Supervisor: dr.

Agus Thoriq, SpOG

DM: Akbar

Case Resume :
No.
1.

Case
Pathology Delivery
G4P2A1L2 41 weeks head presentation
with hypertension gestasional + IUGR
Normal Delivery

Total
2

CASE 1
IDENTITY
Name
Age
Address
No. RM

: Mrs. S
: 26 yo
: Monjok
: 538430

Hozpitalised on 12.15 WITA, 11th May 2014

G4P2A1L2 41 weeks head

presentation with Hypertension
gestasional + IUGR

TIME

SUBJECTIVE

11/05/
14

Patient came to NTB GH with

G4P2A1L2 41 weeks S/L/IU
head
presentation with
hypertension gestational +
IUGR.
Patient
confessed
abdominal pain since 06.00
WITA at 11/05/14, water came
out from her vagina (-), bloody
slim (-), fetal movement (+),.

12.15
WITA

OBJECTIVE

No history of DM, history of,

asthma (+), history of HT (+).
History of food allergic (+).
LMP : 27-07-2013
EDD : 04-05-2014
History of ANC : 3 x in
Posyandu
Last ANC: 20/03/2014, result:
BP: 130/80 mmHg, FHB (+),
head presentation,
History of USG: 1 x
Male, S/L/, 26-27
plasenta in corpus,

weeks,

General status:
GC: well
GCS: E4V5M6
BP: 150/100 mmHg
PR: 84 bpm
RR: 22 rpm
T: 370 C
Eye : anemis (-), icteric (-)
Thorax :
Cor : S1S2 single reguler,
murmur (-), gallop (-)
Pulmo : vesikuler (+/+),
wheezing (-/-), Ronkhi (-/-).
Abdomen : scar (-), striae
livida (+), linea nigra (+),
Extremity : edema (-/-), warm
acral (-/-)
Nutrition status :
Body Height : 134 cm
Body weight : 48 kg
Obstetrical status:
L1: breech
L2: back on the right side
L3: head
L4: 4/5
UFH: 25 cm
EFW: 2170
UC: 2x10~20
FHB: 12-12-12 (144x/min)

ASSESTMENT
G4P2A1L2 41
weeks head
presentation
with
Hypertension
gestasional +
IUGR

PLANNING
Obs mother & fetal
well being
Obs. Progress of
labor

TIME

SUBJECTIVE

OBJECTIVE

History of Family Planning:

injection
Next Family Planning: History of obstetry:
1.Aterm, spontan, traditional
attendan, 3300 gram female,
14 yo
2.Aterm , spontan, 3300
gram, female 9 yo
3.Abortus

VT : 2 cm , eff 25%, amnion

(+), head presentation, denom
unclear, HI, unpalpable small
part of fetal

Chronologist: (-)

Lab Result
Hb : 11,7 x 106/ L
WBC : 13,23 x 103/ L
PLT : 376x 103/ L
HCT : 34,1 %
HBsAg : (-) non reactive
Proteinuria : (-)

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

12.45
WITA

Abdominal pain +

UC: 2x10~20
FHB : 12-12-12 (144)

13.15
WITA

Abdominal pain +

UC: 3x10~35
FHB:13-12-13 (160)

ASSESTMENT

PLANNING
Obs mother & fetal
well being
Obs. Progress of
labor

G4P2A1L2 41
weeks head
presentation
inpartu with
Hypertension
gestasional +
IUGR

Dm pro ctg, GP
advice CTG, consult
result of ctg to GP,
GP advice
recutitation
intrauterine

TIME

SUBJECTIVE

OBJECTIVE

12.45
WITA

Abdominal pain +

UC: 2x10~20
FHB : 12-12-12 (144)

13.15
WITA

Abdominal pain +

UC: 3x10~35
FHB:13-12-13 (160)

ASSESTMENT

PLANNING
Obs mother & fetal
well being
Obs. Progress of
labor

G4P2A1L2 41
weeks head
presentation
inpartu with
Hypertension
gestasional +
IUGR

Dm pro ctg, GP
advice CTG, consult
result of ctg to GP,
GP advice
recutitation
intrauterine

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

14.45
WITA

Abdominal pain ++

UC: 3x10~45
FHB : 12-12-12 ( 144)

G4P2A1L2 41
weeks head
presentation
active phase
first stage of
labor with
Hypertension
gestasional +
IUGR

