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Supervisor: dr. Agus Thoriq, SpOGDM: Akbar
Case Resume :No. Case Total
Pathology Delivery 2
1.
2.
G4P2A1L2 41 weeks head presentation with hypertension gestasional + IUGRG2P1A0L1 40-41 weeks head presentation with protracted active phase 1st stage of laborNormal Delivery -
IDENTITYName : Mrs. S
Age : 26 yo
Address : Monjok
No. RM : 538430
Hozpitalised on 12.15 WITA, 11th May 2014
• G4P2A1L2 41 weeks head presentation with Hypertension gestasional + IUGR
CASE 1
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
11/05/14
12.15 WITA
Patient came to VK IRD confessed abdominal pain since 06.00 WITA at 11/05/14, water came out from her vagina (-), bloody slim (-), fetal movement (+),.
No history of DM, history of, asthma (+), history of HT (+). History of food allergic (+).
LMP : 30-07-2013EDD : 06-05-2014
History of ANC : 3 x in PosyanduLast ANC: 20/03/2014, result: BP: 130/80 mmHg, FHB (+), head presentation,
History of USG: 1 x Male, S/L/, 26-27 weeks, plasenta in corpus posterior (14/02/2014)
General status:GC: wellGCS: E4V5M6BP: 150/100 mmHgPR: 84 bpmRR: 22 rpm T: 370 C
Eye : anemis (-), icteric (-)Thorax :Cor : S1S2 single reguler, murmur (-), gallop (-)Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-).Abdomen : scar (-), striae livida (+), linea nigra (+), Extremity : edema (-/-), warm acral (-/-)Nutrition status : Body Height : 134 cmBody weight : 48 kgObstetrical status:L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 25 cm EFW: 2170UC: 2x10’~20”FHB: 12-12-12 (144x/min)
G4P2A1L2 41 weeks head presentation with 1st stage latent phase Hypertension gestasional + IUGR
• Obs mother & fetal well being
• Obs. Progress of labor
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
History of Family Planning: injectionNext Family Planning: -History of obstetry:1.Aterm, spontan, traditional birth attendan, 3300 gram female, 14 yo2.Aterm , spontan, 3300 gram, female 9 yo3.Abortus4.This
Chronologist: (-)
VT : Ø 2 cm , eff 15%, amnion (+), head presentation, denom unclear, ↓HI, unpalpable small part of fetal
Lab ResultHb : 11,7 x 106/ µLWBC : 13,23 x 103/ µLPLT : 376x 103/ µLHCT : 34,1 %HBsAg : (-) non reactiveProteinuria : (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
12.45 WITA
Abdominal pain + UC: 2x10’~20”FHB : 12-12-12 (144)
G4P2A1L2 41 weeks head presentation with 1st stage latent phase Hypertension gestasional + IUGR
• Obs mother & fetal well being
• Obs. Progress of labor
13.15
WITA
Abdominal pain + UC: 3x10’~35”FHB:13-12-13 (160)
G4P2A1L2 41 weeks head presentation with 1st stage latent phase Hypertension gestasional + IUGR
Dm pro ctg, GP advice CTG, consult result of ctg to GP, GP advice recutitation intrauterine
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
14.00 Abdominal pain ++Mothers confessed, water leaked out from her vagina
UC: 3x10’~45”FHB : 12-12-12 ( 144)VT:Ø 5cm , amnion (-), head presentation, denom unclear, ↓HII, unpalpable small part of fetal
G4P2A1L2 41 weeks head presentation active phase first stage of labor with Hypertension gestasional + IUGR
Observation progress of labor
14.30 Abdominal pain ++ UC: 3x10’~45”FHB : 12-12-11 ( 140)
G4P2A1L2 41 weeks head presentation active phase first stage of labor with Hypertension gestasional + IUGR
Observation progress of labor
15.00 Abdominal pain ++ UC: 3x10’~45”FHB : 12-12-11 ( 140)
G4P2A1L2 41 weeks head presentation active phase first stage of labor with Hypertension gestasional + IUGR
Observation progress of labor
TIME SUBJECTIVE OBJECTIVE ASSESMENT PLANNING
