Supervisor :dr. Fadjrir, SpOG

Mentor :dr. Juhriani M. Lubis

Presenter :Winson

Wawan HarimawanFairuz Syarifuddin

Supervisor :dr. Fadjrir, SpOG

Mentor :dr. Juhriani M. Lubis

Presenter :Winson

Wawan HarimawanFairuz Syarifuddin

DefinitionSpontaneous vaginal delivery is the proses of birth of aviable newborn with a vertex presentation due to thecontraction of the uterus and and maternal efforts,without any assistance of tool within 24 hours

Parturition

Parturition1. Phase I

a. Uterine quiescenceb. Cervical softening

2. Phase II : Preparation of labora. Myometrial changesb. Cervical ripening

1. Phase Ia. Uterine quiescenceb. Cervical softening

2. Phase II : Preparation of labora. Myometrial changesb. Cervical ripening

Parturition3. Phase III : Labor

First stage labora. Uterine labor contractionb. Uterine shape changesc. Effacement and dilatation of cervix

Second stage labor: fetal descentThird stage labor : delivery of placenta and membrane

4. Phase IV : Puerperium

3. Phase III : LaborFirst stage labor

a. Uterine labor contractionb. Uterine shape changesc. Effacement and dilatation of cervix

Second stage labor: fetal descentThird stage labor : delivery of placenta and membrane

4. Phase IV : Puerperium

Sign and Symptom in LaborPreparatory stage of labor : Lightening Pollakiuria False labor contraction Softening of the cervix Bloody show discharge

In labor: Frequent, forceful, prolonged and reguler contraction Increase of bloody show discharge On vaginal examination, found cervix effacement and

dilatation

Preparatory stage of labor : Lightening Pollakiuria False labor contraction Softening of the cervix Bloody show discharge

In labor: Frequent, forceful, prolonged and reguler contraction Increase of bloody show discharge On vaginal examination, found cervix effacement and

dilatation

Examination1. Abdominal Palpation (Leopold’s maneuvers)

2. Vaginal Examinationa. Pelvic adequacyb. bishop score (consisitency, direction, effacement, dilatation, fetal

stationc. Progress of labor

3. Sonography

1. Abdominal Palpation (Leopold’s maneuvers)

2. Vaginal Examinationa. Pelvic adequacyb. bishop score (consisitency, direction, effacement, dilatation, fetal

stationc. Progress of labor

3. Sonography

Cardinal movement : Engagement Flexion Decent Internal rotation Extension External rotation Expulsion

Mechanisms of LaborCardinal movement : Engagement Flexion Decent Internal rotation Extension External rotation Expulsion

Stages of Labor1. First stage: interval between

onset of labor until completecervical dilatationa. latent phaseb. active phase

1. Second stage: From completecervical dilatation until deliveryof newborn

2. Third stage: From delivery ofinfant until delivery of placenta

3. Forth stage: immediatepostpartumperiode of approximately 2hoursafter delivery of placenta

1. First stage: interval betweenonset of labor until completecervical dilatationa. latent phaseb. active phase

1. Second stage: From completecervical dilatation until deliveryof newborn

2. Third stage: From delivery ofinfant until delivery of placenta

3. Forth stage: immediatepostpartumperiode of approximately 2hoursafter delivery of placenta

Partograph Graphic recording of the progress of labour Recording of salient conditions of the mother and

fetus Useso To detect labour that is not progressing

normallyo To indicate when augmentation of labour is

appropriateo To recognize CPD long before obstruction

occurs

Graphic recording of the progress of labour Recording of salient conditions of the mother and

fetus Useso To detect labour that is not progressing

normallyo To indicate when augmentation of labour is

appropriateo To recognize CPD long before obstruction

occurs

Who should not have aPartograph?

