Case Report

Name

: Mrs. AH

RM

: 044829

Age

: 26 years old

Address : Sesela, Gunung Sari

Admitted

: July 2nd 2012 at 11.50

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

02/07
/2012

Patient referred from Gunung

Sari PHC with G1P0A0L0 40
weeks
S/L/IU
head
presentation
with
latent
phase 1st stage of labor and
severe preeclampsia.
Patient confessed abdominal
pain that spread to frank
since 10.00 (01/07/2012).
History rupture of membrane
(-), bloody slim (+) since
07.00 (02/07/2012), FM (+).
No history of
nausea,
vomiting, headache, visual
disturbance and epigastric
pain.
No history of DM, HT,
asthma.

General Status :
GC : well
BP : 160/110 mmHg
PR : 96 bpm
RR : 20 bpm
T : 36,1OC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo
:
vesicular
(+/+),
wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).

G1P0A0L0 39-40
weeks S/L/IU with
latent phase 1st
stage of labor &
severe
preeclampsia

Observation
mother & fetal
well being.
Observation
progress of labor.
Continue
drip
MgSO4
40%
6
gram 28 tpm from
PHC.
Insert DC
DM co to SPV,
advice : continue
therapy of severe
preeclampsia and
observation.

11.50

LMP : 26/09/2011
EDD : 03/07/2012
History of ANC : > 4x at
Posyandu
Last ANC : 01/07/2012
History of USG : never
History of family planning :
(-)
Next
family
planning
:
Injection 3 months
Obstetrical History :
I.This

Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 31 cm
EFW : 3100 gram
UC : 2x/10~30
FHB : 12-12-12 (144 bpm)
VT : 2 cm, effacement 25%,
amnion (+), head palpable
HI+, denominator unclear,
impalpable small part and
umbilical cord.

TIME

SUBJECTIVE
Chronologist at Gunung Sari PHC
(02/07/2012)
06.30
S : Patient confessed abdominal pain
that spread to frank.
O : GC : well
BP : 120/80 mmHg
PR : 82 bpm
RR : 20 bpm
T : 36,6OC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 3/5
UFH : 30 cm
EFW : 2945 g
UC : (+)
FHB : (+) 136 x/min
VT : 2 cm, eff 25%, amnion (+),
head palpable, denominator unclear,
HI,
impalpable
small
part
/
umbilical cord.
A : 1st stage of labor
P:
Explain result of examination
Suggest mother to eat & drink
Observation 4 hours

OBJECTIVE
Pelvic Evaluation :
Spina
ischiadica
prominent
Os coccygeus mobile
Arcus pubis > 90o
Lab Examination :
HGB : 11,8 g/dl
HCT : 40,1 %
RBC : 5,46 M/uL
WBC : 11,30 K/uL
PLT : 488 K/uL
HbSAg : (-)
Protein urine : +2
GDS : 102 mg/dl
SC : 0,5 mg/dl
Ureum : 23 mg/dl
SGOT : 24 mg/dl
SGPT : 21 mg/dl

ASSESSMENT
not

PLANNING

TIME

SUBJECTIVE
10.30
S : Patient confessed abdominal
pain more frequently.
O : GC : well
BP : 170/110 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,6OC
UC : (+) 2x/10 ~ 35
FHB : (+) 136 bpm
VT : 2 cm, eff 25%, amnion (+),
head
palpable,
denominator
unclear, HI, impalpable small
part /umbilical cord.
Proteinuria : +2
A:
G1P0A0L0 40 weeks S/L/IU head
presentation, mother & fetal well,
latent phase 1st stage of labor
with severe preeclampsia.
P:
Explain result of examination
Observation progress of labor
Therapy :
Infus RL : bolus MgSO4 40% 4 g,
drip MgSO4 40% 6 g.
Nifedipine tab 10 mg
Refer to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

15.50

(-)

GC : well
BP : 160/110 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,7OC
UC : 2x/10 ~ 20
FHB : 12-11-11 (136 bpm)
VT : 2 cm, effacement
25%, amnion (+), clear, head
palpable
HI+,
denom
unclear, impalpable small
part and umbilical cord.
UO : 75 cc/hours

G1P0A0L0 39-40
weeks S/L/IU with
latent phase 1st stage
of labor & severe
preeclampsia

Observation mother &

fetal well being.
Observation progress
of labor.
Continue drip MgSO4
40% 6 gram 28 tpm.

19.50

(-)

GC : well
BP : 180/100 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36,5OC
UC : 2x/10 ~ 20
FHB : 12-12-12 (144 bpm)
VT : 3 cm, effacement
25%, amnion (+), clear, head
palpable
HI+,
denom
unclear, impalpable small
part and umbilical cord.
UO : 50 cc/hours

G1P0A0L0 39-40
weeks S/L/IU with
prolonged latent phase
1st stage of labor &
severe preeclampsia

receive
Patient
Nifedipin tab 10 mg at
18.30.
Observation mother &
fetal well being.
Continue drip MgSO4
40% 6 gram 28 tpm.
DM consult to GP,
advice : acceleration
with oxytocin drip if
CTG reactive.