15.15
WITA

Mothers want to bearing down

UC: 3x10~45
FHB : 12-12-12 ( 144)
VT : complete ,
amnion (-), head
presentation, denom
unclear, HIII, unpalpable
small part of fetal

G4P2A1L2 41
weeks head
presentation
second stage
of labor with
Hypertension
gestasional +
IUGR

15.25
WITA

PLANNING

Conduct of labor

Baby
was
born
spontaneusly, male,
AS: 6-8, BW/BL =
2000 gr/46 cm, anus
+,
anomaly
kongenital -

TIME
15.30
wita

17.30

SUBJECTIVE
Patient confessed abdominal
pain

OBJECTIVE

ASSESTMENT

PLANNING

UC (+)

3rd stage of
labor

Management active
of 3rd stage
Placenta was born
spontan, complete,
weight
400
gr,
bleeding 150 cc

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C

2 hours post
partum

Obs. Mother well

being
Suggest mother to
eat and drink

UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)

Baby in NICU

TIME
07.00
(12/05
/14)

SUBJECTIVE

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 120/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)
Lochea rubra (+)
Baby in NICU
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2C

ASSESTMENT
1 day post
partum

PLANNING
Obs. Mother well
being
Suggest mother to
eat and drink

Baby

3
3
3
3
3
2
17

3
3
4
3
3
3

19

Conclusion:
Baby aterm (38-40)
Baby IUGR because < 10 Percentil
Risk Factor:
mother body height ( 134 cm)
hypertension

CASE 2
IDENTITY
Name
Age
Address
No. RM

: Mrs. M
: 26 yo
: Batu layar
:

Hozpitalised on 17.30 WITA, 11th May 2014

G2P1A0L1 40-41 weeks head

presentation with protracted active
phase 1st stage of labor

Time

Subjective

11/05/2
014

Patient referred from

Meninting PHC with
G2P1A0L1
40-41
weeks S/L/IU head
presentation
with
protracted active phase
1st stage of labor.
Patient
confessed
abdominal pain since
07.00
WITA
(11/05/2014),
water
came out from her
vagina since 07.00
WITA, bloody slim (+),
fetal movement (+)
No history of DM, HT,
asthma.
No history of allergic
reaction to medicine or
food.

17.30
WITA

LMP : 01/08/2013
EDD: 07/05/2014

Objective
Examination:
General condition : Well
GCS : E4V5M6
BP : 110/90 mmHg
PR : 90 x/m
RR : 21 x/m
Temp : 36,8 C
General Status
Eyes : an-/-, ict -/Cor : s1s2 single, m -, g
Pulmo : Ves +/+, rh -/-,
whz -/Abdomen : scar (-), striae
gravidaum (+), linea nigra
(+)
Ext : oedem-/-, warm +/+
Status Obstetric
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5

Assesment

Planning

G2P1A0L1 4041 weeks S/L/IU

head
presentation
with protracted
active phase 1st
stage of labor +
leukositosis

Observation mother well

being
CIE mother and family
IVFD RL 20 tpm
DM co to GP pro obs.
Sign of labor,inj ceftriaxon
1 gr/iv and ctg, GP advice
obs. Sign of labor , inj
ceftriaxon 1gr /iv and ctg

Time

Subjective

Objective

History of ANC : 5 x at
PHC
Last ANC: 10/05/2014,
result:
BP:
110/80
mmHg, UFH : 31cm,
head presentation,4041 weeks, FHB (+)

UFH : 30 cm
EFW : 2945 gram
FHR: 13-13-13 (154)
UC : 3x10~30
VT : 4 cm, eff 50%,
amnion (-),clear, head
palpable HII, denom
unclear, unpalpable small
part of fetus

History of USG : History

of
Family
Planning: Next Family Planning:
injection
History of obstetry:
1.Male,
spontan,
midwife, aterm, 3000
gram, 5 yo
2.This

Lab Result
Hb : 10,7 x 106/ L
WBC : 22,65 x 103/ L
PLT : 252 x 103/ L
HCT : 33,5 %
HBsAg : (-) non reactive

Assesment

Planning

Time

Subjective

11/05/2
014
(07.30)

Chronologist at Meninting PHC

S: Patient pregnant 9 month come
to Meninting PHC confessed
abdominal pain and water leak from
her vagina since
07.00 wita
(11/05/2014)
O:
GC : Well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 x/m
Temp : 36,5 C
UFH : 31 cm
FHB: 12-12-11( 136)
UC : 2x10~25
VT: 2 cm, eff. 25 %, amnion (+)
clear,
head
palpable
HI,
denominator unclear, unpalpable
small part of fetal & umbilical cord.

