Coass in charge: Fara/Vicia/Yanti/ Eva/Tryas/Desi Supervisor: Dr. Mulyo Hadi Sungkono, Sp.

OG(K)

 Reg.

1124075 Mrs. S/36 y.o/ 6 y.o.e/housewife Mr. K/41 y.o/ 6 y.o.e/driver Address : Polowijen II/452 RT1/33 Admitted at September 17th,2011, at 18.25pm Marriage 1x 19 years Patient came to RSSA because was referred by midwife Contraception: inj. 3 months, stopped 1 year ago This is the fifth pregnancy

 Children:
1. 2.

3.
4. 5.

At/?/spt.B/dukun/F/17 yo/L At/?/spt.B/dukun/M/13 yo/L At/3350 gr/spt.B/midwife/M/8 yo/L At/3000 gr/spt.B/midwife/F/3 yo/L This pregnancy

SUBJECTIVE September 17th 2011

at 10.00 am patient complained of uterine contraction went to midwife because post date referred to RSSA

ANC: 3x, midwife

LMP 20-11-10 EDD 27-8-11~ 43-44 wks

OBJECTIVE (07.00 PM)

GA : Good , CM BH : 155 cm BW : 60 kg

BP : 110/70 mmHg, PR : 80 bpm, RR :20x/

Tax : 36,6C H/N : an -/- ict -/Trect : 36,8C

Tho : C/P wnl Abd : FH 31 cm, longitudinal lie U , FHR 12.12.13 EFW 2945 gr, uterine contraction infrequently

VT: Dilatation 1 cm, Eff: 50 %, H I,

Amniotic Membrane (+), Head

presentation Denominator minor fontanela Pelvic Measurement~ wnl Pelvic score: 6

LABORATORY
CBC NST

: 11.900/10,4/31,6/363.000

: normal baseline rate: 150 bpm variability: 5-15 bpm acc: (+) dec: (-) USG: intrauterine fetus S/L letak bujur kepala di bawah

LABORATORY (contd.)
USG:

intrauterine fetus S/L letak bujur kepala di bawah BPD: 86.5 (34 w 5 d) AC: 313 (35 w 1 d) FL: 73.2 (37 w 3 d) EFW: 2832 AFS: 13.5 Placental implantation on fundus Maturation grade III

ASSESSMENT
G5 P4004 Ab000 part 43-44 weeks T/H + post term + age more than 35 years

PDx: DL, admission test PTx: Termination w/ OD 8 tpm increase 4 tpm every 15 mnt (max. 40 tpm). Evaluation 2 hours after adequate uterine contraction Pro expect pervaginam PMo: Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour PEd: CIE

September 17th 2011, 09.00 pm Subjective

Uterine contraction adequate with OD 12 drops/m. Adequate his at 07.00 PM.

Objective

GA: Good, CM BP: 100/70, HR: 88 bpm, RR: 20 tpm H/N: an -/-, ict -/Tho: c/p wnl Abd: FH 21 cm, longitudinal lie U, FHR: 11.13.11, EFW: 2945 gram, His 10.3.35/ms

VT: 4cm, Eff. 100%, H I, amniotic (+) clear, head presentation, denominator minor fontanela 2 oclock, pelvic measurement ~ wnl

Assesment

G5 P4004 Ab000 part 43-44 weeks T/H + First Stage Active Phase + Post term + age more than 35 years

Planning:

Evaluated 2 hours later (11.00 pm) Pro exp pervaginam Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour

September 17th 2011, 09.15pm Subjective Uterine contraction regularly (OD 12 drops/m) Rupture of fetal membrane spontaneously Objective GA: Good, CM BP: 110/70, HR: 88 bpm, RR: 20 tpm H/N: an -/-, ict -/ Tho: c/p wnl Abd: FH 31 cm, longitudinal lie U, FHR: 11.12.11, EFW: 2945 gram, His 10.3.40/ms VT: 8cm, Eff. 100%, H II, amniotic (+) clear, head presentation, denominator minor fontanela 1 oclock, pelvic measurement ~ wnl Assesment G5 P4004 Ab000 part 43-44 weeks T/H + First Stage Active Phase + Post term + age more than 35 years

Planning: Evaluated 2 hours later (11.15 pm) Pro exp pervaginam Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour CIE

September 17th 2011, 09.55pm Subjective Mother wanted to push Uterine contraction regularly and adequate Objective GA: Good, CM BP: 100/70, HR: 88 bpm, RR: 20 tpm H/N: an -/-, ict -/ Tho: c/p wnl Abd: FH 31 cm, longitudinal lie U, FHR: 12.13.12, EFW: 2945 gram, His 10.3.40/ms VT: complete, H III, amniotic (+) clear, head presentation, denominator minor fontanela 12 oclock, pelvic measurement ~ wnl Assesment G5 P4004 Ab000 part 43-44 weeks T/H + Second Phase + Post term + age more than 35 years Planning: Ibu dipimpin mengejan pro exp pervaginam Obs. VS, complaint, uterus contraction, fetal heart rate, progress of labour

OUTCOME

On September 17th , 2011 at 10.00 p.m a male baby was born, 3000gr / 47 cm/ AS 7-9

(Ballard score = 37 39-40 weeks)