Women with problems which are identified beforelabour starts or during labour which need specialattention

Women with problems which are identified beforelabour starts or during labour which need specialattention

Observations charted on the Partograph Fetal condition Fetal heart rate Membranes and liquor Moulding of the fetal skull

The Progress of labour Cervical dilatation Descent of fetal head Uterine contractions –duration, frequency

Maternal condition Pulse/ BP / Temp Urine –volume, acetone, protein Drugs & IV Fluids Oxytocin regime

Fetal condition Fetal heart rate Membranes and liquor Moulding of the fetal skull

The Progress of labour Cervical dilatation Descent of fetal head Uterine contractions –duration, frequency

Maternal condition Pulse/ BP / Temp Urine –volume, acetone, protein Drugs & IV Fluids Oxytocin regime

Normal Delivery Care Comprised of 60 steps for complete and appropriate

care in spontaneous vaginal delivery. The 60 steps are divided as follows : Observation of second stage delivery Preparation for delivery assistance Confirmation of complete dilatation with normal fetal

condition Preparing family and mother to assist with straining

process Preparation for baby delivery

Comprised of 60 steps for complete and appropriatecare in spontaneous vaginal delivery. The 60 steps are divided as follows : Observation of second stage delivery Preparation for delivery assistance Confirmation of complete dilatation with normal fetal

condition Preparing family and mother to assist with straining

process Preparation for baby delivery

Assisting delivery of baby Delivery of head Delivery of shoulder

Management of the newborn Active management of third stage Injection of oxytocin Controlled Cord Traction Uterine massage

Haemorrhage evaluation

Assisting delivery of baby Delivery of head Delivery of shoulder

Management of the newborn Active management of third stage Injection of oxytocin Controlled Cord Traction Uterine massage

Haemorrhage evaluation

Postpartum Evaluation / Fourth Stage Clean-up Documentation

Postpartum Evaluation / Fourth Stage Clean-up Documentation

Preparation for delivery assistance Wearing apron and assistant sanitary Wearing sterile handgloves Preparing oxytocin injection and put on partus set

Confirmation of complete dilatation with normal fetalcondition Vulva and perineum hygiene with sublimat cotton Performing vaginal examination to ensure complete

dilatation Evaluate fetal heart rate and documenting in partograph

Preparing family and mother to assist with strainingprocess Inform condition to mother and positioning the mother Performing delivery guidance

Preparation for delivery assistance Wearing apron and assistant sanitary Wearing sterile handgloves Preparing oxytocin injection and put on partus set

Confirmation of complete dilatation with normal fetalcondition Vulva and perineum hygiene with sublimat cotton Performing vaginal examination to ensure complete

dilatation Evaluate fetal heart rate and documenting in partograph

Preparing family and mother to assist with strainingprocess Inform condition to mother and positioning the mother Performing delivery guidance

Preparation for baby delivery Preparing towels to hold the baby and to hold perineum in head

delivery Open partus set, prepare all tools and drugs

Delivery of head When head stretch vulva with 5-6 cm diameter, asisstant holds

perineum with one hand and the other hand put on head. With gentle pressure and not inhibit expulsion of the head, assist

head to move outward slowly. After delivery of the head, Wipe face, mouth and nose with sterile

gauze or towel. Evaluate if theres entrapment of umbilical cord on the neck, do a

gently traction and release from upper side of head. Wait for head to perform external rotation

Preparation for baby delivery Preparing towels to hold the baby and to hold perineum in head

delivery Open partus set, prepare all tools and drugs

Delivery of head When head stretch vulva with 5-6 cm diameter, asisstant holds

perineum with one hand and the other hand put on head. With gentle pressure and not inhibit expulsion of the head, assist

head to move outward slowly. After delivery of the head, Wipe face, mouth and nose with sterile

gauze or towel. Evaluate if theres entrapment of umbilical cord on the neck, do a

gently traction and release from upper side of head. Wait for head to perform external rotation

Delivery of shoulder After external rotation, place two hands in biparietal

position. Telling mother to strain in next contraction. With gentle pressure pull downwards and outward to

deliver the anterior shoulder and pull upwards to deliverposterior shoulder After both of the shoulders delivered, follow through the

hand to deliver elbow and hand and one hand follow todeliver all body

Delivery of shoulder After external rotation, place two hands in biparietal

position. Telling mother to strain in next contraction. With gentle pressure pull downwards and outward to

deliver the anterior shoulder and pull upwards to deliverposterior shoulder After both of the shoulders delivered, follow through the

hand to deliver elbow and hand and one hand follow todeliver all body

Management of the newborn Evaluate newborn quickly the put over mothers

abdomen, with head position slightly under the body.Do a resuscitation if theres sign of neonatal asphyxia Wrap head and body with towel and maintain a skin

contact with mother. Clamp umbilical cord about 3 cm from baby’s side. And

clamp 2 cm from that point to the mother’s side. Cut inbetween Wipe the baby, change the towel and wrap baby with

clean and dry towel. Give the baby to the mother andrecommend the mother to contact with the baby andbegan lactation.

