Case report

IDENTITY
Name
MR No. Date

Adress

: Mrs Elvi Nila S (27 years old) : 83 0p0 87 : May 29th, 2013 : Parak Buruk Street, Padang City

 History taking:
A 27 years old patient was admitted to the Delivery

Room of Dr. M. Djamil Central General Hospital on May 29th, 2013 at 05.00 am with a chief complain of water leakage from the vagina since 2 hours ago.

Present Illness History :

Fluid leakage from the vagina since 7 hours ago soaking a piece of sarong, with clear color and putrid smell Pelvic pain radiating to the groin (-) Bloody show (-) Massive vaginal bleeding (-) Amenorrhea since 9 months ago. First date of last menstrual period was forgotten Estimation date of delivery cant be predicted Fetal movement was felt since 4 months ago.

 No complain of nausea, vomiting and vaginal bleeding

neither during early pregnancy nor late pregnancy. Prenatal care to midwife every month since the age of pregnancy was 3 months, fetal and mother in a good condition. Menstruation History : menarche at 13 years old, irregular cycle, once a month which last for 4 to 6 days each cycle with the amount of 2-3 times pad change/day without menstrual pain.

Previous Illness History : There wasnt previous history of heart, lung, liver, kidney, DM, hypertension and drugs allergic. Family Illness History : There wasnt history of hereditary disease, contagious and psychological illness in the family.

Marriage history : Once in 2012 History of pregnancy/abortion/delivery : 1/0/0 1. Present History of family planning : (-) History of immunization : (-) History of formal education: Senior High School graduated History of Habitually : Cigarrete (-), alcohol(-), drugs(-)

Physical Examination : GA : Moderate Consciousness : CMC Blood Pressure : 120/80 mmHg Pulse rate : 82x / Respiratory Rate : 20x/ Temperature : 36,7 C
BWbefore pregnant: 49 Kg Body Weight

: 60 Kg Body Height : 153 cm Upper arm circumference : 25 cm BMI : 20,94 kg/m2 Nutrition state : Normoweight

 Eyes : Conjunctiva wasnt anemic, Sclera wasnt icteric

Neck

: JVP 5-2 cmH2O, thyroid gland no enlargement Chest : H/L normal

Abdomen : OR Genitalia : OR Extremity : Edema -/-, Physiological Reflex +/+,

Pathological Reflex -/-

Obstetric Record : Abdomen : I : Enlargement in accordance with term pregnancy, median line hyperpigmentation, striae gravidarum (+), cicatrix (-) Palpation : L1: Uterine fundal height was palpable 2 fingers below xiphoideus processus. A large, soft, nodular mass was palpable, not fixed L2: Greatest resistance was palpable on the left side. Numerous small, irregular structure were felt on the right side

L3 : A hard mass was palpable, fixed L4 : Convergen Uterine Fundal Height : 30 cm Estimated fetal body weight : 2635 gr Uterine contraction :

Pe : Tympani Au : Peristaltic sound was normal

FHR : 130-140x/1

Genitalia
Inspection : normal V/U, vaginal bleeding -

Inspeculo : Vagina : tumor (-),laceration (-), fluxus (+), there was clear fluid pooling at posterior fornix, litmus test (+) Portio : NP, size of adult thumb. Tumor (-), laceration (-), fluxus (+), there was clear fluid passing from cervical canal, external cervical ostium was closed.
VT :

no Portio thickness 1.5cm, posterior position, moderate consistency Amnion (-), clear residu Head presentation H I-II

 Internal pelvic measurement:

Promontory was not reached Innominate line was 1/3-1/3 palpable Concave sacrum os Straight pelvic side wall Ischiadic spines did not protrude excessively coccygeus os was flexible Pubic arch > 90 Intertuberous distance could accomodate an adult fist (> 10.5 cm)

Pelvic Outlet examination :

Impression : there is no contracted pelvic

Laboratory Finding
Parameter Result Unit

Haemoglobin Leukocyte Thrombocyte Hematocrit Eritrocyte

10.3 9.8 222 30 3.5

g/dl 103/mm3 103/mm3 % 103/mm3

Diagnose : G1P0A0 L0 term pregnancy + PROM 2 hours ago Fetal alive, singleton, intra uterine, head presentation at HI-II

