Supervisor: dr. Edi PW, Sp.

OG
DM: gede, umam,dede

No Case Total
Pathologic delivery

1 1
G2P1A0L1 38-39
weeks/S/L/IU head
presentation with
prolonged 2
nd
stage of
labor

Mrs. L, 27 yo,
From Lingsar

Hozpitalised on 13.30 WITA, 10 Feb 2014

G2P1A0L1 38-39 weeks/S/L/IU head presentation
with prolonged 2nd stage of labor

CASE 1
Time Subject Object Assessmen
t
Planning
10/02/
2014
13.30
Patient reffered from
PHC Lingsar with
G2P1A0L1 38-39
weeks/S/L/IU head
presentation with
prolonged 2
nd
stage of
labor. Patient confesed
abdominal pain since
08.00 (10/02/14) and no
history of water leaked
out from her vagina.
Bloody slim (+). FM (+).
History of DM (-), HT (-),
asthma (-).

LMP : 11-05-2013
EDD : 18-02-2014
History of ANC :10x at
PHC
Last ANC : 10-02-14
Result: 38-39 weeks
S/L/IU, back on the left
side
History of USG : -

General status
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR: 88 bpm
RR: 22 x/min
T: 37,2C

Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular
M (-), G(-)
Abd : striae gravidarum
(+), linea nigra (+), scar (-)
Ext : edema (-/-)

G2P0A0L1
38-39
weeks/S/L/I
U head
presentation
with
prolonged
2
nd
stage of
labor.
-Obs. Mother
and fetal well
being.


DM co. to GP
pro SC, GP co.
to SPV, advice:
Resusitation
Inj.Ceftriaxo
n 1 g/IV
Observation
2 hours

Time Subject Object Assessment Planning
History of family planning:
-
Next family planning: IUD
Obstetric History:
1. Female/aterm/dukun/
11 years/life
2. This

Cronologist :
10/02/2014 at Lingsar
PHC (13.00)
S : patient, pregnant 9
month, confesed
abdominal pain since
08.00 WITA. No history of
water leaked. Bloody
slim (+), FM (+).

Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 2/5
UC : 3x10- 40
FHB : 13-12-12
(148bpm)
UFH: 33cm,
EFW : 3410 g
VT : VT : 10 cm, eff
100%, amnion (+), Head
palpable HII, Caput
(+), impalpable small
part / umbilical cord

Lab result
HB : 12,5
HCT : 36,8
WBC : 15,5
PLT: 896
HbsAg : (-)
Time Subject Object Assessment Planning
General status
GC : well
BP : 120/80 mmHg
PR: 84 bpm
RR: 20 x/min
T: 36,1C

FHB : 12-11-12 (140x )
UC: 4x10~45
UFH : 36cm
Breech at fundus, head
presentation.
VT : 10 cm, eff 100%,
amnion (+), head
presentation, H II,
impalpaled small part of
fetus and umbilical cord.

A: G2P1A0L1 39 weeks
/S/L/IU head presentation
with prolonged 2
nd
stage
of labor.
P: -rehidrasi RL 2 fl+ D5%
-Reffer to NTB GH



Time Subject Object Assessment Planning
15.30














16.00








Abdominal pain (+) and
wants to bearing down













Abdominal pain (+) and
wants to bearing down

GC : well
UC : 3x10 45
FHB : 13-12-12
(148bpm)











GC : well
UC : 3x10 45
FHB : 12-12-12
(144bpm)
VT : 10 cm, eff 100%,
amnion (+), Head
palpable HII, Caput
(+), impalpable small
part / umbilical cord











-Obs. Mother well
being.
-DM co. to GP
pro amniotomy,
GP co. to SPV,
advice:
- Amniotomy
acc
- Inj ceftriacon
1 gr IV
- Observation 1
hours



- DM co To GP
for SC, GP co to
SPV
Advice :SC CITO

- CIE patient &
familiy for SC




Time Subject Object Assessment Planning
16.30

16.37






























CS began

Baby was born :
I. Male. BW:
3700 g BL: 53cm,
head
circumference :
34cm, AS 6-8
Anus (+). Caput
(+). Congenital
anomaly (-).

Placenta was
born. Manually.
Complete.
500gram.
Bleeding 300cc




Time Subject Object Assessment Planning
18.00










11-02-
2014

07.00
Mother confese wound
pain

GC : well
BP : 100/70 mmHg
PR : 84 x/minute
RR : 20 x/minute
T : 36,8 C
UFH : 2 finger below
umbilicus
UC: (+) well
Active bleeding: (-)





GC : well
BP : 110/70 mmHg
PR : 84 x/minute
RR : 20 x/minute
T : 36,8 C
UC: (+) well
Lochea : (+)
Baby in NICU
GC : well
RR: 40 x/minute
PR: 144 x/minute
T: 36,7 C

2 hours post
SC












P2A0L2 1
day post SC
-Obs. Mother
well being.
-CIE mother to
eat and drink.










-Obs. Mother and
baby well being.
-CIE mother to
breast feeding.
-CIE mother to
eat and drink.