Case Report

Name

: Mrs. NM

RM

: 065421

Age
Address

: 40 YO
: Bayan, Lombok Utara

Hospitalization
2012 at 14.15

: November 12nd

TIME

SUBJECTIVE

12/11/1
2
14.15

Patient referred from Bayan

PHC with G1P0A0H0 39-40
Wk
S/L/IU
Head
presentation with fitrs stage
of labour latent phase and
severe
pre-eclampsia.
Abdominal Pain (+), Bloody
Slim (+), FM (+). No history
DM, Asthma. History of HT
(+). No history of nausea,
vomiting, headache, visual
disturbance and epigastric
pain and seizure (-)
LMP : 09/02/2012
EDD : 16/11/2012
ANC : >4x at posyandu
Result : Normal

OBJECTIVE
General Status :
GC : Well
BP : 160/110
PR : 96 bpm
RR : 24 tpm
T : 36,9 C
Local Status :
Eye : Anemis (-/-), Icteric (-/-)
Cor : S1S2 Single regular,
murmur (-), gallop (-)
Pulmo : Vesicular (+/+), wheezing
(-/-) ronkhi (-/-)
Abdomen : Scar (-), Striae
Gravidarum
(+),
Linea
nigra(+)
Extremity : Oedema :
Warm acral :

USG : Next Family Planning : IUD

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : Head
L4 : 4/5
UFH : 32 cm
EFW :3255
UC : 2x/10~15
FHB : 11.12.12 (140 x/minute)
VT : 1 cm, effacement 10%,
amnion (+), Head palpable,
H1, denominator unclear,
impalpable small part and

ASSESSMENT

PLANNING

G1P0A0H0 3940 Wk S/L/IU

head
presentation
with first stage
of labour latent
phase and
severe preeclampsia, old
primi

Observation
mother and fetal
well being
Check
CBC,
HBsAG, UL, SGOT,
SGPT, BT, CT
DM co to SPV, SPV
adv: SOP theraphy
for PEB, Nifedipine
tab, if in 6 hours
General
status
stable oxytocin
drip
Insert DC
CTG
Injection MgSO4
bolus 4 g (was
done in PHC)
Drip MgSO4 6g 28
tpm
Nifedipine 10 g/8
hour

TIME

SUBJECTIVE

OBJECTIVE
Laboraturium Examination :
HGB : 12,6 g/dl
RBC : 4,34 x10^6 /uL
HCT : 38,5 %
WBC : 11,47 x10^3 /uL
PLT : 214x10^3 /uL
HbSAg : (-)
Protein urine : +3

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronology at PHC
S : Patient referred from
polindes, patient confess
had an abdominal pain
since 10/11/2012, bloody
slim (+). History ruptur of
membrane (-). No history of
visual disturbance
O:
GC : Well
BP : 140/110
PR; 94
RR : 20
T : 36,9
UFH : 31 cm
EFW : 3100 gr
HIS : (+) 2x10~20
FHR :12-12-12 (144x/m)
VT : 1 cm, effacement
10%, amnion (+), Head
palpable, H1, denominator
unclear, impalpable small
part and umbilical cord
A: G1P0A0H0 A/S/L/IU head
presentation, mother and
fetal well being, and first
stage latent phase of
labour with severe- preeclampsia
P:
Injection MgSO4 4 gr bolus

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

18.00

General Status :
GC : Well
BP : 160/110
PR : 88bpm
RR : 24 tpm
T : 36,9 C

20.00

General Status :
GC : Well
BP : 160/110
PR : 88bpm
RR : 24 tpm
T : 36,9 C

ASSESSMENT

PLANNING

DM co to SPV, SPV
adv: Niphedipine/8
jam 2nd induksi

UC: 2x/10~15
FHB: 12.12.11 (140x/minute)
Urine: 700 cc
22.00

13/11/1
2
00.00

GC : Well
BP : 140/90 mmHg
PR : 96x/m
RR: 20x/m
T: 36,8C
UC: 2x/10`15
FHB: 12.12.12 (144x/minute)
VT : 2 cm, effacement 25%,
amnion (+), Head palpable,
H1, denominator unclear,
impalpable small part and
umbilical cord

