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PATHOLOGY
LABOR
1
2
Case Report
Name: Mrs. N
RM
Age
: 542525
: 37 years old
Address : Narmada
Admitted : July, 15th 2014 (22.45)
Diagnose
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
15/07/
2014
22.45
wita
General Status :
GC : moderate GCS : E4V5M6
BP : 120/80 mmHg
PR : 84 bpm
RR : 22 bpm
T : 36,8oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur
(-), gallop (-).
Pulmo : vesiculer (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), stria
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).
G5P4A0L4 with
head presentation
41 wks S/L/IU
with neglected
active phase of
labor
LMP : 01/10/2013
EDD : 08/07/2014
History of ANC : never
History of USG : never
History of family planning : pil
Next family planning : IUD
Obstetrical History :
I. Aterm/female/2500g/normal/
14yo
II. Aterm/female/3000g/normal/
13yo
III. Aterm/female/3100g/normal/
10yo
IV. Aterm/female/3600g/normal/
4,5yo
V. This
Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 3/5
UFH : 33 cm
EFW : 3410 gram
UC : 3x10~35
FHB : 13-13-14 (160 bpm)
VT : 8 cm, eff. 75%, Amnion (-),
head palpable, caput (+), HII,
impalpable small part of fetus or
umbilical cord .
DM co to GP pro
resucitation and CS,
GP advice:
resucitation
GP co to SPV pro CS
and SPV advice :
If his no adequate,
Accelaration till 20
dpm
Observe. Progres of
labor
TIME
SUBJECTIVE
Chronologist at poskesdes:
20.25 wita (15/07/2014)
S/ Patient come to Poskesdes
with lower abdominal pain refer to
flank region and history of bloody
slim, mother wants to bearing
down.
O/
BP : 120 / 80 mmHg
HR: 84 bpm
RR: 21 tpm
T: 36,5
UFH: 31 cm
FHB : 11-12-11 (136 x/minute)
UC: (+) 4x10~40
VT : 9 cm, eff. 90%, amnion
(-), head palpable, HIII, denom
LOA, portio oedema (+),
impalpable small part / umbilical
cord.
A/ G5P4A0L4 40 wks S/L/IU with
head presentation, mother and
fetal well being with neglected
labor
P/
KIE family
Infus RL
Reffer to PHC narmada
OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile,
Arcus pubis > 900
Lab Examination :
HB : 9,6 g/dl
RBC : 3,46 x 106/L
HCT : 28,7 %
WBC : 16,16 x 103/L
PLT : 327 x 103/L
HbSAg : (-)
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
Chronologist at |Narmada PHC:
21.30 wita (15/07/2014)
S/ Patient came from poskesdes
dasan tereng with neglected labor,
patient confess abdominal pain
since 19.00 wita. FM (+), water
leaked out from her vagina since
20.25 at poskesdes
LMP : 01/10/2013
O/
BP : 120 / 80 mmHg
HR: 88 bpm
RR: 20 tpm
T: 37,9
UFH : 34 cm
FHB : 14-14-13 (168 x/minute)
UC: (+) 3x10~35
VT : 8 cm, eff. 75%, amnion
(-), head palpable, portio oedema
(+), head HII, denom. LOA,
impalpable small part / umbilical
cord.
A/ G5P4A0L4 41 wks S/L/IU with
head presentation, mother and
fetal well being with neglected
labor
P/
KIE family
Inj. Ampisilin 1 gr /IV
Paracetamol 500 mg
Reffer to GH NTB with O2 4 lpm
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
23.30 wita
UC : 3x10~30
FHB : 13-13-14 (160 bpm)
16/07/2014
00.00 wita
UC : 3x10~30
FHB : 12-13-12 (148 bpm)
00.30 wita
UC : 3x10~30
FHB : 13-13-12 (152 bpm)
01.00 wita
GC : well
GCS : E4V5M6
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,4oC
UC : 3x10~30
FHB : 14-14-15 (172 bpm)
VT : 8 cm, eff. 75%, Amnion (-),
head palpable, caput (+), HII,
oedema portio (+), molase
(+)impalpable small part of fetus or
umbilical cord
DM co to GP pro CS, co
to SPV , advice:
Prepare for CS
01.30 wita
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
02.30
wita
PLANNING
CS began
(02.36) Baby was
born, male, BW 3900
gr, BL 54 cm, AS 7-9 ,
anus (+), kongenital
anomaly (-)
Placenta delivered
completed, bleeding
150 cc.
04.30
wita
07.00
wita
2 hours Post CS
Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink
1 day post CS
Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink
TIME
17/07/
2014
07.00
wita
SUBJECTIVE
OBJECTIVE
General condition: Good
BP : 120/80 mmHg
HR : 88 bpm
RR : 20 tpm
T : 36,4oC
UFH : 3 finger bellow umbilikus
UC : + well
Active bleeding: (-)
Lochea rubra +
UO : 60 cc/ho
Baby in NICU
Pulse : 144 bpm
RR : 58x/m
T : 36,4 C
ASSESSMENT
PLANNING
2 day post CS
Observation Mother
and baby well being
Suggest mother to
mobilazation
Suggest mother to eat
and drink
CASE 2
Name : Mrs.H
Age
: 35 years old
Address : Sesela, Gn. Sari
Admitted : 15-07-2014
No. RM
: 54-25-12
G1P0A0L0 A/S/L/IU head presentation
latent phase with history of ROM
Time
15-072014
17.40
Subject
Patient come to NTB GH
referred from Gn. Sari PHC
with G1P0A0L0 A/S/L/IU
head presentation with
latent phase + history of
ROM.
