DRIP FAILURE ON G6P5A0

BY JEFFREY

IDENTITY
Name Age Address : Mrs. I : 40 y.o : Jl. Cikadut Rt 03 RW 04.

Cicaheum, Bandung Education : Primary School Occupation : House wife Date of admission : 18 December 2005 Medrec : 0504xxxx

Anamnesis
Referred by
: Ujung Berung Hospital With note : G6P5A0 parturient 40 41 week 1st Stage Active phase with Prolonged active phase and drip failure Chief complain : For Operation Anamnesis : - G6P5A0 9 months pregnant - Have been Dripped with 2 bottle

- Feel gripes that become stronger since + 18 Hours before come - Show (+) - Rupture Of The membrane : + 12 Hours Before , Clear , odour (-), febris (-) - Fetal movement (+)

Obstetric history
1. RSHS, Aterm, 4000 gr, Spontan, Male, 21 y.o, Life

2. Midwife, Aterm, 3900 gr, Spontan, Male, 20 y.o, Life

3. Heath Centre, Aterm, 3300 gr, Spontan, female, 14 y.o, Life 4. Heath Centre, Aterm, 3300 gr, Spontan, female, 10 y.o, Life 5. Ujung Berung Hospital, aterm, 3300 gr, spontan, male, 10 y.o, Life 6. This pregnancy

ADDITIONAL
Marital state (: (: Contraception LMP LEP PNC Cycle : currently married 19 yo, Primary , housewife) 25 yo, Primary , labor) : Pill since 2002 until 2004 : 11 March 2005 : 18 December 2005 : 6x Midwife : 28 days, regular

General State
Composmentis BP : 120/80 mmHg P : 104 x/minute R : 28 x/minute T : 37o C Other findings within normal limit

Laboratory Results
Hemoglobin Leucocyte Hematocrite Thrombocyte : : : : 13 gr% 27.300/mm3 35 % 152.000/mm3

EXTERNAL EXAMINATION
Fundal Height : Abd. Circumference Fetal lie : His : FHR : EBW : 40 cm u.s : 112 cm Head U 2/5 left back 3-4 1x / 40 strong 172 - 176 x/minute 4000 gr

INTERNAL EXAMINATION
V/v Portio Membrane Head : : : : : within normal limit thick, soft 7-8 cm (-), green fluid rest station 0, sagital suture left cross

DIAGNOSIS
G6P5A0 aterm parturient 1st Stage Active phase + Oxytocin drip Failure + Emergency Fetus

MANAGEMENT
Intra Uterine resuscitation, sleep on left side, O2, Infus cross match, blood Plan for CS Emergency Fetus indication Informed consent Consult to Anesthetic and call Operation Room Admission test

Observation:
Time
23.30 00.30 00.3001.30

His
3-4 1x/40 K 3-4 1x/40 K 3-4 1x/40 K

FHR
168 - 172

BP
120/ 180 120/ 180

HR
88

RR
24

Explaination

172 - 176

92

24

01.1501.30

176 - 180

120/ 180

92

24

Wait for the operation room

02.15 Patient take to the Operation room

Operation report
02.20 Operation began 02.25 Male baby was born BW : 3865 gr BL : 49,8 cm APGAR score : 1:3 5:5 10:9 Injected oxytocin 10 iu im, Good contraction 02.30 Placenta was born with slight stretch to umbilical cord W : 600 gram, S: 22 x 22 x 2 cm 03.35 Operation finished bleeding within operation 200cc

 D/ pre operative :
G6P5A0 aterm parturient 1st Stage Active phase + Oxytocin drip Failure + Emergency Fetus

D/ post operative :
P6A0 partus maturus with cesarean sectio indication drip failure + emergency fetus