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Case Presentation
Michelle H 07120110086
Patient Identity
Name : N.A
Sex: Female
Age : 21
Obstetric status : G1P0A0 now 39 weeks
pregnant
Address : Kampung Pesar
Status : Married
Education : High school
Job: Waitress
Medical record no : RSUS.00-60-27-64
Date of admission : 19th August 2014 (at 11.00
PM)
History Taking
History Taking
Antenatal care : monthly visit to the midwife, she
was given tetanic injection and iron supplement.
Overall, she was in good nutritional state through
out her pregnancy.
Contraception : she was not on any contraception
Family history : her mother and father has
hypertension, she has no siblings, her husband
has diabetes.
Social and economic history : her husband is a taxi
driver, they make enough money to take care of
the family. Her husband is a smoker, she lives with
her husband and parents, and have no pets, no
history of recent overseas travel
Habit : She is a heavy smoker since she was in
junior high school, and smokes 1 pack a day
through out her pregnancy. She tried to quit, but
failed. She doesnt do drugs or alcohol.
Physical Exam
Compos mentis
Vital signs :
-BP : 110/90 mmHg
-Pulse : 82 / min
-RR : 20 /min
-Temp : 36.6 c
Anthropometric :
-Weight : 69 kgs
-Height : 151 cm
Head
Head : normocephaly and symmetrical
Skull : no nodules or masses and depressions when palpated
Face : smooth, uniform consistency and no presence of nodules or masses, no chloasma or rash.
Thorax
Lungs : The chest wall is intact with no tenderness
and masses. Theres a full and symmetric
expansion and the thumbs separate 2-3 cm during
deep inspiration when assessing for the respiratory
excursion. The client manifested quiet, rhythmic
and effortless respirations. Tactile fremitus is equal
between left and right. No ronchi or wheezing on
auscultation
Heart : There were no visible pulsations on the
aortic and pulmonic areas. There is no presence of
heaves or lifts. No gallop or murmur.
Breast : symmetrical, hyperpigmentation in areola,
normal nipple, no discharge, no lumps, no scar.
Extremities
The extremities are symmetrical in size and
length, with mild edema. The muscles are not
palpable with the absence of tremors. They are
normally firm and showed smooth, coordinated
movements. There were no presence of bone
deformities, tenderness and swelling. There
were no joints swelling, tenderness and joints
move smoothly. There are some varicosities on
both her legs.
Obstetric assessment
Inspection : uterus length is larger than broad, which
indicates longitudinal lie. Umbilicus is inverted. There
are stretch marks, linea nigra, and striae gravidarum,
but no scar indicating previous surgery.
Palpation : Fundal height is 33cm , single fetus ,
intrauterus, head presentation, fetal back is on the right
side, fetal descent 3/5, contractions every 3 minutes for
40 seconds, symmetrical, medium contraction power,
fundal dominant, relaxation, interval, and intensity of
contractions are adequate.
Estimated fetal weight : 3410 gr
Vaginal examination : portio thin and soft, effacement
50%, cervical dilatation 5cm, membrane ruptured,
cephalic presentation, fetal station -1. Amniotic fluid can
be observed in the posterior vaginal vault (pooling (+))
Timeline
19th August 2014
11.00 AM
4.30 PM
11.00 PM
04.00 AM
08.00 AM
Admittance
PE 2 :
Mild
PE 3 :
Nausea,
To hospital
Eff : 20%
Contractions
Eff : 50 %
Vomiting,
PE 1 : eff 10 % Dilatation
and cramps
Dilatation 5 cm
Lower abdominal
Cervical dilatation
3 cm
pain
10.30 PM 1 cm
04.30 AM
Membrane ruptured Induction of labor
Fluid leakage
Pooling (+)
Nitrazine test +
Partograph
Observation notes
CTG
CTG
CTG interpretation :
Fetal heart rate : baseline 150 x / min,
reactive, acceleration (+), deceleration
(-), active fetal movement,
contractions every 3 minutes with
moderate power.
Nitrazine test
Nitrazine test was done on 19th August
2014 at 11.00 PM and the result was
positive.
Lab test
Complete blood count,
MCV,MCH,MCHC, iron profile,
bleeding time, clotting time was
done, and the result was all within
normal limit.
Resume
Mrs. N.A 21 y.o G1P0A0 now 39 weeks pregnant
came to RSUS with the chief complaint of sudden
gush of clear fluid out of her vagina 30 minutes
before admittance to RSUS. Fluid leakage
increases with movement change. The fluid has
no blood, mucus, or foul odor. She also
complaints having mild cramping on her
abdomen 6.5 hours before. She experienced
nausea, vomiting, and pain on her lower
abdomen 12 hours before. She didnt have any
infections during her pregnancy, and her
antenatal care was completed. She is however a
heavy smoker (active and passive smoker) since
junior high school and smoked through out her
pregnancy with the amount of 1 pack a day.
Bishop score
Management
Give IV dextrose 5% + 5 iu oxytocin
24 ml/ hour (induction of labor)
Give IV cefotaxime 1 gr (prophylactic
antibiotic)
Check FHR, contraction, and vaginal
exam every 4 hours
Check vital signs every 30 mins
Prepare for delivery
PROM
Definitions
Premature Rupture of Membranes (PROM)
Rupture of Membranes prior to labor onset
Preterm Premature Rupture of Membranes (PPROM)
PROM that occurs prior to 37 weeks gestation
Complications
Premature Birth (PPROM)
Cord compression
Chorioamnionitis
Abruptio Placentae
Respiratory distress syndrome
Malpresentation
Risk Factors
History of PROM in prior pregnancy
Prior cervical biopsy or cone
Uterine distention
Multiple gestation pregnancy
Tobbaco abuse
Polyhydramnios
Cervical or vaginal infections
Intercourse (unproven)
Amniocentesis
MANAGEMENT ALGORITM
Prognosis
Ad vitam
: dubia at bonam
Ad sanactionam : dubia at bonam
Ad functionam : dubia at bonam
FIFE
Feeling : patient is worried and anxious
Insight : patient knows that her
membrane has ruptured and wants to
deliver the baby as soon as possible
Fear : she fears the baby is unwell
because of the premature rupture
Expectation : she expects the baby to
be delivered well through vaginal
delivery
Reference
Paket pelatihan pelayanan obstetri
dan neonatal emergensi
komprehensif (PONEK)
www.acog.org
www.apgo.org
Buku panduan praktis pelayanan
kesehatan maternal dan neonatal