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Case Report

Mrs. M, 22 yo, from Gangga,


Hospitalization on 1st June 2012, 21.50
G2P1A1H0, 39 40 wk /S/L/IU active phase 1st stage of labor,
with history rupture of membrane + dystocia 4 cm

Time

Subject
Chronologist (in Gangga PHC):
20.00 (31/05/2012)
S: pateint gestation 9 month,
confessed abdominal pain
since 07.00 (31/05/2012).
Blood slim (+). Water
cameout (+). FM (+).
O: General status : GC well,
BP 130/90 mmHg, PR
80x/minute, RR
24x/minute, T 37,5 c
Obstetric status:
TFU : 31 cm
EFW: 3100 gram
UC : 2x/10-30
FHR : 110x/minute
VT: 2cm, eff. 25%, Amnion
(+) clear, head palpable
HI, unpalpable small part
of fetal & umbilical cord.
A: P: Infuse RL 24 tpm
Skin test, (-), Inj. Ampicilin
(20.15)

Object
Lab
result
01/06/2012:
Hb = 10,1g/dl
Rbc = 4,34
Leu = 18,38
Plt = 312
Hct = 30,2%
HbSAg = (-)

in

Assessment
22.17,

Planning

Time

Subject

Object

Assessment

Planning

Obstetric status
UC : 3x/10-30
FHR
:
12.12.12
(144x/minute)
VT: 3cm, eff. 25%,
Amnion (+) clear, head
palpable HI, unpalpable
small part of fetal &
umbilical cord.

G2P1A1H0, 39
40 wk /S/L/IU
latent phase
1st stage of
labor, with
history rupture
of membran.

-Obs. Mother and


fetal well being.
-Obs. Progress of
labor.
-Inj. Ampicillin 1g/IV
(04.15)

00.00 (01/06/2012):
S : Abdominal Pain, Blood
slim (+)
O: GC well, BP 120/80 mmHg,
PR 80x/minute, RR
24x/minute, T 37,5 c.
UC : 3x/10-30
FHR : 140x/minute
VT: 2cm, eff. 25%, Amnion
(+) clear, head palpable
HI, unpalpable small part
of fetal & umbilical cord.
A: P: 02/06/1
2
06.30

Abdominal pain (+)

Time
10.30

14.30

Subject
Abdominal Pain ++

Object

Assessment

Planning

Obstetric status
UC : 3x/10-35
FHR
:
12.12.11
(140x/minute)
VT: 4cm, eff. 75%,
Amnion (-) clear, head
palpable HI, impalpable
small part of fetal &
umbilical cord.

G2P1A1H0, 39
40 wk /S/L/IU
active phase
1st stage of
labor, with
history rupture
of membrane.

- Obs. Mother and


fetal well being.
-Obs. Progress of
labor 4 hours later or
if there is indication.
-Suggest mother to
eat and drink.

Abdominal Pain +++


Obstetric status
UC : 2x/10-35
FHR
:
12.11.12
(140x/minute)
VT: 4cm, eff. 75%,
Amnion (-) clear, head
palpable HI, impalpable
small part of fetal &
umbilical cord.

18.00

G2P1A1H0, 39
40 wk /S/L/IU
active phase
1st stage of
labor, with
history rupture
of membrane
+ dystocia
4 cm.

21.50

General Status
BP : 130/70mmHg
PR: 84 tpm
RR: 18 tpm
T: 37,2C
General Status

- Obs. Mother and


fetal well being.
-DM co SPV, advice
call back 16.30.
-DM co SPV again
(16.30), advice:
-CTG, result normal.
-DM co SPV , advice:
resuscitation IU.
- Infuse RL : D5%
(2:1).
- educate mother to
side way to the left

-SPV call advice CS


at 22.00
-CIE patient and
family.
-Inj. Ampicillin 1
g/IV.
-Prepare to CS.

Time

Subject

21.10

Object
-

Assessment
-

Planning
Sc began
Amnion fluid: clear
Baby was born
(21.15). Male. 3250
g. AS 7-9. Anus (+).
Congenital anomaly
(-).
Placenta was born.
Manually. Complete.
300 gram.
Bleeding 300 cc

03/06/12
01.00

GC : well
BP : 110/80 mmHg
PR : 88 bpm
RR : 24 tpm
Temp : 36,5C
UC : +
UFH : 2 finger below
umbilicus.
Active bleeding : UO: 310cc (2 hours)

2 hours post CS
-CIE mother to
breast feeding.
-CIE mother to eat
and drink.

Time
08.00

Subject
Wound pain.

Object
GC : well
BP : 120/70 mmHg
PR : 90 bpm
RR : 20 tpm
Temp :36,0C
UC : +
UFH : 2 finer below
umbilicus
Active bleeding : UO: 500 cc (10 hours)
Baby in NICU:
PR: 148 x/mnt
RR: 48 x/mnt
T: 36,3 C

Assessment
1 day post CS

Planning
- KIE mother to
mobilization, eat
and drink.