Case Report

Name

: Mrs. SRH

RM

: 063069

Age

: 24 Years Old

Address : Getap Barat, Cakranegara

Admitted
20.45

: October 27th 2012 at

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

02/07
/2012

Patient
referred
from
Cakranegara
PHC
with
G2P0A1L0 38 weeks S/L/IU
head presentation with 2nd
stage of labor.
Patient confessed abdominal
pain that spread to frank.
History rupture of membrane
(+), bloody slim (+), FM (+).
No history of DM, HT,
asthma.

General Status :
GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR :20 bpm
T : 37,5 OC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo
:
vesicular
(+/+),
wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).

G2P0A1L0 38
weeks S/L/IU
head
presentation with
2nd stage of
labor

Check CBC and

HbSAg
Tell patient result
of Examination
Skin test, result
(-), inj Ceftriaxon
IV 1 gr
Metronidazole
1
flash IV
DM co to SPV,
advice : VE

20.45

LMP : 27/01/2012
EDD : 3/11/2012
History of ANC :
Last ANC :
History of USG :
History of family planning :
(-)
Next family planning :
Obstetrical History :
I.Abortus
II.This

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 3/5
UFH : 31 cm
EFW : 3100 gram
UC : 4x/10~35
FHB : 12-12-12 (144 bpm)
VT : 10 cm, effacement
100%,
amnion
(-),
head
palpable HIII, denominator
LIUK Kadep, impalpable small
part and umbilical cord.

TIME

SUBJECTIVE
Chronologist at Cakranegara
PHC (27/10/2012)
13.30
S : Patient confessed abdominal pain
that spread to frank. Patient
mengedan sendiri
O : GC : well
BP : 100/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,5OC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 3/5
UFH :
EFW :
UC : (+), 4x/10~45
FHB : (+) 132 x/min
VT : 6 cm, eff 75%, amnion (-),
head palpable, UUK di depan, HII,
impalpable small part / umbilical
cord.
A : 1st stage of labor
P:
Explain result of examination
Suggest mother to eat & drink
Observation 4 hours

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

17.30
(at
PHC)

Abdominal pain came

and relieved

UC : 4 x 10 ~ 40
FHB : 128 bpm
VT : 9 cm, eff 75%, amnion
(-), head palpable, UUK di
depan, HII+, impalpable
small part / umbilical cord.

ASSESSMENT

PLANNING
Rehidration

17.35
(at
PHC)

RL and D5% Given 2:1

18.00
(at
PHC)

Amp Injection 1 gr IV

TIME

SUBJECTIVE

18.35
(at
PHC)

19.15

Pasien mengedan
terus

19.45

Suami mengamuk
marah2 minta di rujuk

19.50

Konsul dokter
dirujuk APS

OBJECTIVE

ASSESSMENT

PLANNING

UC : 4 x 10 ~ 45
FHB : 128 bpm
VT : complete , eff 100%,
amnion (-), head palpable,
UUK
di
depan,
HIII,
impalpable small part /
umbilical cord.

Lie on left side

VT : complete , eff 100%,

amnion (-), head palpable,
UUK
di
depan,
HIII+,
impalpable small part /
umbilical cord.

Ephisiotomy

UC : 4 x 10 ~ 45
FHB : 136 bpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

02/07
/2012

Patient
referred
from
Cakranegara
PHC
with
G2P0A1L0 38 weeks S/L/IU
head presentation with 2nd
stage of labor.
Patient confessed abdominal
pain that spread to frank.
History rupture of membrane
(+), bloody slim (+), FM (+).
No history of DM, HT,
asthma.

General Status :
GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR :20 bpm
T : 37,5 OC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo
:
vesicular
(+/+),
wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).

G2P0A1L0 38
weeks S/L/IU
head
presentation with
2nd stage of
labor

Check CBC and

HbSAg
Tell patient result
of Examination
Skin test, result
(-), inj Ceftriaxon
IV 1 gr
Metronidazole
1
flash IV
DM co to SPV,
advice : VE

20.45

LMP : 27/01/2012
EDD : 3/11/2012
History of ANC :
Last ANC :
History of USG :
History of family planning :
(-)
Next family planning :
Obstetrical History :
I.Abortus
II.This

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 3/5
UFH : 31 cm
EFW : 3100 gram
UC : 4x/10~35
FHB : 12-12-12 (144 bpm)
VT : 10 cm, effacement
100%,
amnion
(-),
head
palpable HIII, denominator
LIUK Kadep, impalpable small
part and umbilical cord.

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT
FHB : 148 bpm

PLANNING
VE Begin :
Failed 3 times
DM Co SPV advice :
SC

22.55

Baby
was
born,
male, 3000 gram,
Body Length : 48
cm,
Head
circumference : 33
cm,
Arm
Circumference : 11
cm, A-S 5-7 caput
(+) on occiput, anus
(+),
anomaly
congenital (-).