lapkas_obstretics_040915
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SPONTANEOUS VAGINAL DELIVERY
IN POST TERM PREGNANCYPresented by
Jane A. Djianzonie 100 100 128R. Pavin Vikneshwaran 100 100 185
Advisordr. Fadjrir, M.Ked (OG), Sp.OG
Mentordr. Rina Sinta Dhanu
SMF ILMU OBSTETRI DAN GINEKOLOGIRSU DR. PIRNGADI MEDAN
2015
INTRODUCTION
INTRODUCTION
Pregnancy usually lasts 40 weeks (280 days) is calculated from the first day of the last menstrual period.
Postterm pregnancy is a pregnancy that lasted more than 42 weeks (294 days) since the first day of the last menstrual period.
Postterm pregnancy incidence between 4-19%, depending on the definition adopted and the criteria used in determining the gestational age.INTR
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INTRODUCTIONIn postterm pregnancy there are changes in placenta, amniotic fluid and fetal circumstances → oligohydramnios, meconium aspiration, asphyxia fetus and shoulder dystocia → increase the risk of poor perinatal outcome increased perinatal mortality
Risk for mothers with postterm pregnancy consist of postpartum bleeding and increased obstetric action.
INTR
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THEORYSpontaneous Vaginal
Delivery
The First stage: stage of cervical effacement and dilatationDefinition: the first stage of labour refers to the period from the onset of true uterine contractions to the fully dilation of the cervix, when the diameter of the cervical os measures 10cm.
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Duration:o primigravida = 8-12 ho multigravida = 6-8 h
Phases of the first stage: Latent phase: started when the cervix dilatated
slowly and reached to about 3cm.A. in primigravida = 8hB. in multigravida = 4h - Active phase: rapid dilatation of the cervix to
reach 10cm A. in primigravda = 4hB. in multigravida =2h
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The active phase is divided into:1. Accelerative phase 2 hr2. Slopping phase 2 hr3. Decelerative: 2 hr
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N.B – in primigravida the cervix dilates from above downwards, in multigravida dilatation of the internal os, taking up of the cervix and dilatation of the external os occurs simultaneously.
II-The Second stage of labour: stage of delivery of the fetus.Definition: the second stage of labour refers to the period from complete cervical dilatation to the birth of the fetus.Duration:A.in primigravida =1 hB.in multigravida = ½ h however the timing of the second stage is very different to determine and controversial and can be extended as much as there is progress in descent and no harm to the mother or fetus Sp
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Cardinal sign of delivery Engagement Descent FlexionInternal rotation ExtensionExternal rotationDelivery of the fetal's shoulder
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• After external Rotation• sides of the head are
grasped with two hands, and gentle downward traction is applied until the anterior shoulder appears under the pubic arch
• Next, by an upward movement, the posterior shoulder is delivered
• The rest of the body almost always follows the shoulders without difficulty
Delivery of Shoulder
•Clamping the cord• 4-5 cm , 2-3 cm fetal abdomen two clamps• Plastic cord clamp
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Signs of placental separation1. uterus becomes globular firm.2. Sudden gush of blood.3. Uterus rises (placenta separated ,
passes dawn to lower u-segment.4. Umbilical cord protrudes farther
out of the vagina.
Third Stage Delivery of the PlacentaActive management of third stage• oxytoxin injection in 1 minute after
baby delivery (10 IU intramuscular at lateral vastus muscle).
• Controlled umbilical cord taut.• Uterine fundus massage after
delivery of the placenta.
Fourth stage of labor• Exam placenta , membranes , umbilical
cord• Completeness , anomalies• Hour immediately fallowing delivery is
Critical fourth stage of labor • uterine atony , BP , pulse every 15
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THEORYPost Term Pregnancy
DEFINITION• The international definition of prolonged
pregnancy, endorsed by the American College of Obstetricians and Gynecologists (2004), is 42 completed weeks (294 days) or more from the first day of the last menstrual period. It is important to emphasize the phrase “42 completed weeks.” Pregnancies between 41 weeks 1 day and 41 weeks 6 days, although in the 42nd week, do not complete 42 weeks until the seventh day has elapsed.
