3. Mrs.

Asih Fitriani/ 23 th/ Living child: 0

MRS 18-9-2014/ at 13.30
G2P1A0 H 40-41 WoP + inlabor stage I active phase+ history of PROM + post date + SLFIU
+ breech presentation + EFW 3400 gr

S) Chief Complaint : contraction
Referal : midwives
RPS: Patient reffered by midwive with G2P1A0 H 40 weeks + SLFIU + breech presentation.
Patient complained contraction since 08.00 oclock, and more frequently. Watery discharge at the
same time. Bloddy discharge (-). Patient then went to a midwive on 13.00 was told that the
opening was 8.

ANC : routinely went to midwive to check the pregnancy, the last time was on 12/09/2014, and was
told that the pregnancyy was in a good state, but the baby was in breech presentation. The USG
was performed with obstetrician.

RPD : HT (-) DM (-) Asthma (-).
Menstruation: M: 13 years FDLM : 05-12-2013
D: 7 days DD : 20-09-2014
C: 28 days GA : 40-41 WoP
Marriage : 1x, 4 years
Contraception : injection/3 mo for the last year
OBSTETRY : 1. 2010/female/hospital/obstertician/aterm/spontaneous labor/2800gram/live
2. 2014/this pregnancy
O) STATUS PRESENT
General condition : good
Consciousness : compos mentis
Vital Signs : BP: 120/80 mmHg; PR: 84x/m; RR: 18x/m; T: 36.5C
Head/Neck : anemic conjunc. (-/-), Icteric sclerae (-/-)
JVP enchancement (-/-) lymphatic node enlargement (-/-)
Thorax : Symmetric vesicular (+) Ronkhi/wheezing (-/-)
S1>S2 regular single, murmur (-)
Extremity : Warm peripherals: hand (+/+) foot (+/+)
Edema: hand (-/-) foot (-/-), Parese hand (-/-) foot (-/-)

STATUS OF obstetry
Inspection : distended abdomen, asymmetric
Palpation :
- L1: FU: 3 finger below prx - Fundal height :33cm
- L2: right back - EFW :3410g
- L3: head presentation - FHR :144x/m
- L4: in the pelvic inlet - His : 2-3x/10/20







2
Vt: 5cm/eff 50% / amnion (-)/ breech / H-II

Pelvimetric : large

A) G2P1A0 H 40-41 WoP + inlabor stage I active phase+ history of PROM + post date +
SLFIU + breech presentation + EFW 3400 gr

P) Complete blood check , NST
IV Line RL 20dpm
Inj. Ceftriaxon 2x1gr
Obs. CPHB
Evaluation for 2 hours pro spt bracht
15.15 consult to dr.M. Robyanoor, Sp.OG
Advice: agree with therapy, evaluation on 16.00, report if there is no
progress of labor

15.50 Advice Sp. V: if there is no progress of labor , prepare for SC

16.30 S) contraction (+),
O) BP 130/90, PR 96, RR 22, T 37
FHR 12-12-12
His 4-5x/10/30-40
VT complete / amnion (-)/ breech/ H-III
A) G2P1A0 H 40-41 WoP + inlabor stage II + history of PROM + post
date + SLFIU + breech presentation + EFW 3400 gr
P) observation for patient want to strain
pro spt bracht

consult to dr.M. Robyanoor, Sp.OG
Advice: agree with therapy, pro spt bracht
watched for FHR till the baby born
16.50 S) contraction (+), watery discharge (+)
O) BP 130/90, PR 92, RR 24, T 37
FHR 12-12-13
His 4-5x/10/40-50
A) G2P1A0 H 40-41 WoP + inlabor stage II + history of PROM + post date + SLFIU + breech
presentation + EFW 3400 gr
P) the patient guide to strain
inj. Oxytocin 5 IU IM

17.02 baby born female , W :3000gr, L: 50 cm, AS: 7-8-9
Anus (+), congenital deformity (-)

17.10 The placenta delivered spontaneously with management In active labor
stage III. Calcification (-), infark (-),
Delivery report + episiotomy
1. Complete dilatation of cervix, head in front of vulva. Episiotomy was
performed at mediolateral regio of perineum. Patient was lead for
delivery process.
2. Consecutively delivered breech, umbilicus spontaneously. Shoulder was
delivered with Lovset manuver, the trunk then rotated half circle left and
right, down with cunam traction to delivered the hand. The head was
delivered with Maurice manuver, consecutively delivered chin, mouth,
eyes, forehead and vertex.
3. 17.02, baby born female with manual aid , W: 3000 gr, L: 50 cm AS : 7-
8-9 anus (+) congenital deformity (-)
4. Clamped and cut the umbilical cord. Injected oxytocin IM 10 IU at lateral
regio of femur
5. Bleeding observation: 100 ml
6. The placenta delivered spontaneously with insertion
7. Episiotomy wound was suture
Routine Blood 18-09-2014
Examination
Result
Unit
Hb
12.4
g/dl
WBC
16.4
ribu/ul
RBC
3.96
juta/ul
HTC
36.9
vol%
Platelet
173
ribu/ul
MCV
93.3
fl
MCH
31.3
pg
MCHC
33.6
%
Random Blood Sugar
108
mg/dl
SGOT/SGPT
25/21
U/I
LDH
495
U/I
Ureum/Creatinin
10/0.5
mg/dl
PT/APTT
11.4/27.3
Albumin
3.8
U/I
Follow up post partum
S) pain (<), bleeding(-)
O) BP: 120/60 mmHg, P: 86x, RR:22x, T:36,4
Fundal height: ~ 2fuumbilical, uterine contraction: (+)
fluxus: (-)

A) P2A0 PP manual aid (breech presentation)
P) PO. mefenamic acid 3x500mg
Cefadroxyl 3x500mg
SF 3x1