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PATHOLOGY
LABOR
1
2
3
CASE 1
Name : Mrs. N
Age
: 23 years old
Address : Langko-Lingsar
Admitted : 29-08-2014
No. RM
: 11-37-57
G2P1A0L1 36-37
weeks/S/L/IU head
presentation with PROM > 12
hours
Time
Subject
29-08-2014
11.20
Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 22 x/m
T: 36,5 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 29 cm
EFW : 2790 gram
UC : FHB : 13-13-13 (159x/min)
Assessment
Planning
Time
Subject
Object
History of USG :-
Assessment
Planning
Time
Subject
Chronologist : at Sigerongan PHC (2908-2014 06.30)
S : Patient confessed flank pain and
abdominal pain since yesterday . Bloody
slim (-) Water come out from her vagina
(+) since yesterday , FM (+).
O : GC : well
Cons : CM
BP : 100/80mmHg
HR : 80x/m
RR : 20x/m
T : 36
UFH : 27cm
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
FHB : 144x/m
UC : VT : 1cm, eff 25%, amnion (+), head
palpable, HI, unpalpable small part of
fetus/ umbilikal cord
A : G2P1A0L1 36 weeks/S/L/IU with
PROM
P : amox 1 x 500 mg
Reffered to NTB GH
Object
Assessment
Planning
Time
Subject
Object
Assessment
Planning
Co CTG to GP, GP co to SPV,
adv: induction with drip oxy 5 IU
CIE patient and family to
induction
14.00
14.30
15.00
15.30
Abdominal
pain
UC : 2 x 10 ~ 30
FHB : 11-11-12 (136 x/min)
5 cm, eff. 50 % amnion (-) clear,
head palpable, HI, denom unclear,
unpalpable small part of fetus/
umbilical cord
16.00
Abdominal
pain
UC : 3 x 10 ~ 25
FHB : 12-12-12 (144 x/min)
16.30
Abdominal
pain
UC : 3 x 10 ~ 30
FHB : 12-11-12 (140 x/min)
17.00
Mother want
to bearing
down
UC : 4 x 10 ~ 40
FHB : 12-13-12 (148 x/min)
Inspection : opening of vulva, bulging
of perineum, pressure of anus
2nd of labor
Time
Subject
Object
Assessment
17.25
17.30
Planning
Baby was born. male.
2600 gram. 48 cm, AS 7-9.
Anus (+). Congenital
anomaly(-).
UC : well
UFH : 2 finger bellow umbilicus
3rd of labor
19.30
2 hours post
partum
30-082014
07.00
CASE 2
Name : Mrs. ES
Age
: 28 years old
Address : Sumbawa
Admitted : 29-08-2014
No. RM
: 11-37-38
G1P0A0L0 38 weeks/G/LL/IU head presentation-head
presentation with active
phase of labor
Time
29-082014
10.30
Subject
Patient come to NTB GH
reffered Brangrea PHC with
G1P0A0L0 39 weeks G/LL/IU.
Patient confessed abdominal
pain since 28-08-14 (22.00),
water come out from her
vagina (-), bloody slim (+)
29-08-14 (03.00), and FM
(+).
History of DM (-), HT (-),
asthma (-).
LMP : 4-12-2013
EDD : 11-09-2014
History ANC : >9x at
posyandu
Last ANC : 28-08-2014
result: BP : 120/80, 38
weeks, mothers and fetals
condition is well.
Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/100 mmHg
HR: 88 x/m
RR: 22 x/m
T: 36,8 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (+/+), warm (+/+)
Obstetric status
L1 : breech, breech
L2 : back on the left and right
side
L3 : head
L4 : 4/5
History of USG : 2x at doctor UFH: 34 cm
Last : 12-08-14 : result :
gemeli, head presentationUC : 3 x 10 ~ 25
head-presentation : EFW :
FHB : I. 12-13-13 (152x/min)
2416 gram, 1808 gram.
II. 12-11-11 (140 x/min)
Assessment
Planning
Time
Subject
Object
History of obstetric :
I.
This
Pelvic examination:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubic > 90 degree
PS :
Cervic dilatation 5 cm : 2
Cerviks length 3 cm: 1
Cerviks consistency mild : 1
Cerviks position posterior: 0
Station H I: 1
Total: 5
Lab:
HGB = 12.4 g/dl
RBC = 4,20 K/ul
WBC = 13.74 M/ul
HCT : 30=7.0 %
PLT = 269 M/ul
HBsAg = (-)
Assessment
Planning
Time
Subject
Chronologist : at Brangrea PHC (29-082014 02.00)
S : Patient confessed abdominal pain since
28-08-14 (22.00), water come out from her
vagina (-), bloody slim (+) 29-08-14 (03.00),
and FM (+).
O : GC : well
Cons : CM
BP : 110/70mmHg
HR : 84x/m
RR : 20x/m
T : 36,5
L1 : breech, breech
L2 : back on the left and right side
L3 : head
L4 : 4/5
UFH : 33cm AC: 92 cm
EFW : 3630 gram
FHR 1: 140x/m
FHR 2: 126 x/m
UC : 3x10-20
VT : 1cm, eff 10%, amnion (-), head
palpable, HII, unpalpable small part of
fetus/ umbilikal cord.
A : G1P0A0L0 +/- 39 weeks G/L-L/IU
P : Obs. Mother and etal well being, RL 20
tpm, refferd to NTB GH
Object
Assessment
Planning
Time
Subject
Object
Assessment
Planning
14.30
Abdominal pain
UC : 3x 10 ~ 30
FHB : I 13-12-13 ( 148/min)
II 11-11-12 (136x/min)
VT : 8cm, eff 75%, amnion (-),
head palpable, HI, unpalpable
small part of fetus/ umbilikal cord.
