Case Report

Name : Mrs. M
Age : 32 years old
Address : Lingsar
Admitted : May 7 2017
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

7/517 Patient referred from Lingsar General Status G3P2A0L2 38- DM Planning
10.00 PHC with G3P2A0L2 38 weeks 39 weeks S/L/IU Resucitation
GC : well
S/L/IU head presentation with with neglected (RL:D5% = 2:1)
BP : 120/80 mmHg
arrested active phase 1st stage active phase 1st 02 4lpm
PR : 82 bpm
of labor+ fetal distress. Patient stage of labor Paracetamol tab
RR : 24 bpm
confessed abdominal pain that 500 mg
T : 38,1oC
spread to frank since 05/05/17 CTG
Eye : anemis (-/-), icteric (-/-)
and water came out from her CBC, HbsAg
Cor : S1S2 single regular,
womb since 08.00 (7/05/2017). Pro Termination
murmur (-), gallop (-).
Bloody slim (+), FM (+).
Pulmo : vesicular (+/+),
No history of DM, HT, asthma. DM co
wheezing (-/-), ronkhi (-/-).
SPVobservation
Abdomen : scar (-), stria
LMP : 12-08-2016 2hours, if theres no
gravidarum (+), linea nigra
EDD : 19-05-2017 progression -> SC
(+).
Extremity : edema (-/-), warm
History of ANC : 10x at PHC
acral (+/+).
Last ANC : 5/05/2017
History of USG : 1x Sp.OG
Obstetrical Status
History of family planning : L1 : breech
spiral L2 : back on the right side
Next family planning : L3 : head
tubectomy L4 : 4/5
UFH : 38 cm
Obstetrical history : EFW : 4185 gram
1. Female/ 17 th/ UC : 3x/10 ~ 40
RSUP/Midwife/ aterm/life FHB : 14-13-13 (164 bpm)
2. Males/ 12 th/ RSUP/Midwife/ VT : 4 cm, portio edema,
aterm/life amnion (-), head palpable
3. This HI+, denominator unclear,
caput (+), impalpable small
part / umbilical cord.
 TIME SUBJECTIVE OBJECTIVE ASSESTMEN PLANNING
T
06/05/1 Chronologist :
7 S : Patient came to Lingsar PHC that
confessed abdominal pain that
17.00 spread to frank since 05/05/17 and
water came out from her womb since
08.00 (7/05/2017). Bloody slim (+),
FM (+).
O: GC : well
BP : 100/70 mmHg
PR : 82 bpm
RR : 20 bpm
T : 36,8oC
FHB : (+) 142 bpm
VT : 1 cm, eff 25% amnion (+),
head palpable HI+, denom unclear,
impalpable small part /umbilical cord.

A: G3P2A0L2 38 weeks S/L/IU with

laten phase of labor

P: Obs mother and fetal

Obs progression of labor
 TIME SUBJECTIVE OBJECTIVE ASSESTMEN PLANNING
T
06/05/1 S : Patient confessed abdominal pain
7 and dyspneu
O: GC : well
21.00 BP : 110/70 mmHg
PR : 80 bpm
RR : 48 bpm
T : 36,8oC
FHB : (+) 142 bpm
VT : 1 cm, eff 25% amnion (+),
head palpable HI+, denom unclear,
impalpable small part /umbilical cord.

A: G3P2A0L2 38 weeks S/L/IU with

laten phase of labor

P: 02 2 lpm
Obs mother and fetal
Obs progression of labor
 TIME SUBJECTIVE OBJECTIVE ASSESTMEN PLANNING
T
07/05/17 S : Patient confessed abdominal
01.00 pain
O: GC : well
BP : 110/70 mmHg
PR : 80 bpm
RR : 48 bpm
T : 36,8oC
His : (+) 3x 10 40
FHB : (+) 136 bpm
VT : 1 cm, eff 25% amnion (+),
head palpable HI+, denom
unclear, impalpable small part
/umbilical cord.

A: G3P2A0L2 38 weeks S/L/IU with

laten phase of labor

P:
Obs mother and fetal
Obs progression of labor
 TIME SUBJECTIVE OBJECTIVE ASSESTMEN PLANNING
T
07/05/17 S : Patient confessed abdominal
pain
05.00 O: GC : well
BP : 110/70 mmHg
PR : 80 bpm
RR : 48 bpm
T : 36,8oC
His : (+) 3x 10 45
FHB : (+) 136 bpm
VT : 4 cm, eff 25% amnion (+),
head palpable HI+, denom
unclear, impalpable small part
/umbilical cord.

A: G3P2A0L2 38 weeks S/L/IU with

active phase of labor

P:
Obs mother and fetal
Obs progression of labor
 TIME SUBJECTIVE OBJECTIVE ASSESTMEN PLANNING
T
07/05/17 S : Patient confessed water leaked
08.00 from her womb
O: GC : well
BP : 110/70 mmHg
PR : 80 bpm
RR : 48 bpm
T : 36,8oC
His : (+) 3x 10 45
FHB : (+) 160 bpm
VT : 4 cm, eff 25% amnion (-),
head palpable HI+, denom
unclear, impalpable small part
/umbilical cord.

A: G3P2A0L2 38 weeks S/L/IU with

arrested active phase of labor +fetal
distress

P:
O2 5lpm
Inj ampicillin 1 gram IV
IVFD D5 : RL = 2: 1
Refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
12.00 Patient confessed UC : 3x/10 ~ 40 G3P2A0L2 38-39 Consult to SPV, advice :
abdominal pain. FHB : 12-12-13 (148 weeks S/L/IU with prepare CS.
bpm) neglected 1st stage Skin test (-), injection
VT : 4 cm, portio of labor. Cefotaxime 1 g/IV
edema, amnion (-), Insert DC
head palpable HI+, CIE patient and family
denominator unclear,
caput (+), impalpable
small part / umbilical
cord.

12.30 CS began
Baby was born :
Female, BW : 3500 gram,
BL : 51 cm, A-S : 7-9,
meconeal (+), caput (+).
Congenital anomali (-),
anus (+).
Plasenta was born
manually, complete
14.30 Patient confessed GC : well 2 hours post CS Observed mothers
wounds pain BP : 120/70 general condition, vital
PR : 88 bpm sign, and bleeding.
RR : 16 bpm
T : 36,6oC
UC : (+)
UFH : 2 finger below
umbilicus
Lochea rubra : (+)
Operation wounds good