Management of the newborn Evaluate newborn quickly the put over mothers

abdomen, with head position slightly under the body.Do a resuscitation if theres sign of neonatal asphyxia Wrap head and body with towel and maintain a skin

contact with mother. Clamp umbilical cord about 3 cm from baby’s side. And

clamp 2 cm from that point to the mother’s side. Cut inbetween Wipe the baby, change the towel and wrap baby with

clean and dry towel. Give the baby to the mother andrecommend the mother to contact with the baby andbegan lactation.

Active management of third stage Check abdomen for second child. Begin management of third stage Inject 10 IU oxytocin intramuscular Perform controlled cord traction. One hand place over

and slightly upper symphisis to palpate for contraction.One hand holds umbilical cord with clamp. Wait for contraction and pull gently outward while the

other hand press dorsocranially to prevent invertio uteri. If theres no contraction, stimulate the nipple to induce

contraction. After placenta detached, continue traction according to

passage and change clamp position every 5-10 cm.

Active management of third stage Check abdomen for second child. Begin management of third stage Inject 10 IU oxytocin intramuscular Perform controlled cord traction. One hand place over

and slightly upper symphisis to palpate for contraction.One hand holds umbilical cord with clamp. Wait for contraction and pull gently outward while the

other hand press dorsocranially to prevent invertio uteri. If theres no contraction, stimulate the nipple to induce

contraction. After placenta detached, continue traction according to

passage and change clamp position every 5-10 cm.

After placenta is sighted at introitus vagina, continuedelivery of the placenta with both hands holdingmembrane and rotating clockwise until membraneencapsulated the placenta and then gently pull out theplacenta. Evaluate weight and number of cotyledons. Perform a uterine massage with hand on fundal and

massage circularly until contractions are established.

After placenta is sighted at introitus vagina, continuedelivery of the placenta with both hands holdingmembrane and rotating clockwise until membraneencapsulated the placenta and then gently pull out theplacenta. Evaluate weight and number of cotyledons. Perform a uterine massage with hand on fundal and

massage circularly until contractions are established.

Haemorrhage evaluation Examine the placenta and contraction. Evaluate

bleeding. Check for laceration and do suture repair iflacerations existed.

Postpartum Evaluation / Fourth Stage Observing contractions, bleeding, and mother’s vital

sign every 30 minutes for 2 hours Clean-up Documentation

Haemorrhage evaluation Examine the placenta and contraction. Evaluate

bleeding. Check for laceration and do suture repair iflacerations existed.

Postpartum Evaluation / Fourth Stage Observing contractions, bleeding, and mother’s vital

sign every 30 minutes for 2 hours Clean-up Documentation

Supervisor : dr. Fadjrir, SpOGMentor : dr. Juhryani M. Lubis

Presenter :Winson

Wawan HarimawanFairuz Syarifuddin

Supervisor : dr. Fadjrir, SpOGMentor : dr. Juhryani M. Lubis

Presenter :Winson

Wawan HarimawanFairuz Syarifuddin

PATIENT IDENTITY Name : Dewi Paraguna Sitompul Age : 27 years old Religion : Moslem Occupation : Housewife Ethnicity : Batak Education : Senior High School Address : Jl. Pelajar Timur Gg. Ikhlas Medan Admission Date : June 11th, 2013 Admission Time : 21.00 WIB MR number : 88.64.36

Name : Dewi Paraguna Sitompul Age : 27 years old Religion : Moslem Occupation : Housewife Ethnicity : Batak Education : Senior High School Address : Jl. Pelajar Timur Gg. Ikhlas Medan Admission Date : June 11th, 2013 Admission Time : 21.00 WIB MR number : 88.64.36

HISTORY TAKINGMrs. D, 27 years old, G2P1A0, Moslem, Batak, Senior High School,Housewife, wife of Mr. A, 26 years old, Moslem, Batak, Senior HighSchool, entrepreneur, came to ER Dr. Pirngadi General Hospitalwith Chief Complain : Labor Contraction Description : It has been experienced by the patient

since June 11th, 2013 at 07.00 AM, with bloody show since June11th, 2013 07.00 AM. History of water broke since June 11th, 201309.00 AM. The water was clear and odorless. At 10.oo AM patientwent to midwife and was discharged home due to dilatation wasminimal. History of fever in pregnancy is not found. Micturitionis normal. Defecation is normal.

