Resume of CaseSeptember 16th, 2011

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

Identitied

• Name : Mrs. S• Age : 31 years old• MR : 254353• Adressed: Kr. Lendong, KLU

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

Time Subject Object Assestment Planning

00.05(16/9/2011)

Patient reffered from Tanjung GH with G2P1A0L1 39 weeks/S/L/IU head presentation Latent phase 1st stage of labor + Suspect Severe preeclamsia . Abdominal pain since 09.00 WITA (15-09-2011), bloody slim (+) 09.00 WITA (15-09-2011), History rupture of membrane (-), FM (+), headache (-), blurred vision (-), epigastric pain (-) , seizzure (-), History of HT (-), DM (-), Asthma (-), history of SC 12 years ago because of eclamsia.

LMP : 16-12-2010EDD : 23-09-2011History of ANC : 2x at PolindesHistory of family planning : injection 3 monthNext family planning :tubectomyHistory of obstetric 1. term, Male, SC, Doctor, 2400, 12 years2. This

Chronologist : in Tanjung GH15-09-201121.45 WITA S : patient 9 month pregnancy came to Tanjung GH confess abdominal pain since 09.00 WITA (15-09-2011), bloody slim (+) 09.00 WITA (15-09-2011), FM (+), headache (-), epigastric pain (-) .

General status:General condition : wellCons : CMBP : 150/90 mmHgPR : 100 bpmRR : 20 x/minuteT : 37’C

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

Obstetrics statusL1 : breech L2 : back on the leftL3 : headL4 : 4/5UC : -UFH : 28 cmEFW : 2635 gramFHB : 11.11.11 (135x/minute)

VT : Ø 1 cm, eff 10%, amn (+) , ↓HI ,unpalpable small part or umbilical cord.

G1P0A0L0 39 weeks/S/L/IU head presentation + PER and previous SC 12 years ago

- Obs. Mother and fetal well being-DL and HBsAg-Coass to GP: pro CTG -Report to GP:Adv : Move to VK terataiObservation

Examination in tanjung GH15/09/2011 (21.40 Wita)GC : wellCons : CMEmotion : stabil TD : 150/100mmHgPR : 84x/minuteTemp : 36’7°CRR : 22x/minuteAbdominal palpation : UFH 29cm,L1: breech L2: Back on leftL3: head presentationL4: 4/5EFW 2790 grFHB : 11-12-12 (140x/minute)UC : 3x10’=35”VT : Ø 1 cm, amn (+), eff 25%, head palpable, ↓HI, unpalpable small part or umbilical cordA:G2P1A0L1 39 weeks/S/L/IU head presentation Latent phase 1st stage of labor + Suspect Severe preeclamsiaP: - insert RL drip MgSO4 40% 28 tpm 15/09/2011 (22.15 wita)P : - bolus MgSO4 40% 10 cc - KIE family - referred to NTB GH

Lab exam : WBC : 10,85RBC : 4,32HGB :11,7PLT : 371Hct : 35,8MCV: 82,9MCHC : 27,1Protein : +1HBsAg : -

Time S O A P

02.20(16/9/2011)

General condition : wellBP : 150/80 mmHgPR : 94bpmRR : 20 x/minuteT : 36’CHis: 2x10’=20”DJJ: 11-11-12

G1P0A0L0 39 weeks/S/L/IU head presentation + PER and history of SC 12 years ago

07.00(16/9/2011)

BP : 130/90 mmHgPR : 88bpmRR : 20 x/minuteT : 36,2’CHis: 1x10’=20”DJJ: 12-12-12

Co to supervisorAdv: observation 2 hour

10.30(16/9/2011)

Supervisor called to VK TerataiAdv supervisor : prepare to SCInsert DC and infusInjection ampi 2 gr/iv

11.10(16/9/2011)

SC began

11.15(16/9/2011)

Baby was born, Male, BW 2700 gr, BL: 47 cm, A-S ; 7-9 anus (+), congenital anomaly (-), amnion meconeal, bleeding ± 350 ccPlacenta was born manual, completely, Baby was sent to NICU

11.30(16/9/2011)

SC finish

Time S O A P

13.00(16/9/2011)

- MotherGC : wellCons : CMBP ; 140/80mmHgPR : 94bpmRR : 20 xT : 36 ‘CTFU : 1 finger above umbilicusUC (+) hardActive bleeding :(-)Lochea :(+)UO : 100 cc

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

14.00 - MotherGC : wellCons : CMBP ; 140/80mmHgPR : 91bpmRR : 20 xT : 36 ‘CTFU : umbilicusUC (+) hardActive bleeding :(-)Lochea :(+)UO : 110 cc

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

Time S O A P

07.00 Wound operation pain (+) MotherBP: 110/80 mmHgPR: 79/minuteRR: 20/minuteT: 36,7’CUC: (+), wellUFH: 1 finger below umbilicusUO: 300 ccVaginal active bleeding (-)Baby in NICUPR: 140/minuteRR: 45x/minute

1 day post SC Obs vital sign and active bleeding