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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
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Name : Mrs. M
Age : 32 yo
Adress : Bagek Nunggal, lombok tengahAdmitted : August, 18th 2012 at 11.45
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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.
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
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
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TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
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