History of Previous Illness : Diabetes Mellitus (-),Hypertension (-)

History of Previous Treatment : -

Mrs. D, 27 years old, G2P1A0, Moslem, Batak, Senior High School,Housewife, wife of Mr. A, 26 years old, Moslem, Batak, Senior HighSchool, entrepreneur, came to ER Dr. Pirngadi General Hospitalwith Chief Complain : Labor Contraction Description : It has been experienced by the patient

since June 11th, 2013 at 07.00 AM, with bloody show since June11th, 2013 07.00 AM. History of water broke since June 11th, 201309.00 AM. The water was clear and odorless. At 10.oo AM patientwent to midwife and was discharged home due to dilatation wasminimal. History of fever in pregnancy is not found. Micturitionis normal. Defecation is normal.

History of Previous Illness : Diabetes Mellitus (-),Hypertension (-)

History of Previous Treatment : -

Menstrual History Menstrual Cycle : Regular Cycle Length : 28 days Menstrual Duration : 6-7 days Menstrual Volume : 1-2 menstrual pad / days Complain during menstruation : dismenorrhea (-) Last Menstrual Period : September 15th, 2012 Expected Date of Delivery : June 22nd, 2013 Antenatal Care : Midwife , 3 times

1st Trimester : once2nd Trimester : once3rd Trimester : once

Menstrual Cycle : Regular Cycle Length : 28 days Menstrual Duration : 6-7 days Menstrual Volume : 1-2 menstrual pad / days Complain during menstruation : dismenorrhea (-) Last Menstrual Period : September 15th, 2012 Expected Date of Delivery : June 22nd, 2013 Antenatal Care : Midwife , 3 times

1st Trimester : once2nd Trimester : once3rd Trimester : once

Labor History Male, term, Spontaneous Vaginal Delivery, doctor,

hospital, 3000 grams, 2,5 years old, alive. This pregnancy

Present State Sensorium : compos mentis Blood Pressure : 120/80 mmHg Pulse : 88 bpm Respiratory Rate : 20 tpm Temperature : 36,80C

Sensorium : compos mentis Blood Pressure : 120/80 mmHg Pulse : 88 bpm Respiratory Rate : 20 tpm Temperature : 36,80C

Obstetric Examination Abdomen : enlarged asimmetrically SFH : 3 fingers below xyphoid process

(32cm) Stretch : left Bottom : head (3/5) Movement : (+) Contraction : 2 x 30”/ 10’ FHR : 144 bpm EBW : 2945 grams

Abdomen : enlarged asimmetrically SFH : 3 fingers below xyphoid process

(32cm) Stretch : left Bottom : head (3/5) Movement : (+) Contraction : 2 x 30”/ 10’ FHR : 144 bpm EBW : 2945 grams

Vaginal Examination Axial Cervix Cervix Diameter 4 cm Effacement 80%, Membrane (-) SRM 12 hours ago Head in HI-II Posterior fontanella 3 o’clock direction Gloves : bloody show (+), water (+) clear

Axial Cervix Cervix Diameter 4 cm Effacement 80%, Membrane (-) SRM 12 hours ago Head in HI-II Posterior fontanella 3 o’clock direction Gloves : bloody show (+), water (+) clear

USG : TRANSABDOMINAL SONOGRAPHY

Singleton, head presentation, living Fetal movement (+), Fetal heart rate (+) BPD = 88,2 mm FL = 73,0 mm AC = 301 mm Placenta corpus anterior grade III Conclusion : Intrauterine Pregnancy (38-39) weeks +

Head Presentation + Alive

Singleton, head presentation, living Fetal movement (+), Fetal heart rate (+) BPD = 88,2 mm FL = 73,0 mm AC = 301 mm Placenta corpus anterior grade III Conclusion : Intrauterine Pregnancy (38-39) weeks +

Head Presentation + Alive

Laboratory Results

DIAGNOSIS SG + IUP (38 3/7) weeks + Head Presentation + Living + In

Labor

THERAPY IVFD Ringer’s Lactate 20 drips/ minute Amoxicillin tab 3x500mg

PLANNINGMonitor vital sign , FHR, dan labor progression withpartograph

DIAGNOSIS SG + IUP (38 3/7) weeks + Head Presentation + Living + In

Labor

THERAPY IVFD Ringer’s Lactate 20 drips/ minute Amoxicillin tab 3x500mg

PLANNINGMonitor vital sign , FHR, dan labor progression withpartograph

Spontaneous Vaginal Delivery ReportAt 01.25 AM, June 11th, 2013 patient felt longer, stronger,and closer contractions and the urge to strain, vaginalexamination was done with complete dilatation. Labormanagement was started : The patient was laid in gynecologic bed with Mc

Robert position Bladder was emptied and vulva hygiene was done. With adequate contraction, head of fetus was sighted

in introitus vagina and stayed.

