Case 2

Name
: Mrs. S
Age
: 21 years old
Address
: Penimbun
Admitted
: January 7th 2016
No. RM : 572290

TIME

SUBJECTIVE

7/1/2016
00.00

Patient referred from PHC with

G1P0A0L0 37-38 weeks S/L/IU
head presentation, mother and fetal
well being with history of ROM
and oligohidroamnion. Patient
confessed Water leaked from her
womb (+) since 21.00 pm
(6/1/2016), abdominal pain (+)
since 23.00 pm (6/1/2016), bloody
slime (-), FM (+).
History of DM (-), HT (-), asthma
(-) and allergy (-).
LMP : 10/4/2015
EDD : 17-01-2016
History of ANC : 12x at PHC
Last result: (30/12/2015)
BP 90/60 mmHg, GW 37 wk, UFH
32 cm, head presentation, FHB (+)
History of USG : 1x last result
(6/1/2016)
S/L/IU,
head
presentation, GW 37-38 wk, EFW
2740 g, AFI 8,4
History of family planning:Next family planning : injection
Obstetrical hsitory
I. This

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 82 bpm
RR: 20 bpm
T: 36,6C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular, m (-), g
(-)
Abd : striae gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (-/-), warm acral (+/+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 29 cm
EFW : 2790 gr
UC : FHB : 12-12-12
VT : 1 cm, eff 25%, amnion (-),
clear, head presentation, denom
unclear, HI, impalpable small part
and umbilical cord

ASSESSMENT

PLANNING

G1P0A0L0 38-39
weeks S/L/IU head
presentation with
PROM

DM planning:
Diagnostic :
- CTG
- CBC, APTT/PPT,
HbsAg
Therapy :
- Pro induction of labor
with oxytocyn drip
- CIE : CIE mother and
family about diagnostic
planning and therapeutic
planning
DM consult to GP about
patient condition and
planning, GP co to SPV
SPV advice :
- Acc oxytocyn drip if
CTG reactive

TIME

SUBJECTIVE
Chronology at Penimbung PHC
(07/01/2016)
S :Patient came to the hospital with
9 month pregnancy with water
leaked from her womb since
21.00 pm (6/1/16) Fetal
movement (+)
O:
GC : well
GCS : CM (E4V5M6)
BP : 110/70 mmHg
PR : 80 x/m
RR : 20x/m
Temp : 36,6oC
FHB : 134 x/min
UC : (+) 1x10-25
UFH : 28 cm EFW : 2480 gr, head
presentation, back on the right side,
5/5
VT : 1 cm, eff 25%, amnion (-),
head presentation, denom unclear,
HI, impalpable small part and
umbilical cord
A : G1P0A0L0 37-38 week
/S/L/IU head presentation othe and
fetal in well condition with history
of ROM + oligohidroamnion
P : -IVD RL 28tpm
reffered to NTB GH

OBJECTIVE
Pelvic score = 4
Dilatation of cervix : 1
Length of cervix : 0
Station : 1
Consistency : 1
Position : 1
Lab
Hb 9,1
RBC 3,59
HCT 29,1
WBC 7,61
PLT 303
HbsAg (-)
PPT 13,7
APTT 35,5

ASSESSMENT

PLANNING

TIME

30SUBJECTIVE

06.30

OBJECTIVE

ASSESSMENT

PLANNING

UC : 2x10-15
FHR : 12-12-12

Start oxytocyn drip flash I

8 dpm

07.00

Abdominal pain (+)

C : 2x10-15
FHR : 11-12-12

OD 12 dpm

07.30

Abdominal pain (+)

UC : 2x10-20
FHR : 12-12-12

OD 16 dpm

08.00

Abdominal pain (+)

UC : 2x10-20
FHR : 12-12-11

OD 20 dpm

08.30

Abdominal pain (+)

UC : 2x10-25
FHR : 12-11-12

OD 24 dpm

09.00

Abdominal pain (+)

UC : 3x1030
FHR : 12-12-12

OD 28 dpm

09.30

Abdominal pain (+)

UC : 3x10-35
FHR : 12-13-13

OD 32 dpm

10.00

Abdominal pain (+)

UC : 3x10-35
FHR : 12-12-12

OD 36 dpm

10.30

Abdominal pain (+)

UC : 3x10-40
FHR : 12-12-13
VT : 6 cm, eff %, amnion (-),
clear, head presentation, LOA,
HI, impalpable small part and
umbilical cord

Active phase of labor

with history of ROM

OD 40 dpm
Observation progress of
labor with WHO
partograph

11.00

Abdominal pain (+)

UC : 3x10-45
FHR : 12-12-13

OD 40 dpm

11.30

Abdominal pain (+)

UC : 3x10-45
FHR : 12-12-13

OD 40 dpm

TIME

30SUBJECTIVE

OBJECTIVE

12.00

Abdominal pain (+)

UC : 3x10-45
FHR : 12-13-13

OD 40 dpm

12.30

Abdominal pain (+)

UC : 4x10-45
FHR : 13-12-13

OD 40 dpm

13.00

Mother want to bearing down

UC : 4x10-45
FHR : 13-13-12
VT : 10cm, eff 100%, amnion
(-), clear, head presentation,
denom LOA, HIII, impalpable
small part and umbilical cord
sign of 2nd stage of labor

ASSESSMENT

2nd stage of labor

PLANNING

Conduct mother to
bearing down
Baby was born at 13.30
WITA with umbilical cord
twist 1x , male, AS 5-7,
BW 24000g, BH 48 cm,
HC 32 cm, AC 10 cm
Placenta was born
completely at 13.40 WITA
Umbilical cords length 50
cm
Baby take to the NICU

TIME
15.30

SUBJECTIVE
-

OBJECTIVE
GC : well
BP : 100/70 mmHg
PR : 90 bpm
RR : 19 bpm
T : 36,5OC
UC : (+) well
UFH : 2 finger below umbilicus
Active bleeding (-)

ASSESSMENT

PLANNING

2 hours post partum

Suggest mother to rest,

eat and drink

1 days Post partum

Observed mother &

baby well being
Suggest mother to eat
and drink

Baby in NICU
HR : 145x/min
RR : 48x/min
T ; 36,3
8/1/2016
07.00

GC : well
BP : 100/70 mmHg
PR : 88 bpm
RR : 18 bpm
T : 36,7OC
UC : (+) well
UFH : 2 finger below umbilicus
Lochea : (+)
Baby in NICU
HR : 140x/min
RR : 40x/min
T : 36,5

3
2
2
3
3
3
16

4
3
3
3
3
3

19

Kurva Lubchenco