Management : Control GA, VS, FHS, Uterine Contraction Informed consent Check routine blood
Plan : Pervaginam delivery

09.00 am
A/ Feeling of pain from waist region which referred to the groin (+) Fetal movement (+)
PE/ GC Mod Con CMC BP 120/80 PR 80 RR 20 Temp 37

Abd : his 2-3x/40/moderate, FHR (140-145 x/i)

Genitalia: I : V/U normal Vaginal toucher: 2-3 cm Amniotic sac (-), clear residue Head was palpated sagittal suture transvers HI-II
D/ G1P0A0 L0 Parturient term pregnancy stage I latent phase + PROM 2 hours ago Fetal alive, singleton, intra uterine, head presentation at HI-II

Management : Control GA, VS, FHS, Uterine Contraction Control 4 hours again
Plan : Pervaginam delivery

01.00 pm
A/ Feeling of pain from waist region which referred to the groin (+) Fetal movement (+)
PE/ GC Mod Con CMC BP 110/70 PR 80 RR 20 Temp 37

Abd : his 2-3x/45/strong, FHR (135-142 x/i)

Genitalia: I : V/U normal Vaginal toucher: 5-6 cm Amniotic sac (-), clear residue Head was palpated occiput transvers HI-II
D/ G1P0A0 L0 Parturient term pregnancy stage I active phase + PROM 2 hours ago Fetal alive, singleton, intra uterine, head presentation at HI-II

Management : Control GA, VS, FHS, Uterine Contraction Control 4 hours again
Plan : Pervaginam delivery

02.00 pm
A/ Feeling of pain from waist region which referred to the groin (+) Fetal movement (+)
PE/ GC Mod Con CMC BP 120/80 PR 80 RR 20 Temp 37

Abd : his 3-4x/45/strong, FHR (135-140 x/i)

Genitalia: I : V/U normal Vaginal toucher: 8-9 cm Amniotic sac (-), clear residue Head was palpated left occiput transvers HI-II
D/ G1P0A0 L0 Parturient term pregnancy stage I active phase + PROM 2 hours ago Fetal alive, singleton, intra uterine, head presentation at HI-II

Management : Control GA, VS, FHS, Uterine Contraction Control 4 hours again
Plan : Pervaginam delivery

03.15 pm
A/ Patient feels pain and desires to want to surrender Fetal movement (+)
PE/ GC Mod Con CMC BP 120/80 PR 80 RR 20 Temp 37

Abd : his 3-4x/45/strong, FHR (140-150 x/i)

Genitalia: I : V/U normal Vaginal toucher: complete Amniotic sac (-), clear residue Head was palpated left occiput transvers HI-II
D/ G1P0A0 L0 Parturient term pregnancy stage II + PROM 2 hours ago Fetal alive, singleton, intra uterine, head presentation at HI-II

Management : Control GA, VS, FHS, Uterine Contraction

Plan : Pervaginam delivery

04.15 pm
A/Patient feels pain and desires to want to surrender Fetal movement (+)
PE/ GC Mod Con CMC BP 110/70 PR 82 RR 20 Temp 37

Abd : his 3-4x/50/strong, FHR (130-140 x/i)

Genitalia: I : V/U normal Vaginal toucher: complete Amniotic sac (-), clear residue Head was palpated left occiput transvers HI-II
D/ G1P0A0 L0 Parturient term pregnancy stage I I + PROM 2 hours ago + failure of descent Fetal alive, singleton, intra uterine, head presentation at HI-II

Management : Control GA, VS, FHS, Uterine Contraction Informed Consent Report to operating room Consult to perinathology

Prepare blood transfution (crossmatch)

Plan : Cyto CS

 At 11.00

: TPPCS was performed A male baby was born by TPPCS with 3100 gram in weight, 52 cm in height, Apgar score : 8/9. Placenta was born with a light traction on umbilical cord, complete, 1 piece. It was 17 x 16 x 3 cm in size, and 500 gram in weight, umbilical cord 60 in length. Paracentralis insertion. IUD was put in the uterine cavum Bleeding during operation 250 cc D/ P1A0L1 post TPPCS on indication failure of descent ec malpresentation + IUD acceptor Mother Child were in care S/ Observe after operation Rooming in