KB : -

History :

General Examination :
General Condition : good/Concious
Blood pressure : 110/80 mmHg Pulse rate : 82 x/minute
Respiration rate : 20 x/minute Temperature : 36.8 ° C
Conjunctive : anemic -/- Sclera : icteric -/-
Heart and lung : within normal limits Extremities : oedema -/-
Body height : 154 cm Body weight : 54 kg

Obstetrics examination :
Fundal height
EFW
Fetal presentation
FHS
Uterine contraction
: 32 cm
: 3100 gram (JT)
: Cephalic presentation U back on the right
: 135-140 times/minute
:-

Vaginal Touche :
Soft thick portio, axial position, no cervical dilation, presenting part still high, Nitrazine test (+)

USG :
Intrauterine fetal, singleton
FM (+), FHM (+)
BPD : 9,26 cm, AC : 33,15 cm, FL : 7,57 cm
EFW : 3200 – 3300 grams
Placental implantation at fundus grade III
AFL < 2 cm
Conclusions : Fullterm of pregnancy + cephalic presentation + oligohydramnios (PROM)

Laboratory:
Hb : 10.7 g/dL, WBC : 9800 /mm3, Platelets : 289.000 / mm3
ECG:
Within Normal Limits

Diagnose:
G2P1A0 27 years old 40 - 41 weeks of pregnancy + 1 day of PROM + previous Cesarean section
Intrauterine fetal singleton alive cephalic presentation still high

Management:
 Antibiotic
 Emergency Caesarean Section
 Counseling informed Consent
 Counsling Contraception  refused IUD
 Observation vital signs, uterine contraction, fetal heart sound
 Consulted to supervisor  advice : Emergency Caesarean Section
Observation vital signs, uterine contraction, fetal heart sound

Observation
09.30 – 10.30 pm UC: none FHS : 145-150 bpm
10.30 – 11.30 pm UC: none FHS : 140-145 bpm
11.30 – 12.30 pm UC: none FHS : 140-145 bpm
12.30 – 01.30 pm UC: none FHS : 140-145 bpm
01.30 – 02.30 pm UC: none FHS : 140-145 bpm
01.30 – 02.30 pm UC: none FHS : 140-145 bpm

1
02.30 pm : The mother was brought to the operation theatre
03.05 pm : Operation was begun, low segment cesarean section was performed
03.12 am : Male baby was born, BW: 3250 grams, BL: 49 cm, AS: 6-8
04.10 am : Operation finished.

Up to now the mother and the baby is in good condition (Hb still in examination) and baby is in transition room

Observasi :

Jam 00.00 – 00.30 His: 2’-3’//50”-55” BJJ: 170-175x/menit

Jam 00.30 – 00.50 His: 2’-3’//50”-55” BJJ: 160-165x/menit

Jam 00.50 : Pasien didorong ke OK cito

Jam 01.10 : Operasi dimulai dilakukan SCTP
Jam 01.15 : Lahir bayi perempuan, BBL: 3200 gram, PBL : 48 cm, AS : 6-8
Lilitan tali pusat 1x di leher
Infark plasenta 30%, Clifford Sign grade II, Ballard score 40-42 minggu
Jam 02.10 : Operasi selesai

Sampai saat ini KU ibu cukup (Hb dalam pemeriksaan). Bayi dirawat di ruang transisi