Prolong active
phase
16.30
UC : 3x 10 ~ 30
FHB : I 12-12-12 ( 144x/min)
II 12-11-11 (136x/min)
17.00
UC : 4 x 10 ~ 30
FHB : I 12-12-13 ( 148x/min)
II 11-12-12 (140x/min)
17.30
UC : 4 x 10 ~ 30
FHB : I 12-12-12 ( 144x/min)
II 12-12-11 (140x/min)
18.00
UC : 4 x 10 ~ 30
FHB : I 12-12-12 ( 144x/min)
II 12-12-11 (140x/min)
18.30
UC : 4 x 10 ~ 40
FHB : I 12-12-12 ( 144x/min)
II 12-12-11 (140x/min)
VT : 9 cm, eff 80%, amnion(-),
head palpable, HII, unpalpable
small part of fetus/ umbilikal cord.
Prolong active
phase
Time
Subject
19.30
20.30
Object
Assessment
UC : 4 x 10 ~ 40
FHB : I 11-12-13 ( 144x/min)
II 12-13-12 (148x/min)
Mother wont to
bearing down
UC : 4 x 10 ~ 40
FHB : I 11-12-11 ( 136x/min)
II 12-12-12 (144x/min)
Inspection : opening of vulva,
bulging of perineum, pressure of
anus
Planning
Oxy drip: 24 dpm
2nd stage of
Conduct mother to bearing
labor (first baby)
down
20.55
21.20
21.30
Mother wont to
bearing down
2nd stage of
labor (second
baby)
Time
Subject
Object
Assessment
Planning
3rd of labor
21.40
UC : well
UFH : 1 finger bellow umbilicus
23.30
2 hours post
partum
Observation mother
Suggest mother to eat and
drink
Suggest mother to
mobilitation
30-082014
07.00
Observed mother
Suggest mother to eat and
drink
suggest mother to breast
feeding
Suggest mother to
mobilisation.
4
3
4
5
2
2
20
3
3
3
2
3
3
17
Bayi
pertumbuhan
janin
terhambat dan
kecil masa
kehamilan
Case Report 3
Name: Mrs. BS
RM
Age
: 545572
: 32 years old
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
29/082
014
23.50
wita
General Status :
GC : moderate GCS : E4V5M6
BP : 140/90 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur
(-), gallop (-).
Pulmo : vesicular (+/+), wheezing
(-/-), rhonchi (-/-).
Abdomen : scar (+), stria
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).
G2P1A0L0
A/S/L/IU Head
presentation with
active phase +
gestasional HT +
history of asthma
and CS 1,5 years
ago
LMP : forgotten
EDD : unknown
History of ANC : 2 times at
Malaysia and PHC
Last result: 27/08/2014
BP:130/90, 36 wks, UFH 30 cm,
head presentation, FHB (+)
History of USG : 1 time at
Malaysia
Last result: normal range
History of family planning : Next family planning : IUD
Obstetrical History :
I. Aterm/male/Malaysia/SCTP/
2600 g/ dead
II. This
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 25 cm
EFW : 2480gram
UC : 3 x/10~ 35
FHB : 12-13-13 (152 bpm)
VT : 4cm, eff. 50%, Amnion (-),
clear, head palpable, HI, denom
unclear, impalpable small part of
fetus or umbilical cord .
DM co to GP pro
observation, GP co to
SPV pro CS and SPV
advice : Observation
Progress of labor, if
there is asthma
exacerbation co to
interna
Documentation of
partograph
TIME
SUBJECTIVE
Chronologist at RSUD KLU:
21.00 wita (29/08/2014)
S/ Patient referred from Bayan
PHC confessed lower abdominal
pain that spread to flank region
since 19.30 wita (29/08/2014),
water leaked out (-), bloody slim
(+). Fetal movement (+). history of
CS 1,5 years ago
O/
BP : 140 / 90 mmHg
HR: 84 bpm
RR: 21
T: 36,5
UFH: 27 cm , 4/5
FHB : 12-12-12 (144 x/minute)
EFW :2480 gr
UC: (+) 2x10~25
VT : 2 cm, eff. 25%, amnion
(+), head palpable, HI, denom
unclear, impalpable small part /
umbilical cord.
A/ G2P1A0L0 37 wks S/L/IU
head presentation, with latent
phase of labor and LMR
P/
IVFD RL flash 1 - 20 dpm
Co to SPV advice: Refer to NTB
GH with CIE family
OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile,
Arcus pubis > 900
Lab Examination :
HB : 11 g/dl
RBC : 4.62 x 106/L
HCT : 35.1 %
WBC: 14.17 x 103/L
PLT : 245 x 103/L
HbSAg : (-)
Proteinuria (-)
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
30/08/2014
03.50 wita
GC : well
GCS : E4V5M6
BP : 140980 mmHg
PR : 84 bpm
RR : 20 bpm
UC : 3x10~35
FHB : 12-13-12 (148 bpm)
VT : 6 cm, eff. 60%, Amnion (-),
clear, head palpable, caput (+), HII,
impalpable small part of fetus or
umbilical cord
Prolonged active
phase
Co to GP pro observation
mother and fetal well
being
Suggest mother to eat
and drink
04.30 wita
UC: 4x/10 ~ 35
FHB: 12-12-12
Inspection: opening vulva (+),
bulging of perineum (+), pressure of
anus (+)
04.55
05.00
Conduct labor
Placenta delivered
completed, bleeding 150
cc.
TIME
07.00
wita
SUBJECTIVE
OBJECTIVE
General condition: Good
BP : 120/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below umbilical
UC : (+) well
Lochea rubra +
Active bleeding (- )
Baby is rooming in
HR : 128 bpm
RR : 50
T : 37,0
ASSESSMENT
PLANNING
2 hours Post
partum
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