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Case Report
Mrs. S, 19 years old, from Ampenan,
Hospitalization on 15.22, 12/08/2013.
G2P0A1H0 33-34 wk S/L/IU head presentation with PROM > 12 hours.
Time
Subject
12/08/13
15.30
WITA
Object
General status
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR: 82 tpm
RR: 20 tpm
T: 36,3C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor /S1S2 single reg. M(-), G(-)
Abd : striae gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
UFH: 28 cm
L2 : back on the right side
L3 : head
L4 : 4/5
UC : FHB : 12.12.12 (144bpm)
EFW :2635 gram
VT : CD 1 cm, eff 10%, amnion
(+), head presentation, denom
unclear, H I, small part of fetus
or umbilical cord unpalpabled.
PE:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeous mobile
Pubic arch > 90
Assessment
G2P0A1L0 33-34
weeks S/L/IU head
presentation with
PROM > 12 hours
Planning
-Obs. Mother and fetal
well being.
- Ceck CBC and HBsAg
- DM co. to GP, advice :
pro CTG
- GP co. CTG result to
SPV, advice:
- Obs. and move to VK
Teratai.
-Inj. Dexamethason 1
ampul/ 6 hours
-Inj. Ampicillin 1 g/24 h
-Pro USG
Time
Subject
Cronologist :
10.19 (11/8/2013) at PHC
Patient came to Tanjung Karang
PHC confessed abdominal pain since
03.00 (11/8/2013), history of water
leakage 9-), bloody slim (-), FM (+).
General status : well
BP : 100/80 mm Hg
P :84 x/m
RR :20 xm
Temp : 36,7C
UFH : 27 cm , palpable breech on
fundus, back on right side, head on
pelvic inlet 4/5 part.
EFW : 2480 g
UC: 1x 10 20
FHB : 12-11-11 (136 bpm)
VT : CD icm, eff 25%, amnion (+),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
A : G1P0A0L0 36 weeks S/L/IU
head presentation, mother and fetal
are well being, inpartu observation.
11.30
Ruptur of amnion membran
spontaniously, clear, 100 cc.
VT : CD icm, eff 25%, amnion (+),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
T : Skin test (-),
Object
Lab:
Hgb : 9,9
Rbc : 3,77
Hct : 29,1
Wbc : 16,47
Plt : 394
HBsAg : -
Assessment
Planning
Time
Subject
11.45
Inj. Vicillin 1 g/IV/6 hours
FHB : 146 bpm
UC : 1x 10 25
15.30
UC : 3x10 30
FHB : 12-11-12 (140 bpm)
VT : CD 1 cm, eff 25%, amnion (-),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
17.45
Inj. Vicillin 1 g/IV/ 6 hours
19.30
UC : : 3x10 30
FHB : 12-12-12 (144 bpm)
VT : : CD icm, eff 25%, amnion (-),
head presentation, denom unclear,
H I, small part of fetus or umbilical
cord unpalpabled.
23.30
UC : seldom
FHB : 11-12-12 (144 bpm)
Inj. Vicillin 1 g/IV/6 hours
03.30 (12/8/2013)
UC : seldom
FHB : 11-12-12 (140 bpm)
Object
Assessment
Planning
Time
Subject
Object
Assessment
Planning
05.45
Inj. Vicillin 1 g/IV/6 hours
07.30
FHB : 11-12-11 (136 bpm)
UC : seldom
11.30
FHB : 11-11-12
UC : +
14.00
FHB : 12-11-11
UC : BP : 110/70 mmHg
P : 80 x/m
Tax : 37C
Co. dr. advice : Reffered to RSM
13/08/
2013
08.00
G2P0A1L0 33-34
weeks S/L/IU head
presentation with
PROM > 12 hours
- SPV advice :
Termination with
oxytocin drip.
-CIE patient and family
-Obs. Mother and fetal
well being
- Suggest mother to drink
and eat
Time
Subject
Object
20.00
13/08/
2013
BP : 110/70 mmHg
P : 80x/m
RR: 20 x/m
Temp: 36,5C
UC : FHB : 12-12-12
06.00
Assessment
G2P0A1L0 33-34
weeks S/L/IU head
presentation with
PROM > 12 hours
Planning
Time
Subject
Object
Assessment
Planning
09.45
UC : FHB : 12-11-12
10.15
UC : 1 x 10 10
FHB : 13-13-12
10.45
UC : FHB : 13-13-12
11.15
UC : FHB : 13-12-13
11.45
UC : FHB : 12-12-12
12.15
UC : 1 x 10 20
FHB : 13-12-13
12.45
UC : 1 x 10 20
FHB : 12-13-12
13.15
UC : 1 x 10 20
FHB : 12-13-12
13.45
UC : 2 x 10 20
FHB : 12-11-12
14.15
UC : 2 x 10 25
FHB : 12-13-12
14.45
UC : 2 x 10 25
FHB : 12-12-12
Time
Subject
Object
Assessment
Planning
15.15
UC : 3 x 10 30
FHB : 11-12-12
15.45
UC : 3x 10 35
FHB : 11-11-12
16.00
16.15
UC : 4 x 10 40
FHB : 11-12-12
16.45
16.50
G2P0A1L0 33-34
weeks S/L/IU head
presentation with 1st
stage of labor active
phase with history of
water leakage
-Conduct mother to
delivery the baby
Time
Subject
Object
Assessment
Planning
17.00
18.50
07.00
- Obs.mother condition
-Mobilitation
-Suggest mother to eat
and drink.