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INSIDENCE• Approximately 7% of the 4 million babies
born in the United States in 2001 is estimated to have been born at 42 weeks or more. Analysis of 27 677 women born in Norway, an increase of 10% to 27%, if the first birth postterm and to 39% if the twice-born postterm.
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EtiologyEffects of Progesterone• ↓progesterone ↑sensitivity of uterus to oxytocin
The theory of oxytocin• release of less oxytocin from the neurohypophysis pregnant women on advance
gestational age is suspected as a factor in postterm pregnancy
Theory of Cortisol / fetus ACTH • Fetal cortisol placenta ↓progesterone & ↑estrogen ↑ prostaglandin• anencephaly, fetal adrenal hypoplasia and absence of the pituitary gland ↓prod
cortisol postterm
Uterus Neural • pressure on the cervical ganglion of Frankenhauser plexus will excite uterine
contractions• location abnormality, short umbilical cord and the lower part is still high
Hereditary• mother gave birth to a daughter postterm, it is probable that her daughter will
become postterm pregnant
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DiagnosisMenstrual history
History of antenatal care• Pregnancy test• Fetal movement• Fetal heart rate
Position of uterine fundus
Ultrasonography (USG) Examination • The earlier ultrasound examination performed, then the pregnancy
age is obtained will be more accurate
Radiological examination
Examination of amniotic fluid• Levels of Lecithin / spingomielin• Amniotic fluid Tromboplastin activity (AFTA) • Amniotic fluid cytology
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Changes in Post Term Pregnancy
Changes in amniotic fluid
Changes in the placenta
• Fetal weight• postmaturitas syndrome• Fetal distress or perinatal death
Changes in the fetus
• Morbidity / mortality of mothers• emotional aspects
The influence to the motherPOST
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Postmaturity Syndromepeeling, wrinkled and patchy skin
long and thin body, indicate wasting;
opened up of the baby's eyes
unusual alert, old and worried-looking.
wrinkling mostly on the hands and feet palms.
Typically quite long nails.
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Postmaturity Syndrome
Depending on the degree of placental insufficiency occurs postmaturity signs can be divided into three stages, namely: 3
Stage I: The skin shows loss of vernix caseosa and skin maceration in the form of dry, brittle and peeling
Stage II: plus meconium staining of the skin
Stage III: plus a yellowish coloring of the nails, skin and the umbilical cord
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Fetal distress or perinatal death increased after 42 weeks gestation or more, mostly occurs intrapartum. Generally caused by:
Macrosomia can cause dystocia in birth
Placental insufficiency resulting in:• Stunted fetal growth• Oligohydramnios:
cord compression occurs, release of thick meconium
• fetal hypoxia• fetal meconium
aspiration
Congenital defects: mainly due to adrenal
hypoplasia and anencephaly
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Management
Only normal pregnancies should allow to go past the expected date of delivery (EDD)
Terminating the pregnancy will correct the problem
The in utero environment must be monitored for the risk of oligohydramnios and placental insufficiency,
Delivery problems of shoulder dystocia with macrosomic infants, meconium aspiration and hypoxia
must be avoided.
TreatmentPO
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CASE REPORT
Name : DR
Age : 23 years old
Religion : Christian
Race : Batak
Occupation : Housewife
Education : High school (SMA)
MR Num. : 97.11.83
Admission Date : 11 August 2015
PATIENT’S IDENTITYCA
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Mrs DR, 23 yo, G1P0A0, Christian, Batak, Housewife, wife from Mr.H, 33yo,
private servant, came to ER with :
Chief complaint : exited expected date of delivery (EDD).
Strain on labor (-), History of bloody show (-), Histoy of amniotic Fluid Leakage (-)
History of previous disease : -
History of previous med : -
Menstrual History
LNMP : 19/10/2014
EDD : 26/07/2015
ANC : Midwife 2x and SpOG, 4x.
History of Labor
1. This pregnancy
History TakingCA
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Status Present
Sens : CM Anemis : -
BP : 120/80mmhg Icteric : -
HR : 90 times /second Cianoteic : -
RR : 20 times /second Dyspneu : -
Temp : 36,5⁰C Oedem : -
Obstetrics Status
Abdomen : asymetric enlargement,
Fundal height : 4 fingers below proc. Xypoid(31 cm)
Tension Part : Left
Lowest Part : head presentation
Fetal Heart Rate(FHR) : 130 x/i, Reguler
Fetal Movement (FM) : (+)
Uterine Contraction : (-)
Estimated Birth Weight : 3000-3200gr
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Clinical Pelvic Assessment - Sacral Promontory : not palpable
- Shape of sacrum : Concave
- Ischial spine : not prominent
- Pubic arch : Blunt
- Os. Coccygeus : mobile
Conclusion : pelvic adequate
Vaginal Examination (VT) : Cervix closed in tight.