At 01.25 AM, June 11th, 2013 patient felt longer, stronger,and closer contractions and the urge to strain, vaginalexamination was done with complete dilatation. Labormanagement was started : The patient was laid in gynecologic bed with Mc

Robert position Bladder was emptied and vulva hygiene was done. With adequate contraction, head of fetus was sighted

in introitus vagina and stayed.

With subsequent adequate contraction, patient wasencouraged to strain and head was born started withposterior fontanella, anterior fontanella, forehead,face, chin and the rest of head. After external rotation,with the helper’s hand on biparietal, head is pulledgently downwards to deliver anterior shoulder andpulled upwards to deliver posterior shoulder. Then thehead was held on one hand and the other handfollowing along on the back simultaneously to deliverthe body.

With subsequent adequate contraction, patient wasencouraged to strain and head was born started withposterior fontanella, anterior fontanella, forehead,face, chin and the rest of head. After external rotation,with the helper’s hand on biparietal, head is pulledgently downwards to deliver anterior shoulder andpulled upwards to deliver posterior shoulder. Then thehead was held on one hand and the other handfollowing along on the back simultaneously to deliverthe body.

At 01.45 AM was born a female baby, with weigh 3080grams, body length 48 cm, head circumference 32 cm,Apgar Score : 9/10, anal verge positive, and with NewBallard Score 35 (38-40 weeks) AGA.

At 01.45 AM was born a female baby, with weigh 3080grams, body length 48 cm, head circumference 32 cm,Apgar Score : 9/10, anal verge positive, and with NewBallard Score 35 (38-40 weeks) AGA.

Umbilical cord was clamped in two point, then cut inbetween. Then Oxytocin 10 IU intramuscular was injected on lateral

thigh After 5-10 minutes, placenta was delivered with controlled

umbilical cord stretching, intact, weigh 500 grams, with 16cotyledons (all intact). The passage was evaluated, found perineal laceration grade I Then the laceration was sutured with chromic catgut 2-0 Evaluation of bleeding : 150 cc Patient’s condition after SVD : stable

Umbilical cord was clamped in two point, then cut inbetween. Then Oxytocin 10 IU intramuscular was injected on lateral

thigh After 5-10 minutes, placenta was delivered with controlled

umbilical cord stretching, intact, weigh 500 grams, with 16cotyledons (all intact). The passage was evaluated, found perineal laceration grade I Then the laceration was sutured with chromic catgut 2-0 Evaluation of bleeding : 150 cc Patient’s condition after SVD : stable

THERAPY IVFD Ringer’s Lactate + Oxytocin 10 IU drip 20

drips/minute Amoxicillin tab 3 x 500mg Vitamin B complex tab 2 x 1

THERAPY IVFD Ringer’s Lactate + Oxytocin 10 IU drip 20

drips/minute Amoxicillin tab 3 x 500mg Vitamin B complex tab 2 x 1

Fourth Stage ObservationTime Blood Pressure Pulse Respiratory

RateContraction Bleeding

02.00 110/70 mmHg 80 bpm 18 tpm strong 5 cc

02.30 110/70 mmHg 80 bpm 18 tpm strong 10 cc

03.00 110/70 mmHg 86 bpm 20 tpm strong 15 cc03.00 110/70 mmHg 86 bpm 20 tpm strong 15 cc

03.30 120/80 mmHg 84 bpm 20 tpm strong 15 cc

04.00 120/80 mmHg 82 bpm 20 tpm strong 15 cc

Laboratory results 2 hours after SVD

Follow up (June 12th, 2013)S : fever (-)O : Status presens

Sensorium : compos mentisBlood Pressure : 120/80 mmHgPulse : 80 bpmRR : 22 tpmTemperature : 36,80C

