A.

Identity
Name
Age
Sex
Medical record
Address
Religion
Date of entry

: Mrs. DN
: 27 years old
: Female
: 168437
: Intan Residence, D-15, Nongsa
: Islam
: January 10, 2017

Proxy
Age
Sex
Address
Religion
Occupation

: Mr. A
: 36 years old
: Male
: Intan Residence, D-15, Nongsa
: Islam
: Government Employee

B. Anamnesis
1. Chief complaint
Patient came with complaint thea was a roung of clear fluid from the vagina
2. History of present illness
Patients arrived from PONEK, with complaint thers was a mount of clear fluid
from the vagina at 3am (early morning). This patiens complaint about with labor,
there is bloody (-). The Fluid berwarna jernih dan tidak berbau, ibu tidak demam,
gerakan janin masih dirasakan oleh ibu sejak 2 hari yang lalu Riwayat
tekanan darah tinggi, jantung, asma dan diabetes mellitus disangkal oleh pasien.
Pasien menikah 1 kali selama 1 tahun. Riwayat pemakaian KB disangkal oleh
pasien. Riwayat alergi disangkal oleh pasien
3. Post illness history
- Hypertension (-)
- Asthma (-)
- Mellitus Diabetic (-)
- Allergies (-)
- Heart Disese (-)
4. Family illness history
- Hypertension (-)
- Asthma (-)
- Mellitus Diabetic (-)
- Heart Disese (-)
5. Menstruation history
- Menarch in 15 years old
- Menstruation cycle is 28-30 days

Duration as long as 3 days. Regular

First day of last menstruation; April 05, 2017

6. Antenatal care history

Patient had ANC 7 times during pregnancy with doctors
7. Marriage history
Married , once for 1 years until now at 2016
8. Obstetric history
This is her 1 pragnancy and baby
- Sex: Female
- BW: 2948 gr
- BL: 49 cm
9. Contraception history
Never use contraception
10. Habbit history
- smoking (-)
- alcohol (-)
- drugs & herb (-)
C. physical examination
a. general status
- general condition
: moderate
- sensorium
: compos mentis
- weight
: 59 kg
- height
: 151 cm
- BMI
: 25,87
vital sign :
BP
: 120/70 mmhg
HR
: 80 x/i
RR
: 20 x/i
T
: 36,8 oC
- Head
: normochepali
- Eye
: conjungtiva anemis (+/+), sklera icteric (-/-)
- Neck
: Normal
- Thorax :
Pulmo : vesicular (+/+), ronchi wheezing (-/-)
Cor
: regular
- Abdomen
: arah memanjang, nigra linea (+), peristaltic (+)
Leopold examination
- Leopold I : Teraba bokong
- Leopold II. Teraba punggung sebelah kiri
- Leopold III. Teraba kepala
- Leopold IV. Belum masuk PAP
Pelvic examination
- Promontorium : Tidak teraba

- Spina Isciadica: Agak menonjol

- Intertuberum Distance : 7 cm

D. Obstetric Status
Fundal Height : 30 cm
Leopold examination
- Leopold I : Teraba bokong
- Leopold II. Teraba punggung sebelah kiri
- Leopold III. Teraba kepala
- Leopold IV. Belum masuk PAP
Pelvic examination
- Promontorium : Tidak teraba
- Spina Isciadica: Agak menonjol
- Intertuberum Distance : 7 cm
Inspekulo : Tampak cairan keluar dari OUE dengan tes lakmus (-)
VT : P 2 cm, efficement 25%, ketuban (+)
Tidak teraba portio lunak, penurunan Hodge I
Tidak teraba bagian kecil/tali pusat.
E. Workup
Laboratory studies, January 10, 2017
HEMATOLOGI, KIMIA DARAH, IMUNOSEROLOGI
Result
Reference value
Hb
8.3
11.0 16.5
Leukosit
11.300
3500 10.000
Ht
26
35 50
Eritrosit
3,8
3.8 - 5.8

Satuan
gr/dl
/ul
%
juta/ul

Platelet
MCV
MCH
MCHC

ribu/ul
fl
pg
g/dl

388
69
21.4
31

150 500
80.0 - 97.0
80.0 - 97.0
31.5 35.0

F. Working diagnosis
G3P2A0H1 gestasional age 40-41 week + CPD +
(Hb : 8,3 gr/dl)

G. Working Management
- IUVD RL 30 gtt/i
- Ceftriaxone Inj. 1gr
- Dexamethasone Inj. 2 amp

PPROM + Anemia moderate

Prepare CS Cito with dr.Ni Made Indri DS, Sp.OG

H. Report of cesarian section

- Do the aseptic and antiseptic
- Make a pfanenstiel incision (8cm) in length
- after opened the peritoneum, visible the front wall of the uterus
- the vesicouterina plica is cut cross wise
- make a concave in the lower segment of the uterus, dilated to left and right
- the baby delivered. BW : 1700 gr , BL : 44 cm
- deliver the placenta
- lower segment of the uterus is satured
- control the bleeding
- abdomen count satured loyer by loyer
I. Post operation diagnosis
P3A0H2 post CS with indication CPD + PPROM + Anemia moderate (Hb : 8,3 gr/dl)
J. Management post operation
- IUVD RL drip tramadol 28 gtt/i
- Ceftriaxone Inj. 2x1
- Metronidazole Inj. 3x1
- Ketorolac Inj. 2x1
- Pronalgess Supp 2x2
- Transfusion PRC 2 kolf

Follow up after operation

S:
O : - general condition
-

sensorium
vital sign :

: moderate

: compos mentis
: 130/70 mmhg
: 88 x/i
: 20 x/i
: 36,7 oC
Fundal height
: parallel with umbilical
A : P3A0H2 post cesarian section with indication previous cesarian section 2x + antepartum
BP
HR
RR
T

haemorrahage (heavy, reccurance) e.c placenta previa + anemia moderate (hb: 8.6 gr/dl)
P : IUVD RL drip tramadol 28 gtt/i

Ceftriaxone 2x1 gr
Metronidazole 2x500mg
Ketorolac 2x1 amp
Transamin 3x1 amp
Vik K 3x1 amp
Vit C 3x1 amp
Transfusion PRC 2 kolf
-