : 36,5C UC : : 3x10 lamanya 25 DJJ : +, 144x/minute

A G2P1A1L0 40 weeks/S/L/IU head presentation+ macrosomia + Susp. CPD

P SC at 16.30

14.00wita

17.45 wita

SC began Baby was born, Female, BW ; 4750gr, BL: 50cm, A-S ; 7-9, anus (+), congenital anomaly (-), amnion meconeal + , bleeding 100 cc Baby was sent to NICU

18.20wita

18.30

Plasenta was born manually, complete, 500 gr. bleeding 100 cc

Time

19.15

Mother GC : well BP ; 130/80mmHg PR : 100x/ bpm RR : 24 x T : 36,3C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 300 cc
Mother GC : well BP ; 120/80mmHg PR : 88 bpm RR : 20 x T : 36,3C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 400 cc GC : well BP : 120/80 mmHg PR : 80 bpm RR : 18 tpm T 36,5C TFU : 1 finger below umbilicus UC : + Active Bleeding (-) GDS: 148 mg/dl

1 hour post SC

Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

19.30

2 hour post SC

Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

(25-08-2011) 07.00

1 st day post SC

Obs vital sign and active bleeding

Baby in NICU: RR : 36 x/minute