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USG TAS- Single Fetus, Head Presentation, Alive Fetus- Fetal Movement (+)- Fetal Heart Rate (FHR) (+)- Biparietal Diameter : 96mm- Femur Length : 84mm- Abdominal Circum. : 342mm- Placenta Anterior Corpus, Calcification (+)- Amniotic fluid (+) normal range (150mm)- Estimated Fetal Weight : 3000-3200
Conclusion :Single Fetus + Intra uterine pregnancy (42-43 weeks) + Head Presentation + Alive Fetus
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Results Normal Values
Hb 4,10 g% 12-14
Erytrocyte 2,78 x106/mm3 4,5-5,5
Leucocyte 12.8 x103/mm3 4.000-10.000
Ht 16,3 % 36-42
Thrombocyte 164 x103/mm3 150-440 x 103
MCV 58,60 fL 80-97
MCH 14,70 pg 27-33,7
MCHC 25,20 g/dL 31,5-35
RDW 22,90 % 10-15
Protrombin time
- Patient- Control
13,0 detik
15,5 detik
INR 1,03 APTT
- Patient- Control
32,3 detik
33,4 detik
AST/SGOT 22,00 U/L 0-40
SGPT 12,00 U/L 0-40
Glucose Ad Random 92,0 mg/dL <140 mg/dL
Ureum 20,0mg/dL 10-50 mg/dL
Creatinin 0,66mg/dL 0,60-1,20 mg/dL
Total Bilirubin 0,50 0,00-1,20 mg/dL
Direct Bilirubin 0,17 0,05-0,30 mg/dL
CASE
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DiagnosisPrimi Gravida + Intrauterine Pregnancy (42 weeks 2days) + Head presentation + Alife Fetus + Non Inpartu + Anemia
Therapy- IVFD RL 20 drips/i
Planning • Improved general condition of the patient.• Transfusion 3 bag (PRC) , a routine blood test is done 6 hours
post-transfusion.• Consult Internal Medicine for Anemic diagnostic confirmation and
tolerance of transfusion.CASE
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CASE
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Date
11 August 2015 S - O Sens: compos mentis
BP : 120/80 mmHg
HR : 82x/I reguler
RR : 20x/I reguler
T : 36,5°C
Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -
Obstetric Status
Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (-)
Fetal Heart Rate : 146 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.
A Primi Gravida + IUP(42 weeks, 2 days) + HP + AF + non inpartu + Anemia
P - IVFD RL 20 gtt/iPlanning :
- Monitor Vital Sign, FHR, Uterine Contraction
- Transfusion PRC 3bag
Date
12 August 2015 S -
O Sens: compos mentis
BP : 120/80 mmHg
HR : 82x/I reguler
RR : 20x/I reguler
T : 36,7°C
Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -
Obstetric Status
Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (-)
Fetal Heart Rate : 146 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.
A Primi Gravida + IUP(42 weeks, 3days) + HP + AF + non inpartu + Anemia
P - IVFD RL 20 gtt/iPlanning :
- Monitor Vital Sign, FHR, Uterine Contraction- Transfusion PRC 2-bag, remainder 1bag.- Internal Medicine Consultation : Screening blood
test on Fe Serum and TIBC test.
Date
13 August 2015 S-
OSens: compos mentis
BP : 120/80 mmHg RR : 20x/I reguler
HR : 88x/I regular T : 36,6°C
Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -
Obstetric Status
Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (-)
Fetal Heart Rate : 148 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.
