Escolar Documentos
Profissional Documentos
Cultura Documentos
20 DESEMBER 2009
Supervisor : dr. G.M Punarbawa, SpOG
Medical Student:
Helmiati
Halia
Cases resume :
1
2
3
1
Normal labor
Name/adress
Age
Time
11.30
Admitted
to
Hospital
: Mrs. A/ Presak-Praya
24 years old
Subject
Object
Therapy:
Infus RL fls I 20 tts
Obstetric status :
L1 : head
L2 : fetal back on the right side
L3 : breech
L4 : was in pelvic inlet 5/5
UFH :33 cm
Abdominal diameter: 96 cm
EFW : 3168 g
FHR : 148 bpm
UC : VT :CD 1 cm, efff 10%, AM (-), clear,
breech palpable, descend HI, denom
unclear, small part and umbilical cord
wasnt palpable.
Lab. Examination :
Hb : 11,1 gr%
Leko : 14.200 mm3
Trombo : 336.000 mm3
Hct : 32,8 gr%
HBsAg : -
Assesment
G1P0A0L0 39-40
w/S/L/IU breech
presentation with
PRoM < 12 hours.
20 desember 2009
11.30 wita
Planning
Time
Subject
Object
ZA score: 1
Paritas: primi = 0
History : tno = 0
EDD: 3168 = 1
Uk: 39-40 = 0
Station: HI = 0
CD: 1 cm = 0
Assesment
Planning
Time
Subject
Object
Assesment
Planning
12.00
PR : 88 bpm
UC : 1 x10- 20
FHR : 144 bpm
12.30
PR : 88 bpm
UC : 1 x10- 20
FHR : 144 bpm
13.00
PR : 88 bpm
UC : 1 x10- 20
FHR : 144 bpm
13.30
PR : 90 bpm
UC : 1 x10- 20
FHR : 146 bpm
T: 37,8 C
14.00
PR : 90 bpm
UC : 2 x10- 25
FHR : 146 bpm
14.30
PR : 98bpm
UC : 2 x10- 25
FHR : 146 bpm
15.00
PR : 98bpm
UC : 3 x10- 25
FHR : 144 bpm
15.30
BP :120/80 mmHg
RR : 24 tmp
PR : 98bpm
T: 37,5 C
UC : 3 x10- 40
FHR : 146 bpm
Time
Subject
Object
Assesment
Planning
16.00
PR : 98 bpm
UC : 3 x10- 40
FHR : 144 bpm
16.30
PR : 98 bpm
UC : 3 x10- 45
FHR : 144 bpm
17.00
PR : 98 bpm
UC : 3 x10- 45
FHR : 144 bpm
17.30
PR : 98 bpm
UC : 3 x10- 45
FHR : 146 bpm
T: 37,8 C
VT :CD 1 cm, efff 10%, AM (-),
clear, breech palpable, descend
HI, denom unclear, small part and
umbilical cord wasnt palpable.
18.00
PR : 98 bpm
UC : 3 x10- 45
FHR : 146 bpm
18.30
PR : 98bpm
UC : 3 x10- 45
FHR : 146 bpm
Prepared to SC
19.32
SC begun
Time
21.32
Subject
Object
-General condition: good
-BP : 120/80 mmHg
-PR : 80 x/mnt
-RR : 20 x/mnt
-T : 37 C
-UFH :2 finger under umbilicus
-UC : good
-Lokea (+)
-Wound of operation : good
Assesment
Planning
2 hours post SC
1 day post SC
Baby:
T:37 C
RR: 38 tpm
HR : 120 bpm
(21/12/0
9)
06.00