Selamat pagi, Melaporkan pasien atas nama Nyonya Dewi umur tiga puluh lima tahun, masuk rumah

sakit tanggal dua puluh tujuh desemeber dua ribu dua belas, jam enam lewat lima puluh menit. Keluhan utama : ingin melahirkan Pasien adalah rujukan dari bidan dengan diagnosis G3P2A0. Pasien lupa tanggal haid terakhir, tetapi pasien merasa hamil aterm. Keadaan umum Tekanan darah seratus empat puluh per delapan puluh, yang lain dalam batas normal. Pemeriksaan obstetri Inspeksi : tampak cembung asimetris L1 : 1 jari dibawah processos xypoideus L2 : Punggung kiri punggung kanan L3 : Kepala L4 : sudah masuk pintu atas panggul TFU : tiga puluh delapan cm TBJ : dua ribu gram - dua ribu gram His : positif, dua tiga kali per 10 menit, lama dua puluh sampai dengan tiga puluh detik. DJJ : seratus empat puluh dua kali, seratus empat puluh delapan kali permenit. Vagina toucher Portio : konsistensi lunak, pembukaan tujuh cm, kulit ketuban negative, penurunan hodge dua. Pemeriksaan penunjang Hb : 12.1 lain lain dalam batas normal Dikamar bersalin didiagnosis dengan G4 P2 A1 hamil aterm + inpartu kala II memanjang ( gameli bayi II) + janin hidup tunggal presentasi kepala 07:00 Sikap observasi CHPB Evaluasi sealama dua jam pro SPT BK Lapor supervisor , acc setuju 09:00 VT : pembukaan sembilan cm, ketuban negative, penurunan hodge 2 Sikap observasi CHPB, evaluasi 2 jam pro SPT BK 11:00 VT: pembukaan lengkap, ketuban negatif, penurunan Hodge 2 Dx: G4 P2 A1 gameli aterm dengan inpartu kala 2 + JTHIU presentasi kepala

12:00 Pasien didiagnosis dengan G4 P2 A1 gameli aterm, ipartu kala II dengan arrest of decent ec power + JTHIU presentasi kepala Sikap: lapor supervisor NST > hasil normal NST Drip oksitosin 14:10 lahir bayi spontan belakang kepala, dua ribu gram, 44 cm, as 5- 6 -7 14: 15 Dilakukan amniotomi dilanjutkan drip oksitosin, Evaluasi 1 jam 16:00 VT : pembukaan lengkap, ketuban negative KIE dan informed consent procito SC + MOW 16 :15 Persiapan OP 16:45 Pasien naik OK 17:00 Anastesi dimulai 17: 20 oprasi dimulai 17: 30 Lahir bayi laki laki, dua ribu sembilan ratus gram, 47 cm, as 7 8 9 Beberapa menit kemudian, plasenta lahir, didapatkan satu plasenta, satu koreon dan dua amnion. Perdarahan kurang lebih lima ratus CC Oprasi selesai

Good morning, Reported a patient on behalf of Mrs Dewi thirty-five years old, entered the hospital on the twenty-seven as of December two thousand and twelve, after six hours and fifty minutes. The main complaint: to give birth The patient was a referral from the midwife to the diagnosis G3P2A0. Patients forget the date of last menstrual period, but the patient was pregnant at term. The general state Blood pressure is one hundred and forty eighty, the other in the normal range. Obstetric examination Inspection: looks convex asymmetric L1: 1 finger under processos xypoideus L2: Left Backs - right back L3: Head L4: has entered the pelvic TFU: thirty-eight cm TBJ: two thousand grams - two thousand grams His: positive, two - three times per 10 minutes, a long twenty to thirty seconds. DJJ: one hundred and forty-two times, one hundred forty-eight times per minute. Vagina toucher Portio: soft consistency, opening seven cm, negative fetal skin, decreased hodge two. Investigations Hb: 12.1 etc. within normal limits Dikamar maternity diagnosed with full-term pregnancy G4 A1 + P2 inpartu stage II elongated (infant Gameli II) + single live fetal head presentation 07:00 Attitude observation CHPB Evaluation sealama two hours pro SPT BK Report supervisor, acc agree 09:00 VT: opening nine cm, negative membranes, decreased hodge 2 Attitude CHPB observation, evaluation pro SPT BK 2 hours 11:00 VT: complete opening, amniotic negative, decreasing Hodge 2 Dx: G4 P2 A1 Gameli aterm with stage 2 + JTHIU inpartu head presentation 12:00

Patients diagnosed with G4 P2 A1 Gameli aterm, ipartu stage II with the arrest of decent power ec + JTHIU head presentation Attitude: report supervisor NST> NST normal results Drip oxytocin 14:10 infants born spontaneously back of the head, two thousand grams, 44 cm, as 5-6 -7 14: 15 Do amniotomy oxytocin drip was continued, Evaluation 1 hour 16:00 VT: complete opening, negative amniotic IEC and informed consent procito SC + MOW 16: 15 Preparation OP 16:45 Patients up OK 17:00 Anesthesia begins 17: 20 oprasi begins 17: 30 Baby born men, two thousand nine hundred grams, 47 cm, as 7 8 9 A few minutes later, the placenta was born, it was found one placenta, one amniotic koreon and two. Bleeding more than five hundred CC Oprasi completed