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Resume of Case August 23th, 2011

Supervisor : dr. Juliawan, SpOG MS :Arif, Tya, Dinmas, Ita, Uyunk, Lili Phisiology : 0 Phatology: 1

Identitied
Name : Mrs. F Age : 25 years old MR : 253552 Adressed: Bengkel

Admitted to GH of NTB on August 23th, 2011 at 08.15

Time 08.15 (23/8/ 2011)

Subject Patient reffered from Bengkel PHC with G1P0A0L0 41weeks/S/L/IU head presentation + prolonged 2nd stage of labor. Abdominal pain since 20.00 WITA (22-08-2011) came to GH of NTB. History rupture of membrane (+), abdominal pain (+) , bloody slim (+), FM (+). History of HT (-), DM (-), Asthma (-) LMP : 9-11-2010 EDD : 16-08-2011 History of ANC : > 4 x at Polindes History of family planning : Next family planning : IUD History of obstetric 1. This Chronologist : 23-08-2011 04.00 WITA S : patient came to Bengkel PHC with G1P0A0L0 41weeks/S/L/IU head presentation + prolonged 2nd stage of labor at 04.00 (23-8-2011). Abdominal pain since 20.00 WITA (22-08-2011) Blood slim (+), FM (+), history ruptur of membrane (+) at 20.00 WITA (22-082011). History of DM (-), HT (-), Asthma ().

Object General status: General condition : well Cons : CM BP : 140/80 mmHg PR : 80 bpm RR : 20 x/minute T : 37C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+), Rh (-/), Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 30 cm L2 : back on the right L3 : head L4 : 3/5 UC : EFW : 3565 gram FHB : 11.12.11 VT : complete, amn (-) clear, head palpable, HII , caput (+) ,unpalpable small part or umbilical cord,

Assestment G1P0A0L0 41 weeks/S/L/IU head presentation neglected 2nd stage of labor

Planning - Obs. Mother and fetal well being -DL and HBsAg Report to GP (09.00 wita): -Pro rehidration, Adv : - Rehidration -Inj Ampisilin 1 gr/IV GP report to Supervisor Adv: - Try termination with EV if failure, pro SC

O: 04.00 WITA GC : well GCS : E4V5M6 TD : 140/80 mmHg PR : 84x/minute Temp : 37C RR : 20x/minute Abdominal palpation : UFH 34cm, breech palpable in fundus. Right back. EFW 3565 gr FHB (+) VT : 8 cm, amn (+), eff 75%, head palpable, HII unpalpable small part or umbilical cord 06.00 WITA FHB (+) VT : complete, amn (-) clear, head palpable, HII unpalpable small part or umbilical cord, prepare to GH NTB 08.00 WITA Sent to GH of NTB with prolonged 2nd stage of labor + Bayi Besar A: G1P0A0L0 41weeks/S/L/IU head presentation + prolonged 2nd stage of labor + Bayi Besar P: Reffered to GH

Lab exam : WBC : 25.000 RBC : 4,36 HGB :10,2 PLT : 348.000 Hct : 34,1 Mcv: 25,2 Mch : 25,5 HBsAg : +

Time 10.30 wita

A G1P0A0L0 41 weeks/S/L/IU head presentation neglected 2nd stage of labor

P EV beganVacum failur

11.00 wita

Co to Supervisor Adv: -Acc SC -CIE Os & Family -Rehidrasi D.C -Cepotaxim 2 gr/IV

11.25 wita 12.15 wita

SC began Baby was born, Male, BW ; 3200 gr, BL: 47 cm, A-S ; 7-9, anus (+), congenital anomaly (-), amnion clear 30 cc, bleeding 100 cc Baby was sent to NICU Placenta was born spontan, completely. bleeding 100 cc

12.20

Time 13.00

S -

O Mother GC : well BP ; 130/80mmHg PR : 70 bpm RR : 19 x T : 36,5C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 250 cc

A 1 hour post SC

P Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

14.00

Mother GC : well BP ; 130/80mmHg PR : 84 bpm RR : 20 x T : 37,1C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 500 cc

2 hour post SC

Obs vital sign and active bleeding CIE mother to eat and drink if not fomit