PATHOLOGIC
AL LABOR
Case Report
Name : Mrs. S
RM
: 11-59-670
TIME
SUBJECTIVE
25/11/20
14
12.00
wita
Patient from
obstetric
department with G2P1A0L0
39-40 weeks /S/L/IU head
presentation latent phase
1st stage of labor with
severe anemia.
Patient
confess
lower
abdominal pain that spread
to
flank
region
since
25/11/2014 (05.00 wita),
history
of
membrane
ruptured (-), bloody slim
(-), fetal movement (+).
Dizzy (-), nausea (-)
history of DM (-), HT(-),
asthma (-) allergy (-).
LMP : 23-02-2014
EDD : 30- 11-2014
History of ANC : 10 times
at polindes
Last result: 25/11/2014 BP
110/70 mmHg, 39-40
weeks, UFH 38 cm, head
presentation, FHB +
History of USG : 1 time at
SpOG
Last result: 20/10/2014
S/L/IU, 35-36 wks, head
presentation, 2721 g,
male, sufficient amnion,
clear, placenta at fundus
grade III.
History of family planning :
OBJECTIVE
General Status :
GC : moderate GCS : E4V5M6
BP : 110/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,2oC
Eye : anemis (+), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), rhonchi (-/-).
Abdomen : scar (+), stria
gravidarum (+), linea nigra
(+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 5/5
UFH : 38 cm
EFW : 4030 gram
UC : (+) 2x/10~25
FHB : 12-12-12 (144 bpm)
VT : 1 cm, eff. 10 %, Amnion
(+),
head
palpable,
HI,
denom unclear,
impalpable
small part of fetus or umbilical
cord
ASSESSMENT
PLANNING
Observation
mother & fetal well
being.
Lab exam
DM co to GP pro
CTG and
transfusion, GP
agreed and co. SPV
advice: pro
transfusion 3 kolf
and CTG
TIME
25/11/14
12.30
wita
SUBJECTIVE
OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile
Arcus pubis <90
Lab Examination :
HB : 6.2 g/dl
RBC : 3.98 x 106/L
HCT : 22.5%
WBC: 11.32x 103/L
PLT : 269 x 103/L
HbSAg : (-)
Proteinuria : (-)
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
25/11/201
4
15.00 wita
16.00 wita
17.30 wita
OBJECTIVE
GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,4oC
UC : (+) 2x/10~25
FHB : 13-13-13 (156 bpm)
Mother
confessed
abdominal pain (+)
ASSESSMENT
G2P1A0L0 3940 weeks with
head
presentation
/S/L/IU with
severe
anemia+susp.
macrosomia
PLANNING
Observation mother &
fetal well being.
Transfusion PRC 1 kolf
CS began
Baby was born, male, BW
3900 gr, BL 50 cm, AS 89 , anus (+), congenital
anomaly (-)
Placenta delivered
completed, bleeding 150
cc
Intraoperatif finding: CPD
Baby was in NICU
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
19.30 wita
2 hours Post CS
Observation Mother
and
baby
well
being
Suggest mother to
mobilization
Suggest mother to
eat and drink
26/11/2014
07.00 am
1 day post CS
Observation Mother
and
baby
well
being
Suggest mother to
mobilization
Suggest mother to
eat and drink
4
3
3
3
3
4
20
4
3
3
3
3
3
19
Case Report
Name : Mrs. Y
RM
: 55 05 19
: Pagutan, Mataram
TIME
SUBJECTIVE
25/11/20
14
09.30
wita
OBJECTIVE
General Status :
GC : well GCS : E4V5M6
BP : 100/60 mmHg
PR : 98 bpm
RR : 22 bpm
T : 36,9oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), rhonchi (-/-).
Abdomen : distention (-), scar
(-), stria gravidarum (+), linea
nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 32 cm
EFW : 3255 gram
UC : 2x/10~ 30
FHB : 12-12-12 (144bpm)
VT : 2 cm, eff 25%, amnion
(+), head palpable, denom
unclear, HI, impalpable small
part of fetal/umbilical cord
ASSESSMENT
G1P0A0L0 3940 wks /S/L/IU
head
presentation
with latent
phase first
stage of labor
PLANNING
Lab exam
CIE and explain
result of
examination
Obs. Mother and
fetal well being.
Obs. Progress of
labor
DM co. to GP pro
CTG, GP agreed and
pro observation.
TIME
SUBJECTIVE
OBJECTIVE
Pelvic Evaluation :
Spina ischiadica not prominent
Sacrum concave
Os coccygeous mobile
Arcus pubis > 900
PS: 6
Dilatation: 1
Length:1
Consistency: 2
Position: 1
Station: 1
Lab Examination :
HB : 12.9 g/dl
RBC : 4.33 x 106/L
HCT : 38.5 %
WBC: 12.71 x 103/L
PLT : 315 x 103/L
HbSAg : (-)
BT: 215
CT: 610
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
13.30
wita
General Status
GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 82 bpm
RR : 21 bpm
T : 37,0 C
UC : 2 X 10~20
FHB : 12 -12-12 (144 bpm)
VT : 2 cm, eff 25%, amnion (+),
head palpable, denom unclear,
HI, impalpable small part of
fetal/umbilical cord
latent phase
first stage of
labor
17.30
wita
General Status
GC : well
GCS : E4V5M6
BP : 115/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
VT : 2 cm, eff 25%, amnion (+),
head palpable, denom unclear,
HI, impalpable small part of
fetal/umbilical cord
prolonged latent
phase first
stage of labor
DM co to GP pro rehydration, GP
agreed and co to SPV. SPV
advice:
-Pro acceleration
CIE patient and family
18.00
wita
UC : 2 X 10~35
FHB : 12 -11-12 (140 bpm)
- Rehydration began
RL: D5% = 2:1
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
20.30
wita
GC : well
GCS : E4V5M6
BP : 115/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
UC : 2 X 10~35
FHB : 12 -11-12 (140 bpm)
- Acceleration began
drip Oxytocin 8 dpm
21.00
wita
UC : 2 X 10~35
FHB : 12 -12-12 (144bpm)
21.30
wita
UC : 2 X 10~35
FHB : 12 -12-12 (144bpm)
22.00
wita
GC : well
GCS : E4V5M6
BP : 115/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
UC : 2 X 10~35
FHB : 12 -13-13 (152bpm)
VT : 2 cm, eff 25%, amnion (-)
meconeal, head palpable, denom
unclear, HI, impalpable small
part of fetal/umbilical cord
Neglected
latent phase of
labor
22.30
GC : well
GCS : E4V5M6
BP : 110/70 mmHg
PR : 88 bpm
RR : 21 bpm
T : 36,6 C
UC : 2 X 10~30
FHB : 12 -11-11 (136 bpm)
Preparing CS
CIE family
23.30
01.30
CS began
Baby was born, male, BW 3800
gr, BL cm, AS 8-9 , anus (+),
congenital anomaly (-)
Placenta delivered completed,
bleeding 150 cc
General condition: Good
BP : 100/80 mmHg
HR : 80 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below umbilical
UC : (+) well
Lochia rubra +
UO : 500cc
Active bleeding (-)
baby was in NICU
HR: 140 bpm RR : 54x/m, T: 36,7
C
2 hours Post CS
TIME
26/11
/14
06.00
SUBJECTIV
E
OBJECTIVE
ASSESSMENT
PLANNING
1 day post CS
4
3
3
3
3
4
20
4
3
3
3
3
3
19