Patient 9 months pregnancy
confessed abdominal pain
since 14-07-2014 (20.00),
bloody slim (+), water come
out from her vagina (+) 1507-2014 (08.00), and FM
(+).
History of DM (-), HT (-),
asthma (-).
LMP : forget
EDD : History ANC : 3x at
posyandu
Last ANC : 28-02-2014
result: BP : 120/80, BW 55
kg, 20 weeks
Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 22 x/m
T: 36,5 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 31 cm
EFW : 3100 gram
UC : 3 x 10 ~ 30
FHB : 11-10-11 (148x/min)
Assessment
G1P0A0L0
A/S/L/IU head
presentation
with latent
phase +
history of ROM
Planning
Obs. Mother and
fetal well being
Observation
progress of labor
Time
Subject
History of USG : History of family
planning : Next family planning :
IUD
History of obstetric :
I.
This
Object
VT : 3 cm, eff. 50 % amnion (-)
clear, head palpable, HI, denom
unclear, unpalpable small part of
fetus/ umbilikal cord
Pelvic examination:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubic > 90 degree
Lab:
HGB = 10.4 g/dl
RBC = 4.00 K/ul
WBC = 17.96 M/ul
HCT : 31.9 %
PLT = 288 M/ul
HBsAg = (-)
BT 250
CT 500
Assessment
Planning
Time
Subject
Chronologist : at Gn. Sari PHC (15-072014 08.15)
S : Patient 9 months pregnancy, confessed
lower abdominal pain and flank pain
since 14-07-2014 (20.00) . Bloody slim
(+) Water come out from her vagina (+)
since 15-07-2014 (08.00), FM (+).
O : GC : well
Cons : CM
BP : 120/70mmHg
HR : 82x/m
RR : 20x/m
T : 36,6
UFH : 31 cm
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
FHR : +
UC : 2x10-35
VT : 1 cm, eff 50%, amnion (-), head
palpable, HI+, unpalpable small part of
fetus/ umbilical cord
A : G1P0A0L0 40 weeks /S/L/IU head
presentation latent phase 1st stage
P : left lateral decubitus position, inj.
Ampicillin, observation mother and fetal
well being
Object
Assessment
Planning
Time
Subject
12.15
S : abdominal pain and flank pain
O : GC : well
Cons : CM
BP : 120/80mmHg
HR : 80x/m
RR : 20x/m
T : 36,5
VT : 2cm, eff 50%, amnion (-) , head palpable, H1,
unpalpable small part of fetus/ umbilcal cord
A : G1P0A0L0 40 weeks /S/L/IU head presentation
latent phase 1st stage with history of ROM
P : suggest mother to eat and drink,
15.00
inj.ampicillin (2nd)
16.15
S : abdominal pain more frequently
O : GC : well
Cons : CM
BP : 120/80mmHg
HR : 84x/m
RR : 22x/m
T : 37,
FHB: 136 ~ 11-11-12
VT : 2cm, eff 25%, amnion (-) clear, head palpable,
H1, unpalpable small part of fetus/ umbilcal cord
A : G1P0A0L0 40 weeks /S/L/IU head presentation
latent phase 1st stage with history of ROM
P : referred to NTB GH, IV line
Object
Assessment
Planning
Time
Subject
Object
Assessment
Planning
21.35
GC: well
BP: 120/70 mmHg
HR: 80 bpm
RR:20 bpm
T: 37 0C
HIS: 3x/10 ~ 30
DJJ: 12-12-13
VT : 4 cm, eff. 50 %,
Amnion (-) clear , head
palpable HI denominator
unclear, impalpable small
part of fetal & umbilical
cord.
Active phase
16-072014
01.45
GC: well
BP: 120/70 mmHg
HR: 80 bpm
RR:20 bpm
T: 37,1 0C
HIS: 4x/10 ~ 40
DJJ: 12-11-12
VT : 4 cm, eff. 50 %,
Amnion (-), head palpable
HI, denominator unclear,
impalpable small part of
fetal & umbilical cord.
Arrested active
phase
DM co to GP pro CS, GP
co to SPV, adv: CS
Preop: dower catheter,
inj.cefotaxim (skintest)
Time
04.15
Subject
Object
Assessment
Planning
CS began
Baby was born (04.24),
female, AS 7-9, 3350
gram, 51 cm, Anus (+),
congenital anomaly (-),
meconeal (-),
Placenta was born
complete, bleeding 400
cc
07.00
Abdominal wound
pain
GC: well
GCS:E4V5M6
BP: 120/70 mmHg
PR: 88x/m
RR: 20x/m
T: 36 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 200cc/2 hour
Lokea rubra (+)
2 hours post CS
Time
Subject
17-072014
07.00
Abdominal wound
pain
Object
GC: well
cons:E4V5M6
BP: 120/80 mmHg
PR: 88x/m
RR: 20x/m
T: 36,4 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 60cc/hour
Lokea rubra (+)
Baby in NICU
Pulse : 140 bpm
RR : 56x/m
T : 36,5 C
Assessment
1 day post CS
Planning
Observed mother and baby
well being
Suggest mother to
mobilisation.
THANKYOU