Objective

Assesment

Planning

Time

Subjective
A: G2P1A0L1 40-411 weeks S/L/IU
head presentation with inpartu latent
phase 1st stage of labor + history of
ROM
P:
Obs. Mother and fetal well being
Obs. Progress of labor

11.30
Wita
(11-052014)

S: abdominal pain more frequently

O:
GC : well
BP:100/80
PR : 88 bpm
RR : 20 x/m
Temp : 36,5C
His : 3x10~30
FHB: 12-12-12 (144)
VT : 5 cm, eff. 50 %, amnion (+)
clear, head palpable HII, denominator
unclear, unpalpable small part of fetal
& umbilical cord

Objective

Assesment

Planning

Time

Subjective
A: inpartu active phase first
stage of labor
P: continue observation

15.30

S: O:
GC : well
BP:100/80
PR : 88 bpm
RR : 20 x/m
Temp : 36,5C
His : 3x10~35
FHB: 12-12-12 (144)
VT : 6 cm, eff. 50 %,
amnion (+) clear, head
palpable HII, denominator
unclear, unpalpable small
part of fetal & umbilical cord
A: inpartu protracted first
stage labor
P: inj ampicilin, infus RL,
prepare for referred to NTB
GH

Objective

Assesment

Planning

Time
16.30

Subjective
S:O: GC : well
BP:100/80
PR : 88 bpm
RR : 20 x/m
Temp : 36,5C
His : 4x10~35
FHB: 12-12-12 (144)
A: Inpartu protracted 1st
stage of labor
P: change infus RL with
D5

Objective

Assesment

Planning

Time
18.00
WITA

Subjective
Abdominal pain +

Objective
UC : 3x10 ~35
FHB : 12-12-12 (144)

Assesment

Planning

G2P1A0L1 4041 weeks S/L/IU

head
presentation
with protracted
active phase 1st
stage of labor +
leukositosis

Obs. Sign of labor

Consult result of ctg,GP
advice continue observation

Time

Subjective

Objective

Assesment

Planning

G2P1A0L1 4041 weeks S/L/IU

head
presentation
with protracted
active phase 1st
stage of labor +
leukositosis

Obs. Sign of labor

Consul result of ctg,GP
advice continue observation

18.00
WITA

Abdominal pain +

UC : 3x10 ~35
FHB : 12-12-12 (144)

18.30
WITA

Abdominal pain +

UC : 3x10 ~35
FHB : 12-12-12 (144)

Obs. Sign of labor

19.00
WITA

Abdominal pain +

UC : 3x10 ~35
FHB : 12-12-12 (144)

Obs. Sign of labor

19.30
WITA

Abdominal pain ++

UC : 3x10 ~40
FHB : 12-12-12 (144)

Obs. Sign of labor

Time
19.40
WITA

19.45
WITA

Subjective
Mothers want to
bearing down

Objective

Assesment

Inspection:
Bulging of perineum,
opening
vulva,
anus presure

G2P1A0L1 40-41
weeks S/L/IU
head
presentation with
protracted active
phase 2nd stage
of labor

Planning
Conduct labor

Baby was born , male, AS: 57, BW/BL = 3550gr/50 cm,

anus +, anomaly kongenital -

Time

Subjective

Objective

Assesment

Planning

19.45

3rd stage of labor

Management active of 3rd

stage

20.00

3rd stage of labor

Placenta was not born

Injection 2nd oxytocin
Cateter

20.30

Placenta was born manual,

uncomplete,
300 gram.
Bleeding 500cc,
Pro usg in monday

Time
22.30
WITA

Subjective

Objective
GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)

Assesment
2 hours post
partum with rest
plasenta

Planning
Obs. Mother well being
Suggest mother to eat and
drink
Pro USG
Baby in NICU

Time
07.00
WITA
(12-052014)

Subjective

Objective
GC: well
GCS: E4V5M6
BP: 120/80 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,80 C
UC (+) well
UFH 2 finger bellow
umbilical
Active bleeding (-)
Lochea rubra (+)
Baby in NICU
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2C

Assesment
One day post
partum

Planning
Obs. Mother well being
Suggest mother to eat and
drink
Pro kuretae if USG (+)

Baby