Supervisor : dr.

Mahayasa, SpOG MS : Ike, Endah, Dian, Mita, Ita, Tomi, Lili Physiology :2 Phatology : 1

Name : Mrs. H

Admitted to GH NTB August 18th, 2011 at 12.00 WITA

Objective General status : GC: well, GCS: E4V5M6 BP:120/80 mmHg RR: 20 x/mnt Pulse :86 x/mnt T: 37,8 C Eyes : an(-) ikt (-) Cor : S1S2 single regular Murmur (), Gallop (-) Pulmo : Vesiculer (+/+), rh (-/-), wh (-/-) Abd : scar (-), striae (+) Extremity edema (-/-) Obstetric status : L1 : breech UFH: 34 cm L2 : back on right L3 : head L4 : 3/5 EFW : 3565 g UC :3x10 ~ 30 FHB : 13-12-12 x/mnt VT : complete, amn (-) unclear, head palpable, denominator unclear, H2+, caput (+) unpalpable small part or umbilical cord Assestment G1P0A0H0 38-39 weeks/S/L/IU head presentation + neglected 2nd stage of labor Planning -Obs mother and fetal well being -DL and HBsAg -Report to GP: Pro rehidration, Adv : - Rehidration -Inj ceftriaxone 1 gr/IV - pro vacum Subjective

Age : 20 years old

Time 18/08/2011 12.00 WITA Patient refered from Pemenang PHC to GH NTB with G1P0A0L0 T/S/L/IU/ head presentation + prolonged 2nd stage of labor. Abdominal pain since 19.00 WITA (17/08/2011). Ruptur of membran (+), Bloody slim (+). FM (+). History of DM (-), HT (-), Asthma (-). LMP : November, 22th 2010 EDD: August, 29th 2011 History of ANC : >4x, at PHC History of family planning : Next family planning: Obstetrical history: I. This Chronologist : 10.00 Wita S: Patient Refered from Setangi Polindes to Pemenang PHC with G1P0A0H0 T/S/L/IU + prolonged 2nd stage of labor at 10.00 wita (18/08/2011). Abdominal pain since 19.00 wita (17/8/2011), Blood slim (+), FM (+), history ruptur of membrane (+) at 19.00 (17/8/2011). History of DM (-), HT (-), Asthma (-).

time

Subjektive O: 10.00 WITA GC : well GCS : E4V5M6 BP : 130/80, RR: 20x, PR : 84, T: 38 Abdominal palpation : UFH 32 cm, breech palpable in fundus. Right back. EFW : 3255 gr UC : 3x10 ~ 30 FHR : + VT : complete, amn (-) clear, head palpable, HIII unpalpable small part or umbilical cord 10.35 -Conduct to bearing down O: HIII Chronologist at polindes (By anamnesis with patient) -Patient came to Setangi polindes at 19.30 Wita (17/08/2011). Abdominal pain (+), bloody slim (+), history ruptur membran (+) since 19.00 wita. -( Mother conduct to bearing down since 07.00 wita until 09.00 (18/8/2011) -- treatment IVFD RL 2 flash A: G1P0A0H0 A/S/L/IU head presentation + prolonged 2nd stage of labor P: IVFD RL 20 dpm

Objective Pelvic evaluation : Sacrum : convexity normal Spina ischiadica prominent Os coccigeous mobile Pubic arch >90 Lab exam : WBC : 16.700 RBC : 4,36 HGB :8,9 PLT : 241.000 Hct : 29,2 HBsAg : +

Assestment

Planning

time 14.00

Subjektive Mother wants to bearing down

objective UC : 3x10 ~ 25 FHB : 14. 15. 14 (172x/minute)

Assestment Neglected 2nd stage of labor

Planning -Obs mother and fetal well being - Resusitation -Pro termination with SC - report to GP

14.30

UC : 3x10 ~ 25 FHB : 12.13.13

Neglected 2nd stage of labor

GP report to Supervisor (14.45) advice try termination with EV if failure, pro SC EV began Baby was born, Male, BW ; 3230 gr, BL: 47 cm, A-S ; 2-5, anus (+), congenital anomaly (-), amnion unclear 30 cc, bleeding 100 cc Placenta was born spontan, completely. bleeding 100 cc

15.20 15.30

15.40

17.40

GC : well BP : 120/80 mmHg PR : 88 bpm RR : 18 tpm T 37,2C TFU : at umbilicus UC : + Bleeding : 15 cc GC : well BP : 120/80 mmHg PR : 88 bpm RR : 18 tpm T 36,5C TFU : 1 finger below umbilicus UC : + Active Bleeding (-) Baby in NICU: RR : 44 x/minute HR : 120 bpm T : 36,6C IVFD D10% + O2

2 hours post partum

Observation mother and baby well being CIE mother to eat and drink

07.00 (19/8/2011)

(-)

1st day post partum

Observe mother and baby well being CIE mother to eat and drink