G1P0A0H0 3940 Wk S/L/IU

head
presentation
with first stage
of labour latent
phase and
severe preeclampsia

MgSO4
Drip
flash I finished,
continue
with
2nd flash
Oxytosin drip flash
I start at 8 dpm

TIME

SUBJECTIVE

OBJECTIVE

00.30

UC: 2x/10`15
FHB: 12.12.12 (144x/minute)

01.00

UC: 2x/10~15
FHB: 12.12.11 (140x/minute)

01.30

UC: 2x/10 ~ 20
FHB: 12.11.11 (136x/minute)

02.00

UC: 2x/10 ~ 20
FHB: 12.12.12 (144x/minute)

02.30

UC: 2x/10 ~ 25
FHB: 12.12.11 (140x/minute)

03.00

UC: 2x/10`30
FHB: 12.12.12 (144x/minute)

03.30

UC: 2x/10~30
FHB: 12.12.11 (140x/minute)

04.00

UC: 2x/10 ~ 30
FHB: 11.11.11 (132x/minute)

04.30

UC: 3x/10`30
FHB: 12.12.12 (144x/minute)

05.00

UC: 3x/10~30
FHB: 12.12.11 (140x/minute)

05.30

ASSESSMENT

PLANNING
Drip Oxytocin 12
dpm
Drip Oxytocin 16
dpm
Drip Oxytocin 20
dpm
Drip Oxytocin 24
dpm
Drip Oxytocin 28
dpm
Drip Oxytocin 32
dpm
Drip Oxytocin 36
dpm
Drip Oxytocin 40
dpm

UC: 3x/10 ~ 30
FHB: 12.11.11 (136x/minute)
Drip Oxytocin 40
dpm

TIME

SUBJECTIVE

OBJECTIVE

06.00

UC: 3x/10`30
FHB: 12.12.12 (144x/minute)

06.30

UC: 3x/10~30
FHB: 12.12.11 (140x/minute)

07.00

UC: 3x/10 ~ 30
FHB: 11.11.11 (132x/minute)

07.30

UC: 3x/10 ~ 30
FHB: 12.12.12 (144x/minute)

08.00

UC: 3x/10 ~ 30
FHB: 12.11.11(136x/minute)

ASSESSMENT

PLANNING
Drip Oxytocin 40
dpm
Drip Oxytocin 40
dpm
Drip Oxytocin 40
dpm
Drip Oxytocin 40
dpm
Drip Oxytocin 40
dpm

TIME

SUBJECTIVE

OBJECTIVE

08.30

UC: 3x/10`30
FHB: 12.12.12 (144x/minute)

09.00

UC: 3x/10~30
FHB: 12.12.11 (140x/minute)

09.30

UC: 3x/10 ~ 30
FHB: 12.12.12 (144x/minute)

10.00

UC: 3x/10`30
FHB: 12.12.12 (144x/minute)
VT : 2 cm, effacement 25%,
amnion (+), Head palpable, H1,
denominator unclear, impalpable
small part and umbilical cord

12.30

14.30

GC: well
BP: 130/80 mmHg
PR: 104 bpm
RR: 24 tpm
T: 37,2oC
UC : (+) well
UFH : 1 fingers below umbilicus

ASSESSMENT

PLANNING
Drip Oxytocin 40
dpm
Drip Oxytocin 40
dpm

G1P0A0H0 3940 Wk S/L/IU

head
presentation
with first stage
of labour latent
phase, with
drip failure and
severe preeclampsia

Drip Oxytocin 40
dpm
DM co to SPV :
SPV adv CS at
12.00 13/11/2012

CS began
Baby was born,
Female, BW :
3450 gram, BL: 49
cm, A-S : 7-9,
anus (+),
congenital
anomaly (-),
Placenta was born
manually,
complete
Bleeding : 500 cc
CS finished
Observed

mother

TIME
14/11/1
2
07.00

SUBJECTIVE

OBJECTIVE
GC : well
BP : 120/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,7OC
UC : (+) well
UFH : 2 fingers below
umbilicus
Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC

ASSESSMENT
1 day post CS

PLANNING
Observation vital sign
and bleeding
Suggest mother to
eat, drink,
mobilisation