15.25
WITA
Mothers want to bearing down UC: 3x10’~45”FHB : 12-12-12 ( 144)Inspeksi : Bulging of perineum, opening vulva (diameter of head ± 5cm), anus pressure,
2nd stage of labor
Conduct of labor
15.30WITA
Baby was born spontaneously, male, AS: 6-8, BW/BL = 2000 gr/46 cm, anus +, anomaly kongenital -
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
15.30 Patient confessed abdominal pain
UC (+) 3rd stage of labor
• Management active of 3rd stage
• Placenta was born spontan, complete, weight 400 gr, bleeding 150 cc
17.30 GC: wellGCS: E4V5M6BP: 120/80 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C
UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)
2 hours post partum
•Obs. Mother well being
•Suggest mother to eat and drink
Baby in NICU
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
07.00(12/05/14)
GC: wellGCS: E4V5M6BP: 150/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C
UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)Lochea rubra (+)
Baby in NICUGC : wellPR : 132 bpmRR : 44 bpmT : 36,2ºC
1 day post partum
•Obs. Mother well being
•Suggest mother to eat and drink
Baby
3
3
3
3
3
2
17
3
4
3
3
3
3
19
Conclusion:
• Baby aterm (38-40)• Baby IUGR because < 10 Percentil• Risk Factor:
hypertension
IDENTITYName : Mrs. MAge : 26 yoAddress : Batu layar
Hozpitalised on 17.30 WITA, 11th May 2014
• G2P1A0L1 40-41 weeks head presentation with protracted active phase 1st stage of labor
CASE 2
Time Subjective Objective Assesment Planning
11/05/2014
17.30 WITA
Patient referred from Meninting PHC with G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor. Patient confessed abdominal pain since 07.00 WITA (11/05/2014), water came out from her vagina since 07.00 WITA, bloody slim (+), fetal movement (+)No history of DM, HT, asthma. No history of allergic reaction to medicine or food.
LMP : 01/08/2013EDD: 07/05/2014
Examination:General condition : WellGCS : E4V5M6
BP : 110/90 mmHgPR : 90 x/mRR : 21 x/mTemp : 36,8 ◦C
General StatusEyes : an-/-, ict -/-Cor : s1s2 single, m -, g –Pulmo : Ves +/+, rh -/-, whz -/-Abdomen : scar (-), striae gravidaum (+), linea nigra (+)Ext : oedem-/-, warm +/+
Status Obstetric L1 : breechL2 : back on the right sideL3 : headL4 : 4/5
G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor
Observation mother well being
CIE mother and family IVFD RL 20 tpmDM co to GP pro obs.
Sign of labor,inj ceftriaxon 1 gr/iv and ctg, GP advice obs. Sign of labor , inj ceftriaxon 1gr /iv and ctg
Time Subjective Objective Assesment Planning
History of ANC : 5 x at PHCLast ANC: 10/05/2014, result: BP: 110/80 mmHg, UFH : 31cm, head presentation,40-41 weeks, FHB (+)
History of USG : -
History of Family Planning: - Next Family Planning: injection
History of obstetry:1.Male, spontan, midwife, aterm, 2800 gram, 5 yo2.This
UFH : 30 cm EFW : 2945 gramFHR: 13-13-13 (154)UC : 3x10’~30”VT : Ø 4 cm, eff 50%, amnion (-),clear, head palpable ↓HII, denom unclear, unpalpable small part of fetus
Lab ResultHb : 10,7 x 106/ µLWBC : 22,65 x 103/ µLPLT : 252 x 103/ µLHCT : 33,5 %HBsAg : (-) non reactive
Time Subjective Objective Assesment Planning
11/05/2014
(07.30)
Chronologist at Meninting PHC
S: Patient pregnant 9 month come to Meninting PHC confessed abdominal pain and water leak from her vagina since 07.00 wita (11/05/2014)O:GC : WellGCS : E4V5M6
BP : 110/80 mmHgPR : 88 bpmRR : 20 x/mTemp : 36,5 ◦C
UFH : 31 cmFHB: 12-12-11( 136)UC : 2x10’~25”VT: Ø 2 cm, eff. 25 %, amnion (+) clear, head palpable ↓HI, denominator unclear, unpalpable small part of fetal & umbilical cord.
