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LAPORAN JAGA VK

26 Desember 2017
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Pembimbing
M. Ilham Aldika., dr., Sp.OG (K)

PPDS:
Junior B: dr. Darmi
Patol A: dr. Dimas
Chief: dr. Atika

DM:
Kamal Musthofa
Tu Gus
Bayuwega

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PASIEN BARU

3
1. Ny.Su/ 40 tahun/
In Hospital 26 Desember 2017 jam 15.00
Adress: Wonokusumo, Surabaya

Oktober 2017 12/12/17 25/12/17 26/12/17 26/12/17,


(12.00) (15.00)
Patient went to In Last pregnancy The patient
midwife because control at felt no fetal Px went to RS Px arrived at
she felt her midwife, she was movement Muhammadiyah VK RSUA with
abdomen was reffered for USG to check the BP: 190/100,
getting bigger because her fetus pregnancy, and
and then was in bad then she reffered
diagnosed with 5 condition to RSUA
months pregnant

Riwayat Penyakit Dahulu:


HT (-), DM (-), asthma (-), alergic (-)
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ANC: Midwife: 2x breech position, baby was in bad condition
HPHT: px forget 32/33
TP: - dari USG minggu

Obstetric History:
1. First born aterm BW 3000gr / Midwife / now 22 years old
2. Second born aterm/ Midwife/ now 20 years old
3. This pregnancy
Marriage: 1x; 23 tahun
Contraception: Injection Contraception 3 months, stop 2
months before known she was pregnant
Physical Examination (Delivery room, 26 Desember 2017 pk 15.00):

Status Generalis
GCS 456 A(-) I(-) C(-) D(-)
BP : 190/107 HR : 87 RR: 20 T :36.2
Cor : normal S1/S2
Pulmo : Vesicular +
+
+
+
+ +
Ronchii - -
- -
- -
Wheezing - -
- -
- -

I
Status Obstetri
TFU : 27 cm
Letak : Breech Position
Fetal heart rate :-
His :-
VT : 1 cm / 25% / Amnion membrane
(+) / breech pos. / H I / PS 2

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Laboratory UL
HB : 13,3 Protein urine +3
Leukosit : 4,39 Eritrosit +5
Trombosit : 287 Lekosit 6-8

PPT px: 12,0


control: 13,5
APTT px: 31,9
control: 31,4

SGOT: 21
SGPT: 10
BUN: 8,7
SK: 0,51

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Diagnosis :
GIIIP 2002 32/33 minggu + breech pos.+ IUFD + PEB + secondary old
pregnancy (40 y.o) + EFW 1600 gr
Tatalaksana :
- Inf RD5 500cc/24 hours
- Inj MgS04 20% 4gr IV continue with MgSO4 40% 1gr/ hour SP
- Nifedipin 3 x 10 mg if BP≥ 160/110
- Metildopa 3 x 500mg
- Pro termination pervaginam with Cervix ripenin: Misoprostol
25mcg per vaginam / 6 hours until PS≥ 5
- If PS≥ 5 pro OD 12 hours
- If Inpartu pro Spt Bracht
- Max drink 1000cc/ 24 hours
- Fluid Balance I = O + 500

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26 Desember 2017 pk 15.00
S: ibu ingin mengejan

O: Status Generalis
GCS 456 A(-) I(-) C(-) D(-)
BP : 110/70 HR : 88 RR: 20 T :36.7
Status Obstetri
HIS (+) DJJ: 12-12-12
VT: Ø lengkap/ketuban(-)/kepala/ UUK depan/H III +

A: GIIP0 010 39/40 minggu THIU + letak kepala + Riwayat


KPP + inpartu kala II+ TBJ 3200 gram

P: Ibu dipimpin mengejan

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19 Desember 2017 pk 16.00
S: ibu tampak kelelahan

O: Status Generalis
GCS 456 A(-) I(-) C(-) D(-)
BP : 110/70 HR : 88 RR: 20 T :36.7
Status Obstetri
HIS (+) DJJ: 12-12-12
VT: Ø lengkap/ketuban(-)/kepala/ UUK depan/H III +

A: GIIP0 010 39/40 minggu THIU + letak kepala + Riwayat


KPP + inpartu kala II+ TBJ 3200 gram

P: Pro percepat kala II dengan tarikan vacum


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• Tanggal 19 – 12 – 2017 pukul 16.15
- Lahir bayi VE/perempuan/3.350 gram/51cm/AS
6-7
- Plasenta lahir lengkap dengan MAK III
- Didapatkan episiotomy  Perineoraphy (+)

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• OBSERVATION (26th Dec 2017)

Time BP HR/mnt Respiratory Temperature Fundus HIS (in VT


rate Height 10
minutes)
17.00 190/107 88 22 36,5’C 27 cm - Ø 1 cm / 25% /
Amnion
membrane (+) /
breech pos. / H I /
PS 2

18.00 190/100 80 24 36,5’C 27 cm - -


19.00 187/105 84 20 36,5’C 27 cm - -
20.00 191/112 79 20 36,5’C 27 cm 1 x 10’ -
21.00 193/115 82 22 36,5 ‘C 27 cm - -
22.00 196/116 80 28 36,5’C 27 cm - -
23.15 199/118 78 24 36,5’C 27 cm - -
23.45 173/93 78 26 36,5’C 27 cm 2 x 10’ -

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• OBSERVATION (27th Dec 2017)

Time BP HR/mn Respira Temperature Fundus Height HIS (in 10 VT


t tory minutes)
rate

00.15 157/82 84 26 36,5’C 27 cm -


00.45 138/71 83 21 36,5’C 27 cm - -
01.15 135/75 96 21 36,5’C 27 cm - -
01.45 151/78 91 20 36,5’C 27 cm - -
02.15 151/78 90 22 36,5 ‘C 27 cm - -
02.45 149/74 86 20 36,5’C 27 cm - -
03.15 155/80 97 23 36,5’C 27 cm - -
03.45 162/87 95 20 36,5’C 27 cm 1 x 10’ -
04.15 155/80 96 22 36,5’C 27 cm - -

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• OBSERVATION (27th Dec 2017)
Time BP HR/mn Respira Temperature Fundus Height HIS (in 10 VT
t tory minutes)
rate
04.45 157/89 103 24 36,5’C 27 cm -
05.15 153/79 89 20 36,5’C 27 cm - Ø 1 cm /
25% /
Amnion
membran
e (+) /
breech
pos. / H
I / PS 2

05.45 147/90 92 24 36,5’C 27 cm - -


06.15 145/89 80 25 36,5’C 27 cm - -
06.45 180/94 70 20 36,5 ‘C 27 cm - -
07.15 161/88 73 23 36,5’C 27 cm - -
07.45 177/85 84 22 36,5’C 27 cm - -
08.15 176/90 95 24 36,5’C 27 cm 1 x 10’ -
08.45 170/100 96 22 36,5’C 27 cm - -
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Tatalaksana:
- Observation every 30 minutes
- Nifedipin 3x10 mg if BP >= 160/110 mmHg

- Asam Mefenamat 3 x 500 mg


- Roborantia 2 x 1
- KIE V/V hygiene
- KIE ASI eksklusif

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• Kondisi Terakhir Pukul 06.00 di Ruang Rawat Inap
- S : Nyeri (+)
- O : GCS : 456
TD : 100/60 N : 80 RR : 16
TFU : 3 jari dibawah Pusat
V/V : perdarahan (-)
Kontraksi uterus : (+)

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THANK YOU

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