No. 1.

Case Resume : Case

Total

Pathology Delivery G1P0A0L0 38-39 weeks S/L/IU with neglected active phase 1st stage of labor Normal Delivery

Name Age Address Admitted No. RM

: Mrs. E : 21 years old : Gegelang, Lingsar : 23rd Oct 2013 : 091711

G1P0A0L0 38-39 weeks S/L/IU with neglected active phase 1st stage of labor

Time 23/10/ 2013 10.30 WITA

Subject Patient referred from Narmada PHC with G1P0A0L0 38-39 weeks S/L/IU with latent phase 1 stage of labor pro USG. Mother confessed abdominal pain spread to flank since 07.00 (22/10/2013), bloody slim (-), history of water leakage (-), Fetal Movement (+). Nausea (-), vomiting (-), headache (-), visual diturbance (-).

Object Examination at VK Teratai Room: General condition : Well GCS : E4V5M6 BP : 120/80 mmHg PR : 88x/ RR : 20x/ Temp : 37,7C General Status Eyes : an-/-, ict -/Cor : s1s2 single, m -, g Pulmo : Ves +/+, rh -/-, whz -/Abdomen : striae gravidaum (+), linea nigra (+) Ext : oedem-/-, warm +/+ Status Obstetric L1 : breech L2 : back on the right side L3 : head, in pelvic inlet L4 : 4/5 UFH : 32 cm EFW : 3.255 gram FHR:20-21-19,reguler (160bpm) (FHR takicardi) UC : 2 x /10~20 VT : 6 cm, eff 50%, Amnion (+), head palpable HI, denominator unclear, small part of fetal/umbilical cord unpalpable

Assesment G1P0A0L0 38-39 weeks S/L/IU with neglected active phase 1st stage of labor

Planning Observation mother and fetal well being Lab. Check (CBC, HBsAg, and Complete Urine) CTG DM Co. to SPV, pro : Inj. ceftriaxon 1g Resusitation intrauterin (RL : D5% = 2 : 1) SC SPV Adv : SPV Acc for SC, Inj ceftriaxon 2g Inj xilomidon 2cc CIE patient and family Pre OP SC

No history of DM, HT, asthma. No history of allergic reaction to medicine or food. LMP : 24 - 1 - 13 EDD: 1 11 - 13 History of ANC : 8x at Posyandu and PHC Last ANC : 13-10-2013 History of USG : Last USG : History of Family Planning : Next Family Planning : IUD History of obstetry: 1. This

Time

Subject Chronology at Narmada PHC 22 /10/2013 at 00.30 WITA S: Patient confessed abdominal pain spread to flank since 07.00 (2/10/2013) LMP : 24- 1- 2013 EDD: 1- 11- 2013 O: General status : GC well, con. CM, BP 130/80mmHg, PR 80 x/minute, RR 20 x/minute, T 36.0 C. Oedema extremeties -/-. Obstetric status: L1: breech TFU: 30 cm EFW: 2790 gram L2 : back on the right L3 : head L4 : 4/5 UC : 2 x 10 ~ 35 FHR : 12- 11 -11 (140x/mnt) VT : 1 cm, eff. 25 %, Amnion (+) clear, head palpableHI, , denominator unclear, impalpable small part of fetal & umbilical cord.

Object

Assesment

Planning

G1P0A0L0 38-39 weeks S/L/IU with latent phase 1 stage of labor.

Time

Subject 22/10/2013 at 07.30 WITA S:O: Obstetric status: UC : 2-3 x 10 ~ 35-40 VT : : 2 cm, eff. 25 %, Amnion (+) clear, head palpableHI, , denominator unclear, impalpable small part of fetal & umbilical cord A: P: 22/10/2013 at 01.00 WITA S: O: General status : -. Obstetric status: UC : 3 x 10 ~ 35 FHR : VT : 2 cm, eff. 25 %, Amnion (+) clear, head palpableHI, , denominator unclear, impalpable small part of fetal & umbilical cord

Object

Assesment

Planning

Time

Subjective 23/10/2013 at 07.00 WITA S: O: General status : -. Obstetric status: UC : 2 x 10 ~ 35 FHR : VT : 2 cm, eff. 25 %, Amnion (+) clear, head palpableHI, , denominator unclear, impalpable small part of fetal & umbilical cord

Object

Assesment

Planning

FHR > 160 bpm

Time 12.00 wita

Subject Patient moved to OK Room -

Object

Assesment G1P0A0L0 38-39 weeks S/L/IU with neglected active phase 1st stage of labor

Planning

Time 13.05 WITA

Subject -

Object

Assesment G1P0A0L0 38-39 weeks S/L/IU with neglected active phase 1st stage of labor

Planning SC Begin

13. 35 WITA

Baby was born, male, birth weight 3.300 g, birth lenght 48 cm, anus (+), congenital anomaly (-), Apgar Score 7-9 Amnion clear Move Baby to NICU

15.35

Patient confessed dizzy (+)

General Status General condition : Well GCS : E4V5M6 BP : 120/80 mmHg PR : 79x/ RR : 18x/ Temp : 36,8C UC : + UFH : 2 fingers below umbilical UO : 500 ml

2 hours post SC

Observation patient general condition, urine output and vital sign Observation SC wound Move patient to Melati room

Time 24/10/13 07.30

Subject Patient confessed dizzy (+)

Object General Status General condition : Well GCS : E4V5M6 BP : 120/80 mmHg PR : 88x/ RR : 22x/ Temp : 36,7C UC : + UFH : 2 fingers below umbilical UO : 400 ml Baby in NICU ; PR: 144 bpm RR: 42 x/m Temp :36,8 C

Assesment 1 day post SC

Planning Observation patient general condition, urine output and vital sign Observation SC wound

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