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Resume of Case September 16th, 2011

Supervisor : dr. Made Mahayase, SpOG MS :Ita, Uyunk, Lili, Atun Phisiology : Phatology:

2011 at 00. KLU • Admitted to GH of NTB on September 16th.00 . S Age : 31 years old MR : 254353 Adressed: Kr. Lendong.Identitied • • • • Name : Mrs.

headache (-). History rupture of membrane (-).11. FM (+).Time 00. SC. Object General status: General condition : well Cons : CM BP : 150/90 mmHg PR : 100 bpm RR : 20 x/minute T : 37’C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+). This Chronologist : in Tanjung GH 15-09-2011 21.00 WITA (15-092011). eff 10%. Wh (-/-) Cor : normal Abd : striae gravidarum (+) Ext : edema (-/-) Obstetrics status L1 : breech L2 : back on the left L3 : head L4 : 4/5 UC : UFH : 28 cm EFW : 2635 gram FHB : 11. history of SC 12 years ago because of eclamsia.45 WITA S : patient 9 month pregnancy came to Tanjung GH confess abdominal pain since 09.unpalpable small part or umbilical cord. amn (+) . headache (-). DM (-). blurred vision (-). Rh (-/).00 WITA (15-09-2011).Obs. seizzure (-). epigastric pain (-) .11 (135x/minute) VT : Ø 1 cm. Assestment G1P0A0L0 39 weeks/S/L/IU head presentation + PER and previous SC 12 years ago Planning . 12 years 2. ↓HI . bloody slim (+) 09.00 WITA (15-092011). 2400. Abdominal pain since 09.05 (16/9/ 2011) Subject Patient reffered from Tanjung GH with G2P1A0L1 39 weeks/S/L/IU head presentation Latent phase 1st stage of labor + Suspect Severe preeclamsia . bloody slim (+) 09. Mother and fetal well being -DL and HBsAg -Coass to GP: pro CTG -Report to GP: Adv : Move to VK teratai Observation . term. History of HT (-). FM (+). LMP : 16-12-2010 EDD : 23-09-2011 History of ANC : 2x at Polindes History of family planning : injection 3 month Next family planning :tubectomy History of obstetric 1. Asthma (-). Doctor.00 WITA (15-09-2011). epigastric pain (-) . Male.

85 RBC : 4. eff 25%.7 PLT : 371 Hct : 35.Examination in tanjung GH 15/09/2011 (21.referred to NTB GH Lab exam : WBC : 10.40 Wita) GC : well Cons : CM Emotion : stabil TD : 150/100mmHg PR : 84x/minute Temp : 36’7°C RR : 22x/minute Abdominal palpation : UFH 29cm. head palpable.KIE family . L1: breech L2: Back on left L3: head presentation L4: 4/5 EFW 2790 gr FHB : 11-12-12 (140x/minute) UC : 3x10’=35” VT : Ø 1 cm. amn (+). unpalpable small part or umbilical cord A: G2P1A0L1 39 weeks/S/L/IU head presentation Latent phase 1st stage of labor + Suspect Severe preeclamsia P: .insert RL drip MgSO4 40% 28 tpm 15/09/2011 (22.9 MCHC : 27.8 MCV: 82.32 HGB :11.bolus MgSO4 40% 10 cc . ↓HI.15 wita) P : .1 Protein : +1 HBsAg : - .

20 (16/9/2011) S O General condition : well BP : 150/80 mmHg PR : 94bpm RR : 20 x/minute T : 36’C His: 2x10’=20” DJJ: 11-11-12 BP : 130/90 mmHg PR : 88bpm RR : 20 x/minute T : 36.10 (16/9/2011) 11. Male. completely.00 (16/9/2011) Co to supervisor Adv: observation 2 hour 10.15 (16/9/2011) SC began Baby was born. BW 2700 gr. bleeding ± 350 cc Placenta was born manual. 7-9 anus (+).2’C His: 1x10’=20” DJJ: 12-12-12 A G1P0A0L0 39 weeks/S/L/IU head presentation + PER and history of SC 12 years ago P 07.30 (16/9/2011) Supervisor called to VK Teratai Adv supervisor : prepare to SC Insert DC and infus Injection ampi 2 gr/iv 11. amnion meconeal. BL: 47 cm.30 . Baby was sent to NICU SC finish 11.Time 02. A-S . congenital anomaly (-).

140/80mmHg PR : 94bpm RR : 20 x T : 36 ‘C TFU : 1 finger above umbilicus UC (+) hard Active bleeding :(-) Lochea :(+) UO : 100 cc A 1 hour post SC P Obs vital sign and active bleeding CIE mother to eat and drink if not vomiting 14.00 (16/9/2011) S - O Mother GC : well Cons : CM BP . 140/80mmHg PR : 91bpm RR : 20 x T : 36 ‘C TFU : umbilicus UC (+) hard Active bleeding :(-) Lochea :(+) UO : 110 cc 2 hour post SC Obs vital sign and active bleeding CIE mother to eat and drink if not vomiting .Time 13.00 - Mother GC : well Cons : CM BP .

7’C UC: (+).Time 07. well UFH: 1 finger below umbilicus UO: 300 cc Vaginal active bleeding (-) Baby in NICU PR: 140/minute RR: 45x/minute A 1 day post SC P Obs vital sign and active bleeding .00 S Wound operation pain (+) O Mother BP: 110/80 mmHg PR: 79/minute RR: 20/minute T: 36.