CASE REPORT NO:

HUSBAND
IDENTITY IDENTITY
 Name: Mrs. Y  Name : Mr. A
 Age: 26 years old  Age : 28 years old

 MR No.: 00855275  Education : High School

 Date: 12-04-2019  Occupation : Enterpreuner
 Education : High School  Adress : Nanggalo
 Occupation : Housewife
 Adress : Nanggalo
 ANAMNESIS

A 26 years old patient was admitted to the

Delivery Room of Dr. M. Djamil Central General
Hospital on April, 12th 2019 at 01.30 am
referred from Private Hospital in Padang with
diagnose G1P0A0L0 39-40 weeks of term
pregnancy + active phase of parturient +
multiple presentation
Present Illness History:
• Previously, patien came to midwife, from the
examination got active phase of parturient labour
with multiple presentation then patien referred to
private hospital, because of the obstetrician was not
in charge, the patien referred to Dr. M. Djamil general
central hospital with infus inserted.
• Feeling of pain from waist region referred to the groin
since 14 hours ago
• Bloody show from the vagina since 14 hours ago
• Fluid leakage from the vagina (+) since 2 hours ago
• Bleeding from the vagina (-)
• Feeling like wanting to strange was (+) since 1 hour
• Amenorrhea since 9 months ago.
• First date of last menstrual period was July 8th, 2018
• Estimation date of delivery was April 15th, 2019
• Fetal movement was felt since 4 months ago
• Prenatal care : she controlled her pregnancy at midwife
6 times at 3,4,5,6,7,8 month of pregnancy. And control
to obstetrician 2 times
• Menstruation history: Menarche at 13 years old,
regullar cycle, which last for 5 to 7 days each cycle with
the amount of 2-3 times pad change/day without
menstrual pain
Previous Illness History:
• There was no previous history, lung, liver, kidney, DM,
hypertension and allergy

Family Illness History:

• There was no history of hereditary disease, contagious
and psycological illness in the family
 Occupation, Socioeconomics,
Psychiatry, and Habitual History:
• Marriage history: once at 2018
• History of pregnancy/abortion/delivery: 1/0/0
1. Present

• History of family planning : (-)

• History of immunization : (-)
• History of formal education : Senior high School
Physical Examination :
• GA Cons BP HR RR T
Mdt CMC 110/80 88 22 36,6

BW Before pregnancy : 75 Kg
BW present : 90 kg
BH : 158 cm
LILA : 31 cm
BMI : 30,04 kg/m2  obecity
• Eyes : Conjunctiva wasn’t anemic , Sclera wasn’t icteric
• Neck : JVP 5-2 cmH2O, no enlargement on thyroid glands
• Chest : Heart/lungs within normal limits
• Abdomen : Obstetrical Record
• Genitalia : Obstetrical Record
• Extremity : Oedema -/-, Physiological Reflex +/+, Phatological
Reflex -/-
Obstetric record
Abdomen
I : Enlarge according to term pregnancy, median line
hyperpigmentation (+), striae gravidarum (+), cicatrix(-)
Pa :
L1 : Uterine fundal was palpable 3 finger under
xyphoideus procesus
a large, soft nodular mass was palpable
L2 : largest resistance was palpable on left side,
small parts of the fetus was palpable on right side
L3 : a round mass, hard was palpated,fixated
L4 : Divergen

UFH : 32 cm His : 4x/40”/ strong

Au : FHS : 140-150 x/’

Genitalia : I : V/U normal, vaginal bleeding (-)
VT : Ø was complete, amnion sac (-), greenish residu,
head presentation, anterior occiput, hodge III – IV
 Laboratorium Routine

PARAMETER RESULT NORMAL LIMIT

Hemoglobin 11,4 g/dl 9,5-15

Leukosit 18.260/mm3 5.900 – 16.900

Hematokrit 35 % 28 – 40

Trombosit 387.000 /mm3 146.000 – 429.000

PT 10,4 second 10,0-13,6

APTT 31,1 second 29,20-39,40

Diagnose :
G1P0A0L0 39-40 weeks of term parturient second stage
Fetal alive singleton intra uterine head presentation ,
hodge III-IV

Management :
 Control GA,VS,HIS,FHS
 IVFD RL 500 cc 20 gtt/bpm

Plan : Vagina delivery  lead to bear down

At April 12th 2018 – 02.30 am
A female baby was born by spontaneous vaginal
delivery with 2900 gr in weight, 48 cm in height
and Apgar Score : 8/9.
Placenta was born with mild traction with size
15x13x2 cm and weight 450 gr Umbilical cord was
50 cm in lenght, paracentral insertion.
Bleeding during parturient 200 cc
A/ P1A0L1 post spontaneous vaginal delivery
Mother and child in care

Management :
• Control stage four
• IVFD RL ( Methergine 0,2 mg + Oxitocyne 1 0 IU)  20 tpm
• Cefixime 2x200 mg
• SF 2x 180 mg tab
• Vit c 3x 50 mg tab
• Paracetamol 3x500 mg
 Pemantauan kala IV
Waktu BP HR RR Temp UFH contrac urine bleeding
tion
02.45 120/80 85 20x 36,9 1 finger below baik - -
umbilcal
03.00 110/70 84 20x 36,9 1 finger below baik 30 cc -
umbilcal
03.15 110/60 82 20x 36,8 1 finger below Baik 50 -
umbilcal
03.30 100/80 80 20 37,0 2 finger below Baik 50 -
umbilcal

04.30 100/65 85 20x 37,0 2 finger below Baik 60 -

umbilcal

05.30 110/75 70 20x 36,9 2 finger below baik 90 -

umbilcal