Blood Test Result (Post Blood Transfusion)
Hb/ Ht/ Leu/ Plt : 6,50 / 23,10 / 14.900 / 127.000
Fe Serum/ TIBC : 23.00 / 619.000
Internal Medicine Consultation : Iron Deficiency Anemia
APrimi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia
P- IVFD RL 20 gtt/iPlanning :
- Monitor Vital Sign, FHR, Uterine Contraction- Transfusion PRC 1bag- Blood Test – Post Blood Transfusion
CASE
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CASE
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Date
14 August 2015 S Straining to give birth
0900 WIT O Sens: compos mentis
BP : 120/80 mmHg RR : 21x/i reguler
HR : 88x/i, regular T : 36,6°C
Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -
Obstetric Status
Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (+), 2 x 10”/10’
Fetal Heart Rate : 148 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.
Vaginal Toucher
Cervix : Axial, Dilation : 5cm, Effacement : 100%, occiput ??, Station of vertex (H II-III), Amnion Sac : (+) Bulging
Glove: bloody show (+), Amnion fluid (-).
A Primi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia
P - IVFD RL 20 gtt/iPlanning :
• Monitor Vital Sign, FHR, Uterine Contraction• Spontaneus Vaginal Delivery• Partography Assessment on the progress of the delivery process.
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09.00 10.00 11.00
RL RL RL
36 37 37 37 37
c c c c c
0930 0900
1 0 023 tahunDR14 /08/ 15
- - - - -
Spontaneus Vaginal Delivery with Vacuum Extraction ReportAt 14th August 2015A Baby Girl Born, BW : 3100 gr, Neonatal Lenght : 49 cm, A/S : 8/9, anus (+)
• Mother was laid on the gynecology table with lithotomy position. Emptying the bladder and cleaning the genital area was done. Intravenous catheter is fixed well.
• Head of the baby can be seen at vaginal introitus, evaluations of occiput is at 12. Do the insertion of small size silicon vacuum cup on the occiput. Evaluate wall of the vagina and cervix, is not narrow. Carried out vacuum in conjunction with adequate straining of the mother. Vacuum pressure lowered from 0.2, 0.4 and 0.6. Evaluation, the baby’s head have entered the vaginal introitus. With a controlled pull in the direction of the birth canal, head of baby was born, the vacuum cup is released, then carried bipariental grip of baby head. The head pulled downward to give birth to the front shoulder, pulled upward to release the back shoulder.
• A baby girl is born, BW : 3100gr, neonatal length : 49cm A/S: 8/9, anus (+)
• The umbilical cord clamps in two places and cut them, then the bladder is emptied with urine catheter. Oxytocin 10 IU (1amp) given intramuscular at the mother’s left thigh.
• With traction of umbilical cord and simple massage at the fundus for 5-10 minutes , the placenta was born spontaneously , evaluation : complete.
• Evaluate of birth canal for any lacerations. Evaluation of bleeding no bleeding.
• Mother condition after Vaginal Delivery good
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Neonatal Assessment
Type of Birth : Single baby
Date of Birth : 14 August 2015,
1130 WIT
circumstances of birth: Alive baby, spontaneous cry.
APGAR score : 8/9
Sex : female
Body Weight : 3100gr
Body Length : 49cm
Head Circumference : 33cm
Trauma : not found
Congenital Abnormalities: not found
Consult to Perinatology
Post Term Syndrome
• Dry skin(Patchy Skin): (+)• Skin wrinkles : (+),Dominant
Palm and Soles
• Skin color : (+), Pale
• Long nails : (+)• Lenugo : (-)• Vernix Caseosa : (-)• Long hair : (+)• Skin maceration : (-)• Meconium apiration: (-)
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Therapy Post Delivery- IVFD RL + Oxytocin 10-10-5-5 UI → 20 drips/i- Cefadroxil 2 x 500mg- Mefenamat Acid 3 x 500mg- Metargin 3 x 1tab
Planning • Transfusion 1 bag PRC• Routine blood test is done 6 hours post-transfusion.• Monitoring Vital Sign, Uterine Contraction and Post partum
haemorrhage.
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Time (hours) WIT
13.00 13.15 13.30 13.45 14.15 14.45 15.15
Heart Rate 84 80 88 84 80 90 82
Blood Pressure (mmHg)
120/70 130/90 120/90 130/90 130/80 120/80 130/80
Respiratory Rate
22 22 20 20 20 20 20
Uterine Contraction
Kuat Kuat Kuat Kuat Kuat Kuat Kuat
Bleeding( in cc)
5 5 10 - - - -
CASE
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Date
15 August 2015 S -
O Sens: compos mentis
BP : 120/80 mmHg RR : 21x/i reguler
HR : 88x/i, regular T : 36,6°C
Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:-, Edema: -
Localized Status
Abdomen : Soepel, Peristaltic (+) normal
Fundus height : 2 finger below the umbical
Vaginal Bleeding : (-) lochia (+) Rubra
Urination : (+) normal.