Pelvic Score : 6
Cervix dilatation 3 cm : 2
Cervix length 2 cm : 1
Cervix consistency moderate
:1
Cervix position posterior : 1
Station -2 : 1

TIME

SUBJECTIVE

OBJECTIVE

02/07/1
2
21.30

Abdominal pain

UC : 3 x 10 ~ 30
FHB : 12-12-13 (148
bpm)

Flash I
Drip oxytocin began 8
tpm

22.00

Abdominal pain came and

relieved

UC : 4 x 10 ~ 40
FHB : 12-13-13 (152
bpm)

Drip oxytocin 12 tpm

Maintenance

22.30

Abdominal pain came and

relieved

UC : 4 x 10 ~ 40
FHB : 12-12-12 (144
bpm)

Drip oxytocin 12 tpm

23.00

Abdominal pain came and

relieved

UC : 4 x 10 ~ 40
FHB : 12-12-12 (144
bpm)

Drip oxytocin 12 tpm

23.30

Abdominal pain came and

relieved

UC : 4 x 10 ~ 40
FHB : 12-12-11 (140
bpm)

Drip oxytocin 12 tpm

03/07/1
2
00.00

Abdominal pain came

more frequently

00.30

Abdominal pain came and

relieved

GC : well
BP : 180/110 mmHg
PR : 92 bpm
RR : 24 bpm
T : 36,2OC
UC : 4 x 10 ~ 40
FHB : 12-12-13 (148
bpm)
VT : 6 cm, eff 75%,
amnion
(+),
head
palpable
HI+,
denominator
ROA,
impalpable small part
and umbilical cord.
UO : 50 cc/hours
UC : 4 x 10 ~ 45
FHB : 12-11-12 (140

ASSESSMENT

G1P0A0L0 39-40 weeks

S/L/IU with active phase
1st stage of labor &
severe preeclampsia

PLANNING

Drip oxytocin 12 tpm

Observation mother
and fetal well being.
Observation
progress of labor
with partograf.
Continue drip MgSO4
40% 6 gram 28 tpm.

Drip oxytocin 12 tpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

02.00

Abdominal pain came and

relieved

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

Drip oxytocin 12 tpm

02.30

Abdominal pain came and

relieved

UC : 4 x 10 ~ 45
FHB : 12-12-13 (148
bpm)

Drip oxytocin 12 tpm

03.00

Abdominal pain came and

relieved

UC : 4 x 10 ~ 40
FHB : 12-12-12 (144
bpm)

Drip oxytocin 12 tpm

03.30

Abdominal pain came and

relieved

UC : 4 x 10 ~ 40
FHB : 12-12-11 (140
bpm)

Drip oxytocin 12 tpm

04.00

Abdominal pain (+++)

Patient confessed water
came out from her womb.

GC : well
BP : 170/100 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,4OC
UC : 3 x 10 ~ 40
FHB : 12-12-13 (148
bpm)
VT : 8 cm, eff 75%,
amnion
(-),
head
palpable
HII,
denominator
ROA,
impalpable small part
and umbilical cord.
UO : 60 cc/hours

04.30

Abdominal pain came and

relieved

UC : 3 x 10 ~ 40
FHB : 12-11-11 (136
bpm)

Drip oxytocin 12 tpm

05.00

Abdominal pain came and

UC : 3 x 10 ~ 40

Drip oxytocin 12 tpm

Drip oxytocin 12 tpm

Observation mother &
fetal well being.
Continue drip MgSO4
40% 6 gram 28 tpm.
DM consult to GP,
advice
:
observe
progress of labor in 2
hours.

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

03/07
/2012
06.00

Abdominal pain (+++)

GC : well
BP : 170/100 PR : 80 bpm
RR : 20 bpm
T : 36,5OC
UC : 3 x 10 ~ 40
FHB : 12-12-13 (148 bpm)
VT : complete, amnion
(-), head palpable HII,
impalpable small part and
umbilical cord.
UO : 50 cc/hours

2nd stage of labor

with severe
preeclampsia

Drip oxytocin 12 tpm

Observation mother &
fetal well being.
Continue drip MgSO4
40% 6 gram 28 tpm.

08.00

Abdominal pain (+++)

GC : well
BP : 190/110
PR : 80
bpm
RR : 20 bpm
T :
36,5OC
UC : 3 x 10 ~ 40
FHB : 12-11-12 (140 bpm)
VT : complete, amnion
(-), head palpable HIII,
caput (+), impalpable small
part & umbilical cord.

Prolonged 2nd
stage of labor with
severe
preeclampsia

Drip oxytocin 12 tpm

Observation mother &
fetal well being.
Continue drip MgSO4
40% 6 gram 28 tpm.
GP consult to SPV : pro
VE SPV advice : Acc VE.

08.45

Abdominal pain came

frequently
Mother wants to bearing
down

09.05

GC : well
BP : 220/130 mmHg
PR : 112 bpm
RR : 24 bpm
UC : 3 x 10 ~ 40
FHB : 12-13-13 (152 bpm)

Drip oxytocin 12 tpm

Continue drip MgSO4
40% 6 gram 28 tpm.
VE began :
VE
succeed
in
1x
traction
Perineum episiotomy
Baby was born, male,
2800 gram, 50 cm, A-S
7-9
caput
(+)
on
occiput,
anus
(+),
anomaly congenital (-).
Placenta
was
born
spontan, complete.

TIME

SUBJECTIVE

03/07
/2012
11.10

Abdominal pain and

delivery wound pain

04/07
/2012
07.00

Delivery wound pain

OBJECTIVE

ASSESSMENT

PLANNING

GC : well
BP : 170/110 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5OC
UC : (+) well
UFH : 2 fingers below
umbilicus
Lochea rubra : (+)
UO : 80 cc/hours

2 hours post VE

Observed mother well being

Observed bleeding & VS
mother
Suggest
mother
to
mobilisation, eat and drink.
Continue drip MgSO4 40% 6
gram 28 tpm.

GC : well
BP : 150/100 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36,7OC
UC : (+) well
UFH : 2 fingers below
umbilicus
Lochea rubra : (+)

One day post VE

Observed mother well being

Suggest mother to
mobilisation, eat, and drink,
medication.
Breast feeding

Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC