Resume of Case August 24th, 2011

Supervisor : dr. Juliawan, SpOG MS :Tomi, Dian, Ita, Mita, Lili Phisiology : 1 Phatology: 2

Identitied • • • • Name : Mrs. H Age : 20 years old MR : 007120 Adressed: Batu layar • Admitted to GH of NTB on August 24th. 2011 at 10.00 .

FM (+). head palpable.Time 12. Rh (-/). abdominal pain (+) . Asthma (-) LMP : 7-11-2010 EDD : 14-08-2011 History of ANC : > 4 x at Polindes History of family planning : Next family planning : History of obstetric 1. CPD Planning .5’C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+). History rupture of membrane (-). Abdominal pain since 14-08-2011.30 .12 VT : Ø 1cm.11.30 (24/8/ 2011) Subject Patient reffered from poli GH NTB with G1P0A0L0 41-42 weeks/S/L/IU head presentation Oligohidramnion + suspect CPD. eff 10%.Obs. DM (-). bloody slim (-). Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 32cm L2 : back on the left L3 : head L4 : 4/5 UC :EFW : 3255 gram FHB : 12. Mother and fetal well being -DL and HBsAg Report to supervisor Adv : -Resusitation -Injeksi ampi 2gr/iv -SC at 16. This Object General status: General condition : well Cons : CM BP : 120/70 mmHg PR : 80 bpm RR : 24 x/minute T : 36. amnion +. ↓HI unpalpable small part or umbilical cord Assestment G1P0A0L0 41 -42 weeks/S/L/IU Oligohidramnion + Susp. History of HT (-).

000 Hct : 35.9 HBsAg : - .700 RBC : 4.36 HGB :11 PLT : 375.Pelvic evaluation : Promontorium not palpable Sacrum : convexity normal Spina ischiadica not prominent Os coccigeous mobile Pubic arch < 90’ Lab exam : WBC : 11.

BL: 48cm.45 . bleeding ± 100 cc •GC : well •BP : 120/80 mmHg •PR : 80 bpm •RR : 18 tpm •T 36.50 wita SC began 17.5’C •TFU : 1 finger below umbilicus •UC : + Active Bleeding (-) 17. anus (+). BW . CPD P SC at 16. 140x/minute A G1P0A0L0 41 -42 weeks/S/L/IU Oligohidramnion + Susp. 7-9.7’C UC : DJJ : +. Female. A-S .30wita Baby was born. 500 gr. complete. 3500 gr. amnion minimal and unclear bleeding ± 100 cc Baby was sent to NICU Plasenta was born manually. congenital anomaly (-).00wita S - O General condition : well Cons : CM BP : 120/70 mmHg PR : 80 bpm RR : 20 x/minute T : 36.30 16.Time 14.

Time 18.30 S - O Mother GC : well BP . 90/60mmHg PR : 108x/ bpm RR : 20 x T : 36.2’C UC (+) hard.30 - Mother GC : well BP . palpable 1 Finger diatas umbilical. Active bleeding (-) UO : 510 cc 2 hour post SC Obs vital sign and active bleeding CIE mother to eat and drink if not fomit . 100/60mmHg PR : 116 bpm RR : 20 x T : 36. Active bleeding (-) UO : 500 cc A 1 hour post SC P Obs vital sign and active bleeding CIE mother to eat and drink if not fomit 19. palpable in umbilical.2’C UC (+) hard.

00 - •GC : well •BP : 110/80 mmHg •PR : 84 bpm •RR : 20 tpm •T 36.5 ‘C 1 st day post SC Obs vital sign and active bleeding .3’C •TFU : 1 finger below umbilicus •UC : + Active Bleeding (-) Baby in NICU: •RR : 36 x/minute •HR : 130 bpm •T : 36.(25-08-2011) 07.

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