fase aktif memanjang drip & kala ii lama ve

7/21/2019 Fase Aktif Memanjang Drip & Kala II Lama VE

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Morning ReportJuly 3rd 2012

Supervisor : dr. Made Mahayasa,Sp.OG

Medical Students :

Yan, Wiwid, Novi, Sapto, Ika, Ira, LaniCASE RESUME

NORMAL LABOR 3

PATHOLOGYLABOR

1. G1P0A0L0 40-41 weeks S/L/IU with prolonged 2nd stage of labor.

2. G4P1A2L1 42-43 weeks S/L/IU with severe pre-

eclampsia

3. G1P0A0H0 A/S/L/IU with neglected active phase 1st

stage of labor & eclampsia.



Case Report

Name : Mrs. L

RM : 044809

Age : 26 years old Address : Ampenan

Admitted : October 2nd 2012



TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

02/10/

2012

23.30

Patient referred from Midwife with

G1P0A0L0 37-38 weeks/S/L/IU

mother and fetal well with inpartu

active phase 1st stage. Patient

confessed abdominal pain that

spread to frank since since 08.00

(02/10/2012). and water came out

from her womb since 19.00

(02/09/2012). Bloody slim (+), FM

(+).

No history of DM, HT, asthma.

LMP : Forgot

EDD : -

History of ANC : > 4x at Polindes

Last ANC : 25/009/2012

History of USG : -

History of family planning : (-)

Next family planning : injection 3

months.

Obstetrical History :I. This

Chronologist : (-)

General Status :

GC : well

BP : 120/80 mmHg

PR : 80 bpm

RR : 20 bpm

T : 36,5oC

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

Cor : S1S2 single regular, murmur (-

), gallop (-).

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

/-), ronkhi (-/-).

Abdomen : scar (-), stria

gravidarum (+), linea nigra (+).

Extremity : edema (-/-), warm acral

(+/+).

Obstetrical Status :

L1 : breech

L2 : back on the left side

L3 : head

L4 : 4/5

UFH : 32 cm

EFW : 3250 gram

UC : 4x/10’ ~45’’ FHB : 12-12-12 (144 bpm)

VT : Ø 8 cm, effacement 75%,

amnion (-) clear, head palpable ↓

HII+, denominator unclear,

impalpable small part and umbilical

cord.

G1P0A0L0

A/S/L/IU active

phase 1st stage

of labor with

history of rupture

membrane + mild

anemia

• Observation mother &

fetal well being.

• Observation progress

of labor

• Cek DL, HBsAg




PE :

Spina ischiadica not

prominent

Os coccygeus mobile

Arcus pubis > 90o

Lab Examination :

Hb : 8,6 g/dl

RBC : 4,12 x 106/µL

HCT : 30,1 %

WBC : 12,59 x 103/µL

PLT : 288 x 103/µL

HbSAg: (-)

03.00 Mother wants to bearing

down

UC : 4x/10’ ~45’’

FHB : 12-11-11 (136 bpm)

VT : Ø complete, amnion (-),

head palpable ↓ HII+, caput

(+), impalpable small part

and umbilical cord.

2nd stage of

labor

• Suggest mother to eat

and drink.

• Suggest mother to

squatting down.

04.00 Mother feels tired to

bearing down

UC : 4x/10’ ~40’’

FHB : 12-12-12 (144 bpm)


head palpable ↓ HIII+, caput

(+), impalpable small part

and umbilical cord.

Prolonged 2nd

stage of labor

DM consult to SPV :

pro VE

SPV advice : acc VE




11.30 Patient confessed abdominal

pain

UC : 2x/10’ ~25’’

FHB : 12-12-12 (144 bpm)

VT : Ø 9 cm, effacement 90%,amnion (-), head palpable ↓

HII+, caput (+), impalpable

small part and umbilical cord.

G1P0A0L0 40-

41 weeks S/L/IU

with prolongedactive phase 1st

stage of labor

with history of

rupturemembrane +

mild anemia

• Observation mother &

fetal well being.• CTG reactive• DM co to GP, GP

advice : acceleration

with drip oxytocin.

12.30 Mother wants to bearing down UC : 4x/10’ ~30’’

FHB : 12-11-11 (136 bpm)


head palpable ↓ HII+, caput(+), impalpable small part and

umbilical cord.

2nd stage of labor • Drip oxytocin began 8

tpm• Suggest mother to eat

and drink.• Suggest mother to

squatting down.

13.00 Patient confessed abdominalpain

UC : 4x/10’ ~30’’ FHB : 12-11-12 (140 bpm)

Drip oxytocin 12 tpm

13.30 Patient confessed abdominal

pain

UC : 4x/10’ ~30’’

FHB : 12-12-12 (144 bpm)


14.00 Patient confessed abdominalpain

UC : 4x/10’ ~30’’ FHB : 12-11-11 (136 bpm)


14.30 Mother feels tired to bearing

down

UC : 4x/10’ ~30’’

FHB : 12-12-12 (144 bpm)


head palpable ↓ HIII+, caput(+), impalpable small part and

umbilical cord.

Prolonged 2nd

stage of labor

GP consult to SPV : pro

VE

SPV advice : acc VE




15.00 VE beganVE succeed in 2 times

traction.

Perineum episiotomy (+)Baby was born, male, 3500

gram, 50 cm, A-S 6-8, caput

(+) on occiput, anus (+),

anomaly congenital (-).

Placenta was bornspontaneous, complete.

Bleeding ± 150 cc

Rupture perineum grade II

17.00 Patient confessed deliverywound

GC : wellBP : 120/90 mmHg

PR: 80 bpm

RR : 20 bpmT : 36.7°CUFH : 2 fingers below the

umbilicus

Lochea rubra : (+)

2 hours post VE • Observe mother and babywell being.

• Suggest mother to take a

rest, eat, and drink.




03/07/

2012

07.00

Patient confessed delivery

wound

GC : well

BP : 110/70 mmHg

PR : 72 bpmRR : 20 bpm

T : 36.2°C

UFH : 2 fingers below

the umbilicus

Lochea rubra : (+)

Baby in NICU :

GC : well

PR : 120 bpm

RR : 52 bpm

T : 36,4oC

1st day post partum • Observe mother and

baby well being.

• Suggest mother totake a rest, eat, and

drink.

fase aktif memanjang drip & kala ii lama ve

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