Defecation : (-), Flatus (+)
Blood Test Result (Post Blood Transfusion – 1bag)
Hb/ Ht/ Leu/ Plt : 9,00 / 30.000 / 13.100 / 92.000
A Post Vaginal Delivery on the indication of occiput anterior position + post partum day 1
P • Cefadroxil 2 x 500mg• Mefenamat Acid 3 x 500mg• Methargin 3 x 1 tab• B- Complex Vitamin 2 x 1 tab
CASE
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Date
16 August 2015 S -
O Sens: compos mentis
BP : 120/80 mmHg RR : 20x/i reguler
HR : 80x/i, regular T : 36,5°C
Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:-, Edema: -
Localized Status
Abdomen : Soepel, Peristaltic (+) normal
Fundus height : 2 finger below the umbical
Vaginal Bleeding : (-) lochia (+) Rubra
Urination : (+), normal.
Defecation : (+), normal
A Post Vaginal Delivery on the indication of occiput anterior position + post partum day 2
P • Cefadroxil 2 x 500mg• Mefenamat Acid 3 x 500mg• B- Complex Vitamin 2 x 1 tab
Planning :Discard today. Control Obstetric Polyclinic as outpatient on the 20 th August 2015.
TIM
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11 August 2015- Chief Complaint : Post Date!!!!- Lab Test : Anemic : 4.10gr%- Fetus in normal condition- Plan for blood transfusion (3bags)- Consult internal medicine for
diagnostic & blood transfusion tolerance
12 August 2015- Transfusion for 2bag- Check lab 6 hours post transfusion.- Answer from the consultant from
internal medicine : check for Fe Serum & TIBC
13 August 2015- Hb : 6,50- Fe/TIBC : 23.00/619.00- Transfusion 3rd bag and check lab
6hours post transfusion - Answer from the consultant from
internal medicine : Iron deficiency Anemia.
14 August 2015- Straining to give birth- Hb : 9,00gr%- Mother delivered at 1132 WIT,
♀,3100gr, BL: 49cm, HC: 33cm- Patient stabil postpartum
15 & 16 August 2015• Patient is monitor after the
delivery.• Patient is stable and getting better.• Discard today. Control Obstetric
Polyclinic as outpatient on the 20th August 2015.
CASE DISCUSSION
CASE
DIS
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Theory In this Case?
Defination of Post Term is prolonged pregnancy, endorsed by the American College of Obstetricians and Gynecologists (2004), is 42 completed weeks (294 days) or more from the first day of the last menstrual period.
This patient is completed 42weeks, where the gestational age is 42weeks and 2days.
Post term diagnosed with :1. History Taking
• Menstrual History• Last normal
Menstrual Period (LNMP)
• Expected delivery date (EDD).
2. USG TAS• Gestational Age• AFI <10cm• Calcification of Placenta
Menstrual HistoryLNMP : 19/10/2014EDD : 26/07/2015
Patient came to ER on the 11th August 2015 Gestational Age :(42weeks, 2days)
Result from USG TAS :AFI : 15cmIUP : 42 – 43 weeks with calcification of placenta gr.II.
Theory In this Case?
Post Term Syndrome there will be changes in fetus like :Dry skin (+), Skin wrinkles(+) , Skin will decolorized as the meconium color, Long nails (+) , Lenugo (-), Vernix Caseosa (-), Long hair (+), Skin maceration (+), meconium aspiration (+).
Dry skin (Patchy Skin) : (+)Skin wrinkles : (+),Dominant Palm
and SolesSkin color : (+), PaleLong nails : (+)Lenugo : (-)Vernix Caseosa : (-)Long hair : (+)Skin maceration : (-)Meconium aspiration : (-)
CASE
DIS
CUSS
ION
• Whether the treatment in this case was appropriate ?• The extent of general practitioners can do, to
handle the post term pregnancy ?
CASE
PRO
BLEM
S CASE PROBLEMS ?
erima Kasih!T
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