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Case report

Identity
 Name : Mrs. R
 Age : 27 years old
 No. RM : 98 07 15
 Date : June 07th, 2017

Husban Identity
 Name : Mr. W
 Age : 30 years old
 Occupation: Private

 Addres : Surau Gadang, Padang

2017 at 17. with chief complain Feeling of pain from waist to region since 6 hours ago .45 AM.Anamnesis :  A 27 years old patient admitted to the Emergency Delivery Room of Dr. Djamil General Hospital Padang on June 7th. M.

vomiting. once in 28-35 days which last for 5 to 7 days each cycle with the amount of 2-3 times pad change/day without menstrual pain .Present Illness History  Feeling of pain from waist to region since 6 hours ago  Bloody show from the vagina since 6 hours ago  Fluid leakage from the vagina since 1 hours ago .9 month ) of pregnancy  Menstruation history: menarche at 12 years old. wetting 2 pieces of panties .  No complain of nausea. irregular cycle. and vaginal bleeding neither during early pregnancy nor late pregnancy. fishy odor and clear residue  Massif bleeding from the vagina was absent  Amenorrhea since 9 months ago  LMP was forgotten EDD : difficult to estimated  Fetal movement was identified since 5 months ago.8.  Prenatal care to Midwife 4x ( 2.5.

kidney. hypertension. and allergy Family Illness History :  There wasn’t history of hereditary disease. liver. DM.Previous Illness History :  There wasn’t previous history of heart. contagious and physicological illness in the family . lung.

Present History of family planning : IUD History of immunization : (-)  Graduate : Junior high school  Occupation : housewife . Doctor.Marriage history : once at 2008 History of pregnancy/abortion/delivery: 2/0/1 1.male. Alive 2. CS oi Contracted Pelvic. 2009.3100gr.

79 kg/m2 (normoweight) .1° C  Body height : 142 cm LILA : 25 cm  Body weight : 50 kg  BMI : 24.Physical Examination  GA : moderate  consiousness : CMC  BP : 120/80 mmHg  HR : 96 x/min  RR : 21 x/min  Temperatur : 37.

tyroid gland no enlargement  Chest : H/L normal  Abdoment : obstetric record  Genitalia : obstetric record  Extremity : oedem -/-. Eyes : conjunctiva wasn’t anemic. RF +/+. sclera wasn’t icteric  Neck : JVP 5-2 cmH2O. RP -/- .

round. Numerous small. A large. sicatrix (+) Pfanensteal  Palpation  L1: Uterine fundal height was 3 fingers below xiphoideus processus. soft. irregular structure were felt on the right side  L3 : A hard. mass was palpable.Obstetric record Abdoment  Inspection : Abdomen seem enlarge according to term pregnancy. nodular mass was palpable  L2: Greatest resistance was palpable on the left side. fixated  L4 : Convergen .

His: 3-4x/45”/S  Auscultation : Fetal heart sound :130-140x/m . EBW: 2945 gr. UFH: 30 cm.

Genitalia  Inspection : V/U normal. vaginal bleeding (-) VT :  8-9cm Amnionic sac (-) clear residue Caput was palpated at HI-II size 4x3x2cm .

5 cm) Impression : contracted pelvic .Pelvic Inlet  Promontory can’t bereached  Inominate line difficult to exam  Sacrum bone : concave  Pelvic side wall : straight  Ischiadic spine : protude  Coccygeus bone : not moveable  Arc of pubic : < 90 Pelvic Outlet : Inter tuberous distance can be passed through by normal adult fist (>10.

CTG .

CTG  Base Line : 140-150  Variability : 5-20  Aceleration : (+)  Deseleration : (-) Impresion : Reative CTG .

USG .

fetal alive .0 mm EFW 2900-3000 gr AC 311 mm FL 71.1 mm • AFI was enough • Placental implanted at anterior corpus gr II-III Impression : term pregnancy.ULTRASOUND • Fetal alive singleton intrauterine head presentation • Fetus movement was good • Biometric : BPD 93.

000/mm3 (150-400)  PT : 10.130/mm3 (5-10)  Hematocryte : 32 % (37-43)  Trombocyte : 280.0-13.40) .Laboratorium  Hb : 10.5 ( 29.2-39.6)  APTT : 31.2 (10.5 gr/dl (12-14)  Leukocyte : 13.

His. FHS • Informed consent • Inj Ceftriaxone 2x1gr IV • Consult Perinatologi • Consult Annasestesiologist Plan : CS .Diagnose : G2P1A0L1 term parturient active phase of first stage + arrest of descent due to CPD + one previous CS Fetal alive singleton intrauterine head presentation with caput palpated at HII Management : • Control GA. VS.

500 gr in weight. umbilical cord’s length 55 cm. insertion paracentralis. complete. Blood loss during operation 250 cc Diagnosis : P2 A0 L2 post TPPCS oi arrest of descentdue to CPD + previous CS Mother-child were in care .5 cm in size. 17x 15x 2.40 PM ) TPPCS was performed A female baby was born by TPPCS :  FW : 3000gr  FL : 49 cm  A/S : 8/9 Placenta was delivered by small traction.07/06/2017 ( 18.

VS. Vaginal Bleading IVFD RL ( Oxitocyn + Methergine ) 20dpm Inj Ceftriaxone 2x1gr IV Pronalges Spp If Need Routine Blood test 6hours Post Operation .Plan : Control GA. Contraction.