Case Report 2

Name : Mrs. M
RM : 562173
Age : 19 years old
Address : Pemenang, North
lombok
Admitted : June 29th 2015 at
02.32 am
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

29/06/2 Patient referred from Tanjung General Status : G1P0A0L0 40-41 DM planning :
015 GH with G1P0A0L0 A/S/L/IU GC : well weeks S/L/IU Diagnostic
22.32 head presentation with latent BP : 120/70 mmHg head presentation Check lab: CBC,
phase of labor + drip failed + PR : 88 bpm with neglected HbsAg,
wita
fetal distress. RR : 22 bpm inpartu active Therapy
Patient confessed abdominal T : 36,5OC phase of labor. Inj ceftriaxone 2 g
pain spread to the flank since Pro CTG
13.00 wita (28/06/2015). Water Eye : anemis (-), icteric (-) Pro CS
leaked out from her womb (+) Cor : S1S2 single regular, murmur
since 12.00 wita (27/06/15), (-), gallop (-). CIE
bloody slim (-), FM (+). Pulmo : vesicular (+/+), wheezing * mother to eat and
No history of DM, HT, asthma or (-/-), drink
allergic. ronkhi (-/-). mother to shift to the
Abdomen : scar (-), striae left side
LMP : 15-09-14 gravidarum (+), linea nigra (+).
EDD: 22-06-2015 Extremity : edema (-/-), warm acral
GW : 40-41 weeks (+/+). DM consult to GP,
GP co to spv. Adv
History of ANC : forget (book Obstetrical Status : termination labor
lost) L1 : breech with CS.
History of USG : - L2 : back on the right side
L3 :head
History of family planning : - L4 : 4/5
Next family planning : inj 3 UFH : 34 cm
month EFW : 3565gram
UC : 3x10 ~ 35
Obstetrical History : FHB : 11-11-11(132 bpm)
I. This VT : 4cm, eff 50%, amniom (-)
meconeal, HI denominator SS,
caput (+), impalpable small part and
umbilical cord.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chonologist at Tanjung (28/06/2015 Lab Examination

at 09.00 wita) 27/06/2015 (15.10 wita) :
S/ Patient referred from Pemenang HGB : 9,8 g/dl
PHC. Patient confessed abdominal HCT : 38,2 %
pain spread to the flank since 13.00 WBC : 26.49 K/uL
wita (28/06/2015). Water leaked out PLT : 268 K/uL
from her womb (+) since 12.00 wita HbSAg : (-)
(27/06/15), bloody slim (-), FM (+).
No history of DM, HT, asthma or
allergic.

O/
GC : well
BP : 100/60 mmHg
PR : 76 bpm
RR : 22 bpm
T : 36,3OC

L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5

UFH : 28cm
FHB : 136 bpm
EFW : 2635 g
UC: 2x10 ~ 20
FHB: 11-11-12 (136 x/m)
VT : 1cm, eff 25%, amnion (+),
head palpable HI denominator
unclear, impalpable small part and
umbilical cord.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

A: G1P0A0L0 40-41 weeks S/L/IU

head presentation with latent phase
of labor

P: GP co to SPV. Adv: termination

with drip oxytocin 5 iu in D5%
-Inj ceftriaxone 2 g/ IV

-10.00 wita
-Start first fflash drip oxytocin 4
dpm, increase 4 dpm every 15
minutes

-13.00 wita
-VT : 2cm, eff 25%, amnion (+),
head palpable HI denominator
unclear, impalpable small part and
umbilical cord.

-15.30 wita
-Start 2nd flash of oxytocin drip, 40
dpm
-UC: 2x10 ~ 20
-FHB: 144 x/m

-19.30 wita
-Finished 2nd flash of oxytocin drip
-UC: 2x10 ~ 20
-FHB: 160 x/m ireguler

-20.00 wita
-Pastient referred to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
22.32 GC : well G1P0A0L0 40- Check lab: CBC, HbsAg,
wita BP : 120/70 mmHg 41 weeks Therapy
PR : 88 bpm S/L/IU head Inj ceftriaxone 2 g
RR : 22 bpm presentation Pro CTG
T : 36,5OC with neglected Pro CS
inpartu active
UFH : 34 cm phase of labor. GP co Spv. Adv: CS
EFW : 3565gram
UC : 3x10 ~ 35
FHB : 11-11-11(132
bpm)
VT : 4cm, eff 50%,
amniom (-) meconeal,
HI denominator SS,
caput (+), impalpable
small part and umbilical
cord.

29/06 CS Began
/15 Baby was born, female, A-S 7-9, BW 3600 grams,
01.00 BL 47 cm. Anus (+), congenital anomaly -.
wita Placenta was born spontan and completed,
bleeding 300 cc.
Amnion: meconeal

03.00 GC: well 2 hours -Obs. Mother well being

wita GCS: E4V5M6 post CS -Observation GC, VS, bleeding
BP: 110/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,60 C

UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
29/6/ GC: well 1 day post Obs. Mother well being
15 GCS: E4V5M6 CS Suggest mother to eat and drink, and
07.00 BP: 120/70 mmHg
wita medication
PR: 88 bpm
RR: 21 rpm mobilistation
T: 36,6 C

UC: (+) well

UFH: 2 finger bellow
umbilical
Lochea (+)

Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2 0C
Labia mayor
not covered
labia minor
 Formed &
firm instant
recoil
Tippled
Areola ;
1-2 mm
bud
abundant
No Creases
3

15
4

3
16
Lubchenco Curve