Localized StateAbdomen : Soft, peristaltic (+) normalSFH : 3 fingers below umbilicus, contraction (+) strongPervaginal Bleeding : (-), Lochia rubra (+)Micturition : (+) normalDefecation : (+) normal

S : fever (-)O : Status presens

Sensorium : compos mentisBlood Pressure : 120/80 mmHgPulse : 80 bpmRR : 22 tpmTemperature : 36,80C

Localized StateAbdomen : Soft, peristaltic (+) normalSFH : 3 fingers below umbilicus, contraction (+) strongPervaginal Bleeding : (-), Lochia rubra (+)Micturition : (+) normalDefecation : (+) normal

A : Post Spontaneous Vaginal Delivery due to PosteriorOccipital Presentation + Puerperium day 1

P: Amoxicillin tab 3x500mg Mefenamic Acid tab 3x500mg Ferrous Sulphate tab 1x1 Vitamin B complex tab 2xI Discharged for outpatient care

A : Post Spontaneous Vaginal Delivery due to PosteriorOccipital Presentation + Puerperium day 1

P: Amoxicillin tab 3x500mg Mefenamic Acid tab 3x500mg Ferrous Sulphate tab 1x1 Vitamin B complex tab 2xI Discharged for outpatient care

Case AnalysisTheory Case

Preparatory labor signs are including:lightening, abdominal distention,pollakiuria, false labor pain, softeningof cervix and bloody show.

Labor signs are including : stronger,frequent and reguler contractions,bloody show, with signs of rupturedmembrane, and dilatation of cervix invaginal examination

Patient came with chief complaint ofLabor contraction , experienced by thepatient since June 11th, 2013 at 07.00AM, with bloody show since June 11th,2013 07.00 AM. History of water brokesince June 11th, 2013 09.00 AM. Thewater was clear and odorless.From obstetric examination was foundregular contraction, with duration2x30”/10’ and from vaginal examinationfound cervix dilatation 4 cm andeffacement 80%

Preparatory labor signs are including:lightening, abdominal distention,pollakiuria, false labor pain, softeningof cervix and bloody show.

Labor signs are including : stronger,frequent and reguler contractions,bloody show, with signs of rupturedmembrane, and dilatation of cervix invaginal examination

Patient came with chief complaint ofLabor contraction , experienced by thepatient since June 11th, 2013 at 07.00AM, with bloody show since June 11th,2013 07.00 AM. History of water brokesince June 11th, 2013 09.00 AM. Thewater was clear and odorless.From obstetric examination was foundregular contraction, with duration2x30”/10’ and from vaginal examinationfound cervix dilatation 4 cm andeffacement 80%

Theory Case

In active delivery, duration ofcontraction can vary between 30 to 90seconds.

In this patient, the duration ofcontraction over time is as follows:21.00 & 21.30: 2x30”/10’22.00 & 22.30: 3x20-40/10’23.00-01.00 : 4x>40”/10’

In this patient, the duration ofcontraction over time is as follows:21.00 & 21.30: 2x30”/10’22.00 & 22.30: 3x20-40/10’23.00-01.00 : 4x>40”/10’

In multiparity, the average rate ofdilatation is 1,5 cm / hour

At 09. o0 PM the dilatation was 4 cmand at 01.25 AM the dilatation wascomplete, so rate of dilatation is 1,44cm/hours

In multiparity, duration of second stageis less than one hour.

At 01.25 AM we found completedilatation and the baby was born at01.45 AM. Duration of second stage is20 minutes.

Theory Case

Duration of third stage is usually lessthan 15 minutes after second stage.

Placenta was delivered 10 minutes afterbaby was born. With controlledumbilical cord stretching, placenta wasdelivered, intact, weigh 500 grams, with16 cotyledons.

Placenta was delivered 10 minutes afterbaby was born. With controlledumbilical cord stretching, placenta wasdelivered, intact, weigh 500 grams, with16 cotyledons.

Post partum haemorrhage is define asbleeding over 500 cc after delivery,which caused by 4T, tonus (in atoniauteri), tissue (in retensio placenta),trauma (laceration of passage) andthrombin (coagulation disorder)

In this patient we found grade Ilaceration on perineum and we did arepair with suture. Fourth Stagebleeding observation was ± 60 cc.

