3. Mrs.

Asih Fitriani/ 23 th/ Living child: 0

MRS 18-9-2014/ at 13.30
G2P1A0 H 40-41 WoP + inlabor stage I active phase+ history of PROM + post date + SLFIU
+ breech presentation + EFW 3400 gr

S) Chief Complaint : contraction
Referal : midwives
RPS: Patient reffered by midwive with G2P1A0 H 40 weeks + SLFIU + breech presentation.
Patient complained contraction since 08.00 oclock, and more frequently. Watery discharge at the
same time. Bloddy discharge (-). Patient then went to a midwive on 13.00 was told that the
opening was 8.

ANC : routinely went to midwive to check the pregnancy, the last time was on 12/09/2014, and was
told that the pregnancyy was in a good state, but the baby was in breech presentation. The USG
was performed with obstetrician.

RPD : HT (-) DM (-) Asthma (-).
Menstruation: M: 13 years FDLM : 05-12-2013
D: 7 days DD : 20-09-2014
C: 28 days GA : 40-41 WoP
Marriage : 1x, 4 years
Contraception : injection/3 mo for the last year
OBSTETRY : 1. 2010/female/hospital/obstertician/aterm/spontaneous labor/2800gram/live
2. 2014/this pregnancy
O) STATUS PRESENT
General condition : good
Consciousness : compos mentis
Vital Signs : BP: 120/80 mmHg; PR: 84x/m; RR: 18x/m; T: 36.5C
Head/Neck : anemic conjunc. (-/-), Icteric sclerae (-/-)
JVP enchancement (-/-) lymphatic node enlargement (-/-)
Thorax : Symmetric vesicular (+) Ronkhi/wheezing (-/-)
S1>S2 regular single, murmur (-)
Extremity : Warm peripherals: hand (+/+) foot (+/+)
Edema: hand (-/-) foot (-/-), Parese hand (-/-) foot (-/-)

STATUS OF obstetry
Inspection : distended abdomen, asymmetric
Palpation :
- L1: FU: 3 finger below prx - Fundal height :33cm
- L2: right back - EFW :3410g
- L3: head presentation - FHR :144x/m
- L4: in the pelvic inlet - His : 2-3x/10/20







2
Vt: 5cm/eff 50% / amnion (-)/ breech / H-II

Pelvimetric : large

A) G2P1A0 H 40-41 WoP + inlabor stage I active phase+ history of PROM + post date +
SLFIU + breech presentation + EFW 3400 gr

P) Complete blood check , NST
IV Line RL 20dpm
Inj. Ceftriaxon 2x1gr
Obs. CPHB
Evaluation for 2 hours pro spt bracht
15.15 consult to dr.M. Robyanoor, Sp.OG
Advice: agree with therapy, evaluation on 16.00, report if there is no
progress of labor

15.50 Advice Sp. V: if there is no progress of labor , prepare for SC

16.30 S) contraction (+),
O) BP 130/90, PR 96, RR 22, T 37
FHR 12-12-12
His 4-5x/10/30-40
VT complete / amnion (-)/ breech/ H-III
A) G2P1A0 H 40-41 WoP + inlabor stage II + history of PROM + post
date + SLFIU + breech presentation + EFW 3400 gr
P) observation for patient want to strain
pro spt bracht

consult to dr.M. Robyanoor, Sp.OG
Advice: agree with therapy, pro spt bracht
watched for FHR till the baby born
16.50 S) contraction (+), watery discharge (+)
O) BP 130/90, PR 92, RR 24, T 37
FHR 12-12-13
His 4-5x/10/40-50
A) G2P1A0 H 40-41 WoP + inlabor stage II + history of PROM + post date + SLFIU + breech
presentation + EFW 3400 gr
P) the patient guide to strain
inj. Oxytocin 5 IU IM

17.02 baby born female , W :3000gr, L: 50 cm, AS: 7-8-9
Anus (+), congenital deformity (-)

17.10 The placenta delivered spontaneously with management In active labor
stage III. Calcification (-), infark (-),
Laporan Delivery dengan
episiotomi
1. Bokong membuka vulva, dilakukan penyumtikan oksitosin 5 IU secara
IM. Ibu dipimpin mengedan.
2. Dilakukan episiotomi mediolateral, berturut-turut lahir bokong sampai
pusar seara spontan. Bahu dilahirkan dengan manuver Lovset, badan
janin diputar setenga lingkaran bolak-balik sambil dilakukan traksi
cunam ke bawah sehingga bahi lahir beserta lengan. Kepala
dilahirkan dengan manuver Mauriceau, lahir berturut-turut dagu,
mulut, hidung, mata, dahi dan ubun-ubun besar janin.
3. Pukul 17.02, lahir bayi perempuan/BB 3000gr/PB 50cm/AS 7-8-9,
anus (+), kelainan kongenital (-)
4. Dilakukan klem 2 posisi pada tali pusat, tali pusat dipotong dilakukan
penyuntikan oksistosis 10 IU (IM) pada regio femur lateral
5. Dilahirkan plasenta lengkap dengan insertio lateralis, kalsifikasi (-),
hematom (-), infark(-)
6. Observasi perdarahan 100 cc
7. Dilakukan penjahitan pada luka episiotomi
Routine Blood 18-09-2014
Examination
Result
Unit
Hb
12.4
g/dl
WBC
16.4
ribu/ul
RBC
3.96
juta/ul
HTC
36.9
vol%
Platelet
173
ribu/ul
MCV
93.3
fl
MCH
31.3
pg
MCHC
33.6
%
Random Blood Sugar
108
mg/dl
SGOT/SGPT
25/21
U/I
LDH
495
U/I
Ureum/Creatinin
10/0.5
mg/dl
PT/APTT
11.4/27.3
Albumin
3.8
U/I
Follow up post partum
S) pain (<), bleeding(-)
O) BP: 120/60 mmHg, P: 86x, RR:22x, T:36,4
Fundal height: ~ 2fuumbilical, uterine contraction: (+)
fluxus: (-)

A) P2A0 PP manual aid (breech presentation)
P) PO. mefenamic acid 3x500mg
Cefadroxyl 3x500mg
SF 3x1