mr 18-19 sept

8/11/2019 MR 18-19 SEPT

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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 o’clock, 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

8/11/2019 MR 18-19 SEPT


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

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Vt: Ø 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. CPHBEvaluation for 2 hours pro spt bracht

8/11/2019 MR 18-19 SEPT


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 Ø 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

8/11/2019 MR 18-19 SEPT


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 (-),

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Laporan Delivery dengan

episiotomi

1. Bokong membuka vulva, dilakukan penyumtikan oksitosin 5 IU secaraIM. Ibu dipimpin mengedan.

2. Dilakukan episiotomi mediolateral, berturut-turut lahir bokong sampaipusar seara spontan. Bahu dilahirkan dengan manuver Lovset, badan janin diputar setenga lingkaran bolak-balik sambil dilakukan traksicunam ke bawah sehingga bahi lahir beserta lengan. Kepaladilahirkan 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 dilakukanpenyuntikan 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

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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

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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 3x500mgSF 3x1

mr 18-19 sept

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