Case 3

Name
Age

: Mrs. A
: 18 years old

Address : Lingsar
Admitted
RM

: October 1st, 2015

: 123172

Time
01-102015
13.50

Subject
Patient referred from Sigerongan
PHC with G1P0A0L0 39 wks
S/L/IU head presentation,
mother and fetus well being
susp. PROM. Patient came to
NTB GH, confessed water
leaked out from her womb since
30-09-2015 (23.00 WITA),
bloody slim (-), abominal pain (-),
FM (+).
No history of DM, HT, asthma.
LMP : 01/01/2014
EDD : 08/10/2015
History ANC : 12x at Posyandu
and NTB GH
Last ANC : 01/10/2015
Result: BP : 120/90, BW 65kg,
GW 37-38 weeks, UFH 31 cm,
head presentation, FHB
(+)152x/minute
History of USG : 2x at
Obstetrician
Last USG: 01/10/2015: fetus
S/L/IU head presentation, back
on left side, BPD 34-35 weeks,
AC 37-38 weeks, FL 37-38
weeks , amnion clear, placenta
on posterior fundus
History of family planning : Next family planning : History of obstetric :
I. This

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 20 x/m
T: 36,8 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 5/5
UFH: 31 cm
EFW : 2945 gram
UC : (-)
FHB : 12-12-11
VT: not performed

Assessment
G1P0A0L0 37-38
weeks S/L/IU head
presentation with
PROM > 12 hours

Planning
DM planning:
Diagnostic
Pro CTG
Therapeutic planning :
Pro termination
pervaginam with
induction using
oxytocin drip
Inj. Ampicillin 1 gr/6
hours
CIE planning
CIE about diagnostic
and therapy
Obs. Mother and fetal
well being
Suggest mother to lie
down the left side, eat
and drink
Obs. progress of labor
DM co to GP pro oxy
drip, GP co to SPV,
SPV advice:
CTG
Termination with
oxytocin drip
GP co to SPV about the
CTG result, SPV
advice:
- Termination with CSection tomorrow
morning

Time

Subjective

Objective

Assessment

15.00

Abdominal pain (-)

GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 20 x/m
T: 36,8 C
UC : (-)
FHB : 12-11-12

16.00

Abdominal pain (-)

UC : (-)
FHB : 12-11-12

Observation of mother
and fetal well being

17.00

Abdominal pain (-)

UC : (-)
FHB : 12-12-12

Observation of mother
and fetal well being

18.00

Abdominal pain (-)

UC : (-)
FHB : 12-12-13

Observation of mother
and fetal well being

GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 20 x/m
T: 36,8 C
UC : (-)
FHB : 12-12-11

Observation of mother and

fetal well being

19.00

G1P0A0L0 37-38
weeks S/L/IU head
presentation with
PROM > 12 hours

Planning
Observation of mother
and fetal well being

20.00

Abdominal pain (-)

UC : (-)
FHB : 12-12-13

Observation of mother and

fetal well being

21.00

Abdominal pain (-)

UC : (-)
FHB : 13-13-13

Observation of mother and

fetal well being

22.00

Abdominal pain (-)

UC : (-)
FHB : 12-13-13

Observation of mother and

fetal well being

Time

Subjective

Objective

Assessment

Planning

23.00

Abdominal pain (-)

GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 96 x/m
RR: 20 x/m
T: 36,8 C
UC : (-)
FHB : 12-12-11

Observation of mother and

fetal well being

24.00

Abdominal pain (-)

UC : (-)
FHB : 12-12-13

Observation of mother and

fetal well being

05.00

Abdominal pain (-)

UC : (-)
FHB : 12-12-12
GCS: CM (E4V5M6)
BP : 110/80 mmHg
HR: 88 x/m
RR: 20 x/m
T: 36,8 C

Observation of mother and

fetal well being

07.00

Abdominal pain (-)

UC : (-)
FHB : 12-13-13

Prepare for C-section

Inj. Ampicillin 2gr Preop

08.00
08.10

C-Section began
Baby was delivered,
male, BW 3000. BL 49cm,
HC: 34cm, A-S 7-9, anus
(+), congenital anomaly (-)
Placenta was delivered,
manually, complete,
amnion clear, bleeding
150 cc.

Time

Subjective

10.00

Objective

Assessmen
t

GC: well
Cons: CM
BP: 120/70
HR: 90 bpm
RR: 20tpm
T: 37,1oC
UC: + well, UO : 100 cc/hours
UFH: on umbilicus, Lochea rubra: +
Active Bleeding (-), Operation wound
normal

2 hours post
c-section

Observed mother and baby well

being
Suggest mother to eat and drink if
mother didnt feel nausea or
vomiting
Suggest mother to do early
mobilisation.
- Inj Ampicillin 1gr/6 hours

One day
post csection

Observed mother and baby

Suggest mother to mobilisation, eat,
and drink, medication.
Continue therapy

Baby in NICU:
HB : 146 bpm
RR : 46 tpm
T: 36,8C
03/10/
2015
07.00

Patient confessed
wound pain

GC: well
Cons: CM
BP: 110/70
HR: 84 bpm
RR: 22 tpm
T: 36,5oC
UC: + , UO : 150 cc/hours
UFH: 2 fingers below umbilicus
Lochea rubra: +
Operation wound well cared
Baby in NICU:
HB : 144 bpm
RR : 48 tpm
T: 36,7C

Planning