Resume of CaseSeptember 16th, 2011

Supervisor : dr. Made Mahayase, SpOGMS :Ita, Uyunk, Lili, AtunPhisiology : Phatology:

Identitied

• Name : Mrs. N• Age : 21 years old• MR : 254350• Adressed: Pemenang, KLU

• Admitted to GH of NTB on September 16th, 2011 at 00.00

Time Subject Object Assestment Planning

00.00(16/9/2011)

Patient reffered from Pemenang PHC with G1P0A0L0 weeks/S/L/IU head presentation + neglected 2nd stage of labor. Abdominal pain since 20.00 WITA (14-09-2011) came to GH of NTB. History rupture of membrane (+) at 20.00 wita (14-9-2011), abdominal pain (+) , bloody slim (+), FM (+). History of HT (-), DM (-), Asthma (-)

LMP : 11-12-2010EDD : 18-09-2011History of ANC : > 9 x at PolindesLast ANC : 15-09-2011History of family planning : -Next family planning : injection 3 monthHistory of obstetric 1. This

Chronologist : in Pemenang PHC16-09-201115.00 WITA S : patient came to Pemenang PHC with Abdominal pain since 20.00 WITA (14-09-2011), Blood slim (+), FM (+), history ruptur of membrane (+) at 20.00 WITA (14-9-2011). History of DM (-), HT (-), Asthma (-).

General status:General condition : wellCons : CMBP : 120/60 mmHgPR : 108 bpmRR : 20 x/minuteT : 37’C

Localis statusHead : an (-/-) ict (-/-)Pulmo : Ves (+/+), Rh (-/-), Wh (-/-)Cor : normalAbd : striae gravidarumExt : edema (-/-)

Obstetrics statusL1 : breech UFC : 30 cmL2 : back on the rightL3 : headL4 : 3/5UC : 1x10’=20”UFH : 34 cmEFW : 3565 gramFHB : 12.12.13

VT : Ø 9 cm, eff 90%, amn (-) , head palpable, ↓HII , caput (+) ,unpalpable small part or umbilical cord

G1P0A0L0 39-40 weeks/S/L/IU head presentation active phase 1st stage of labor

- Obs. Mother and fetal well being-DL and HBsAg-Rehidration -O2

-Inj Ampisilin 1 gr/IV• report to GPAdv:-Move to VK teratai-CTG-If CTG reactif Drip Oxytocin

Examination in Pemenang PHC15/09/2011 (15.00 Wita)GC : wellTD : 110/70mmHgPR : 82x/minuteTemp : 36’6CRR : 22x/minuteAbdominal palpation : UFH 29cmL1: breechL2: back on right L3: headL4: 3/5EFW 2790 grFHB : 11-12-11 (136x/minute)UC : 3x10’=40”VT : Ø 4 cm, amn (+), eff 75%, head palpable, ↓HII, unpalpable small part or umbilical cord18.00 WITAInsert infus D5 %, 20 tpm20.00 WITA VT : Ø complete, amn (-), head palpable, ↓HIII unpalpable small part or umbilical cordMothers conduct bearing down (20,00-21.30 wita)A:G1P0A0L0 weeks/S/L/IU head presentation + neglected 2nd stage of labor.P: - insert D5% 18 tpm I fles - RL 500 gr I fles - Reffered to GH

Pelvic evaluation :Os coccigeous mobilePubic arch >90’

Lab exam : WBC : 18,48RBC : 3,69HGB :10,2PLT : 270Hct : 33,3MCV: 90,2MCHC : 27,6HBsAg : -

Time S O A P

02.15(16/9/2011)

Patient move to VK teratai

General condition : wellHis: 1x10’=20”DJJ: 12-12-12

G1P0A0L0 39-40 weeks/S/L/IU head presentation active phase 1st stage of labor

CTG

02.45(16/9/2011)

Insert drip oxy

03.15(16/9/2011)

Drip oxy 8 tpm General condition : wellHis: 1-2x10’=20”DJJ: 12-13-12

06.45(16/9/2011)

Drip oxy 40 tpm General condition : wellHis: 2x10’=25”DJJ: 12-11-11

Obs. Mother and fetal well being

07.00(16/9/2011

Drip oxy 40 tpm General condition : wellHis: 3x10’=30”DJJ: 12-13-13VT : Ø complet, amn (-) , head palpable, ↓HII , caput (+) ,unpalpable small part or umbilical cord

G1P0A0L0 39-40 weeks/S/L/IU head presentation + prolonged 2nd stage of labor

-Obs. Mother and fetal well being- Menganjurkan ibu mengedan sambil miring kiri

09.00(16/9/2011

Os mengatakan perut mules dan tenaga berkurang

General condition : weakHis: 3x10’=30”DJJ: 12-12-12VT : Ø complet, amn (-) , head palpable, ↓HII , caput (+) ,unpalpable small part or umbilical cord

G1P0A0L0 39-40 weeks/S/L/IU head presentation neglected 2nd stage of labor

-Co supervisorAdv : pro SC at 10.00-Insert DC-Injection ampi 2 gr/iv-Sent patient to OK

Time S O A P

10.10(16/9/2011

SC began

10.15(16/9/2011

Baby was born, Male, BW ; 3550 gr, BL: 47 cm, A-S ; 5-7 anus (+), congenital anomaly (-), amnion meconeal, bleeding ± 350 ccBaby was sent to NICU

10.20(16/9/2011

Placenta was born manual, complete 600 gr, bleeding 350cc

10.35(16/9/2011

SC finish

10.35(16/9/2011)

- MotherGC : wellBP ; 100/60mmHgPR : 105bpmRR : 22 xT : 36,3’CUC (+) hard, palpable in umbilical. Active bleeding (-), Lochea (+)UO : 90 cc

1 hour post SC Obs vital sign and active bleedingCIE mother to eat and drink if not vomiting

Time S O A P

13.40 - MotherGC : wellBP ; 100/70mmHgPR : 100 bpmRR : 24 xT : 36’CUC (+) hard, palpable in umbilical. Active bleeding (-), Lochea (+)UO : 90 cc

2 hour post SC Obs vital sign and active bleedingCIE mother to eat and drink if not vomiting

07.00 Wound operation pain (+) MotherBP: 110/70 mmHgPR: 84x/minuteRR: 20 minuteT: 36 ’CUC: (+), wellUFH: 1 finger below umbilicusUO: 400ccVaginal active bleeding (-)Baby in NICUPR: 148/minuteRR: 40/minute

1 day post SC Obs vital sign and active bleedingS.F 1x1Mefenamic acid 3 X 500Amoxicilin 3x500mg