Clinical Summary Mrs. D, 27 years old, G2P1A0, Moslem, Batak, Senior

High School, Housewife, wife of Mr. A, 26 years old,Moslem, Batak, Senior High School, entrepreneur,came to ER Dr. Pirngadi General Hospital with ChiefComplain Labor Contraction

It has been experienced by the patient since June 11th,2013 at 07.00 AM, with bloody show since June 11th,2013 07.00 AM. History of water broke since June 11th,2013 09.00 AM. The water was clear and odorless. At10.oo AM patient went to midwife and was dischargedhome due to dilatation was minimal.

Mrs. D, 27 years old, G2P1A0, Moslem, Batak, SeniorHigh School, Housewife, wife of Mr. A, 26 years old,Moslem, Batak, Senior High School, entrepreneur,came to ER Dr. Pirngadi General Hospital with ChiefComplain Labor Contraction

It has been experienced by the patient since June 11th,2013 at 07.00 AM, with bloody show since June 11th,2013 07.00 AM. History of water broke since June 11th,2013 09.00 AM. The water was clear and odorless. At10.oo AM patient went to midwife and was dischargedhome due to dilatation was minimal.

Last menstrual period of the patient is September 15th,2013 and Expected Date of Delivery June 22nd, 2013 withantenatal care by midwife , 3 times. With labor history firstkid is male, term, spontaneous vaginal delivery, doctor,hospital, 3000 grams, 2,5 years old, alive.

Vital signs are within normal limit. Obstetric examinationshowed abdomen enlarged asimmetrically, with SFH 3fingers below xyphoid process (32 cm), stretch left, bottomhead, movement positive, contraction 2 x 30”/ 10’, FHR 144bpm, and EBW: 2945 grams

Last menstrual period of the patient is September 15th,2013 and Expected Date of Delivery June 22nd, 2013 withantenatal care by midwife , 3 times. With labor history firstkid is male, term, spontaneous vaginal delivery, doctor,hospital, 3000 grams, 2,5 years old, alive.

Vital signs are within normal limit. Obstetric examinationshowed abdomen enlarged asimmetrically, with SFH 3fingers below xyphoid process (32 cm), stretch left, bottomhead, movement positive, contraction 2 x 30”/ 10’, FHR 144bpm, and EBW: 2945 grams

From vaginal examination, the findings are axialcervix, with dilatation of 4 cm, effacement 80%,membrane (-), SRM 12 hours ago, Head in HI-II ,posterior fontanella 3 o’clock direction, Gloves :bloody show (+), water (+) clear, with USG TASshowing Intrauterine Pregnancy (38-39) weeks + HeadPresentation + Alive

The patient was diagnosed SG + IUP (38 3/7) weeks +Head Presentation + Living + In Labor

From vaginal examination, the findings are axialcervix, with dilatation of 4 cm, effacement 80%,membrane (-), SRM 12 hours ago, Head in HI-II ,posterior fontanella 3 o’clock direction, Gloves :bloody show (+), water (+) clear, with USG TASshowing Intrauterine Pregnancy (38-39) weeks + HeadPresentation + Alive

The patient was diagnosed SG + IUP (38 3/7) weeks +Head Presentation + Living + In Labor

The patient was then monitored with partograph andplanned for spontaneous vaginal delivery At 01.25 AM, June 11th, 2013 patient felt longer, stronger,

and closer contractions and urge to strain, vaginalexamination was done with complete dilatation. Labormanagement was started. At 01.45 PM was born a female baby, with weigh 3080

grams, body length 48 cm, head circumference 32 cm,Apgar Score : 9/10, anal verge positive, with New BallardScore 35 (38-40 weeks) AGA. Patient’s condition after SVD :stable The patient was then monitored for one day with stable

condition and then discharged as outpatient the day after.

The patient was then monitored with partograph andplanned for spontaneous vaginal delivery At 01.25 AM, June 11th, 2013 patient felt longer, stronger,

and closer contractions and urge to strain, vaginalexamination was done with complete dilatation. Labormanagement was started. At 01.45 PM was born a female baby, with weigh 3080

grams, body length 48 cm, head circumference 32 cm,Apgar Score : 9/10, anal verge positive, with New BallardScore 35 (38-40 weeks) AGA. Patient’s condition after SVD :stable The patient was then monitored for one day with stable

condition and then discharged as outpatient the day after.

Problems Is the patient diagnosed correctly ? Are the treatment on this patient appropriate to

protocol ?

Is the patient diagnosed correctly ? Are the treatment on this patient appropriate to

protocol ?