Time Subjective Objective Assesment Planning
11.30Wita
(11-05-2014)
A: G2P1A0L1 40-411 weeks S/L/IU head presentation with inpartu latent phase 1st stage of labor + history of ROM P: •Obs. Mother and fetal well being•Obs. Progress of labor
S: abdominal pain more frequently
O: GC : wellBP:100/80PR : 88 bpmRR : 20 x/mTemp : 36,5◦CHis : 3x10’~30”FHB: 12-12-12 (144) VT : Ø 5 cm, eff. 50 %, amnion (+) clear, head palpable ↓HII, denominator unclear, unpalpable small part of fetal & umbilical cord
Time Subjective Objective Assesment Planning
15.30
A: inpartu active phase first stage of labor
P: continue observation
S: -O:GC : wellBP:100/80PR : 88 bpmRR : 20 x/mTemp : 36,5◦CHis : 3x10’~35”FHB: 12-12-12 (144)VT : Ø 6 cm, eff. 50 %, amnion (+) clear, head palpable ↓HII, denominator unclear, unpalpable small part of fetal & umbilical cordA: inpartu protracted first stage laborP: inj ampicilin, infus RL, prepare for referred to NTB GH
Time Subjective Objective Assesment Planning
16.30 S:-O: GC : wellBP:100/80PR : 88 bpmRR : 20 x/mTemp : 36,5◦CHis : 4x10’~35”FHB: 12-12-12 (144)A: Inpartu protracted 1st stage of laborP: change infus RL with D5
Time Subjective Objective Assesment Planning
18.00WITA
Abdominal pain + UC : 3x10’ ~35”FHB : 12-12-12 (144)
G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor
Obs. Sign of laborConsult result of ctg,GP advice continue observation
Time Subjective Objective Assesment Planning
18.30 WITA
Abdominal pain + UC : 3x10’ ~35”FHB : 12-12-12 (144)
G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor
Obs. Progress of labor
19.00 WITA
Abdominal pain + UC : 3x10’ ~35”FHB : 12-12-12 (144)
G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor
Obs. Progress of labor
19.30 WITA
Abdominal pain ++ UC : 3x10’ ~40”FHB : 12-12-12 (144)
G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor
Obs. Progress of labor
Time Subjective Objective Assesment Planning
19.40 WITA
Mothers want to bearing down
Inspection:Bulging of perineum,
opening vulva, anus presure
G2P1A0L1 40-41 weeks S/L/IU head presentation with 2nd stage of labor
Conduct labor
19.45WITA
Baby was born , male, AS: 5-7, BW/BL = 3550gr/50 cm, anus +, anomaly kongenital -
Time Subjective Objective Assesment Planning
19.45 UC + 3rd stage of labor Management active of 3rd stage
20.00 UC + 3rd stage of labor Placenta was not bornInjection 2nd oxytocinCateter urine
20.15 UC + Retensio plasenta
Placenta was born manual, uncomplete,± 300 gram.Bleeding ± 500cc,Pro usg on Monday (12/05/2014)
Time Subjective Objective Assesment Planning
22.30WITA
GC: wellGCS: E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C
UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)
2 hours post partum with rest plasenta
Obs. Mother well beingSuggest mother to eat and drinkPro USG
Baby in NICU
Time Subjective Objective Assesment Planning
07.00 WITA (12-05-2014)
GC: wellGCS: E4V5M6BP: 90/60 mmHgPR: 90 bpmRR: 22 rpm T: 36,80 C
UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)Lochea rubra (+)
Baby in NICUGC : wellPR : 134 bpmRR : 44 bpmT : 36,2ºCUse O2, IVFD D10%
One day post partum
•Obs. Mother well being•Suggest mother to eat and drink
• Pro kuretase if USG (+) rest plasenta
THANK YOU