CASE REPORT

Mrs. MWA, 27 yo, from Narmada hosptilazed at 21.00 (20/11/2011)

G1P0A0H0 A/S/L/IU head presentation with prolonged 2nd stage of labor

Time 20/11/2011 21.00

Subjective Patient referred from Narmada PHC with G1P0A0H0 A/S/L/IU head presentation and arrested active phase 1st stage of labor. Patient confessed abdominal pain since 23.00 (19/11/2011) and a bit of watery discharge flowing through her vagina at the same time. Bloody slim (+), FM (+), history of DM (-), HT (-), asthma (-). LMP : forgot EDD : History of ANC : >4x, Posyandu Last ANC : 18/11/2011 History of family planning : Next family planning : injection for 3 month

Objective General Condition : well Consciousness : E4V5M6 BP : 100/70 mmHg P : 90 x/min RR: 20 x/min T : 37,5C Local status Eye : an (-/-), ict (-/-) Pulmo: ves (+/+), rh (-/-), wh (-/-) Cor : S1S2 single regular M(-), G(-) Abd : scar (-), striae gravidarum (+) Ext : edema (-/-), warm acral (+/+) Obstetrical status : L1 : breech, UFH: 32 cm L2 : fetal back on left side L3 : head L4 : 3/5 EFW : 3255 g UC: (+), 3 x 10 25 FHR : (+), 12-12-11 (140 x/min) VT : 8 cm, eff 80%, amnion (-), head palpable, H II, unpalpable small part/umbilical cord Laboratorium : Hb : 10,2 HCT : 31,2 WBC : 27,23 PLT : 161 HBsAg (-)

Assessment G1P0A0H0 A/S/L/IU head presentation arrested active phase 1st stage of labor

Planning Observe mother & fetal well being Coass consult to GP advice : observe progressivity of labor Rehydration : RL : D5 = 2 : 1 Motivate patient to lay down on her left side

Obstetrical History : 1. This one

Chronology : 04.00 (20/11/2011) S : Patient came to Narmada PHC confessed 9 month pregnant and abdominal pain since 23.00 (19/11/2011) and a bit of watery discharge flowing through her vagina at the same time. Bloody slim (+), FM (+)

Time

Subjective O: GC : well Consciousness : CM BP : 120/70 mmHg P : 88 x/min RR : 24x/min t : 370C L1 : breech UFH : 32 cm L2 : left back L3 : head L4 : 4/5 FHR : (+), 11-12-12 (140 x/min) UC : (+) 4 x 10 30 VT : 1 cm, eff 10%, Amn (+), head palpable HI, denom unclear, unpalpable small part/umbilical cord

Objective

Assessment

Planning

08.00 VT : 1 cm, eff 10%, Amn (+), head palpable HI, denom unclear, unpalpable small part/umbilical cord
12.00 VT : 3 cm, eff 25%, Amn (+), head palpable HI, denom unclear, unpalpable small part/umbilical cord

14.35 VT : 5 cm, eff 50%, Amn (-), head palpable HI +, denom LOA, unpalpable small part/umbilical cord
18.35 VT : 7 cm, eff 75%, Amn (-), head palpable HII, denom LOA, unpalpable small part/umbilical cord

A : G1P0A0H0 A/S/L/IU head presentation with arrested 1st stage of labor

P: Infuse RL flash II Inj. Ampicilline 1 gr i.v (20.00)

Time 21.30

Subjective Abdominal pain

Objective UC: (+), 3 x 10 35 FHR : (+), 12-12-12 (144 x/min) VT : complete, amnion (-), head palpable, H II, unpalpable small part/umbilical cord UC: (+), 3 x 10 35 FHR : (+), 12-12-11 (140 x/min) VT : complete, amnion (-), head palpable, H III, unpalpable small part/umbilical cord

Assessment G1P0A0H0 A/S/L/IU head presentation 2nd stage of labor G1P0A0H0 A/S/L/IU head presentation 2nd stage of labor

Planning Observe mother & fetal well being Motivate patient to lay down on her left side Coass consult to GP GP consult to supervisor advice : If complete suggest mother to bearing down If prolonged 2nd stage of labor VE If VE failed report back to supervisor

22.00

Abdominal pain and mother wants to bearing down

23.30

Mother wants to bearing down

UC: (+), 3 x 10 35 FHR : (+), 12-12-12 (144 x/min) VT : complete, amnion (-), head palpable, H III, unpalpable small part/umbilical cord

G1P0A0H0 A/S/L/IU head presentation and prolonged 2nd stage of labor

Prepare for VE

23.45

VE began Baby was born male, 3500 gr, AS 7-9. Anus (+). Congenital anomaly (-), Amnion unclear Placenta was born. Manually. Complete. Bleeding 200cc. VE finished

21/11/ 2011 01.0003.00

GCS : E4V5M6 BP : 120/70 mmHg P : 72 x/min RR : 20 x/min t : 36,8C UC : (+), well UFH : 2 fingers below umbilicus Active bleeding : (-)

2 hours post VE

Continue observation of mother and baby well being. Observe general condition, vital sign, uterine contraction, and active bleeding.

Time

Subjective Baby in NICU : P : 145 x/min RR : 44 x/min T : 36,50C

Objective

Assessment

Planning