18 08 12 plasenta previa

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Supervisor : dr. I Made P. Juliawan,

Sp.OGMedical Students :

Jun, Dini H, Erma, Rani, Diah, Dini F, JatnaCASES RESUME

NORMAL LABOR 2

PATHOLOGYLABOR



Name : Mrs. M

Age : 32 yo

Adress : Bagek Nunggal, lombok tengahAdmitted : August, 18th 2012 at 11.45



TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

18/08/201211.45

Patient referred from Praya GH

with G5P3A1L2 A/S/L/IU with

transverse lie and low lying

placenta. Patient confessed

blood come out from her womb

since 20.00 (17/08/12). Water

came out from her womb since20.00 (17/08/12). Abdominal

pain that spread to waist since

05.00 (18/08/12). Bloody slim

(+), FM (+).

No history of DM, HT, asthma.

LMP : forgot

EDD : -

History of ANC : > 4x at

Posyandu

Last ANC : 31/08/2012

History of USG : 1x

Last USG : 18/08/2012

Result : low lying placenta +

transverse lie, EFW : 2450 g.

History of family planning :

injection 3 months

Next family planning :

Tubectomy

General Status

GC : well

Consciusness : CM

BP : 140/90 mmHg

PR : 88 bpm

RR : 24 bpm

T : 36,5oC

Eye : anemis (-/-), icteric (-/-)

Cor : S1S2 single reguler, M (-), G (-)

Pulmo : vesikuler (+/+), wheezing (-/-),

ronkhi (-/-).

Abdomen : scar (-), striae (+), linea

nigra (+).

Extremity : edema (-/-), warm acral(+/+)

Obstetrical Status

L1 : back

L2 :

O

L3 : extremities

L4 : -

UFH : 22 cmEFW : -

UC : 3x/10’ ~ 40’’

FHB : 13-13-12 (152 bpm)

Inspeculo : Ø (+), membrane of

plasenta (+), stolsel (-), livide (+),

active bleeding (-).

VT : not evaluated

G5P3A1H2

A/S/L/IU

transverse lie

with low-lying

placenta +

history rupture of

membrane +gestasional

hypertension

• Observe mother and

fetal well being.

• DM co to SPV pro CS,

advice : Acc CS at

16.00 Wita

- CIE patient and

family- Insert DC

- Skin test (-), inj.

Ampicillin 2 g/IV.




16.30 C-section began :Baby was born, female, BW 2000

gram, AS 6-8

Anus (+), congenital anomaly (-),

Ballard score : 30, Gestation age :

35-36 weeks

Placenta was born manually,complete, bleeding + 500 cc.

Myoma uteri intramuralFimbriectomy bilateral done




19.30 Patient confessed her leg

can’t moved and operation

wound pain

GC : well

BP : 100/60 mmHg

PR : 80 bpm

RR : 24 bpmT : 36,0oC

UFH : 1 finger below umbilicus

UC : (+) well

UO : ± 30 cc/hours

Operation wound good

2 hours post CS • Observe mother well being

• CIE mother to take a rest,

eat, and drink.

19/08/

201207.00

Operation wound pain GC : well

BP : 110/60 mmHgPR : 96 bpm

RR : 24 bpm

T : 37,9oC

UFH : 2 finger below umbilicus

UC : (+) well

Lochea rubra : (+)

Operation wound good

Baby in NICU :PR : 148 bpm

RR : 42 bpm

T : 36,8OC

GDS : 89 mg/dl

1 day post CS +

febris

• Observe mother well being

• CIE mother to mobilisation,eat and drink

• Paracetamol po 3x1

• Breast feeding

18 08 12 plasenta previa

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