Case 1

Name
Age
RM
Address
Admitted

: Mrs. AW
: 18 years old
: 577558
: Selaparang
: 18th June 2016

Time
18
June
2016
14.00

Subject
Patient came to NTB GH with
G1P0A0H0 38-39 weeks S/L/IU and
PROM < 12 hours. Patient confessed
water leaked from her womb (+) since
07.30 WITA (18-06-2016), abdominal
pain (+), bloody slime (-), FM (+).
History of DM (-), HT (-), asthma (-).
Family history: DM(-),HT (-),astha (-).
Alergic (-)
LMP : forgot
EDD : GW : History ANC : 9x at PHC and NTB
GH
Last ANC: 18-06-2016,
Result GW 38-39 weeks, BP : 110/80
mmHg, BW: 55 kg, head presentation,
UFH: 30 cm, FHB 12-12-13
History of USG : 3x at obsgyn
Last (2/5/16): S/L/IU BPD 32-33w AC
34-35w FL 30-31w placenta at fundus
post, amnion enough
History of family planning: Next family planning: implan

Object
General status
GC : well
Consciousness: CM
BP : 110/70 mmHg
PR: 86 tpm
RR: 20 tpm
T: 36,5C
Local status
Eye : anemis -/-, icteric -/Cor : S1S2 single reguler, murmur
(-), gallop (-).
Pulmo : vesikuler (+/+), wheezing
(-/-),ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on left side
L3 : head
L4 : 4/5
UFH : 34cm
EFW: 3565 gr
FHB: 12-13-13 (152x/mnt)
UC : Inspeculo: fluid at fornix post,
clear
VT : 1 cm, eff 10%, amnion (-)
clear, head presentation,
denominator unclear, HI, small
part or umbilical cord unpalpable.

Assessment
G1P0A0H0 38-39
weeks S/L/IU head
presentation with
PROM < 12 hours

Planning
DM PLANING
Diagnostic:
CTG
Lakmus test
Monitoring:
Obs. Temperature for 4
hours.
Obs Sign of Inpartu
Obs. Mother and fetal
well being
Therapy:
Inj. Ampicillin 2gr IV
Ampicillin tab 3x500gr.
IVFD: RL
Termination with Drip
oxytocin start from 8 tpm
after 12 hours (start from
19.30)
CIE planning
- CIE mother and family
about diagnostic planning
and therapeutic planning
Suggest mother to move
freely to the left side, eat
and drink
DM co to GP: Inj.
Ampicilin 2 gr IV,
oxytocin drip
GP co to SPV advice:
1. Pro termination with
oxytocin drip
2. Inj. Ampicilin 2 gr IV

Time

Subject
Obstetric History:
1.This

Object
Pelvic examination
Promontorium unpalpable
Spina ischiadica not prominent
Sacrum convex
Os coccygeus mobile
Arcus pubis > 90
Pelvic Score :
Pelvic dilatation : 1 cm : 1
Cervic length : 2 cm : 2
Cervix consistence : soft : 2
Cervix posisition: post : 0
Station : -2 : 1
Total : 6
Lab (03/05/2016):
HB: 11,8
RBC: 4,59
HCT: 36,4
WBC: 7,95
PLT: 370
HBsAg (-)

Assessment

Planning

TIME

30SUBJECTIVE

18.00

Water leaked out from her

womb (+) Abdominal pain (+)

OBJECTIVE
BP : 100/80 mmHg
PR: 82 bpm
RR: 20 bpm
T: 36,8C

ASSESSMENT
G1P0A0H0 38-39 weeks
S/L/IU head presentation
with PROM < 12 hours

DM Planning:
Obs. Temperature for 4
hours.
Obs Sign of Inpartu
Obs. Mother and fetal
well being

G1P0A0H0 38-39 weeks

S/L/IU head presentation
with PROM > 12 hours

DM Planning:
Termination with
Oxytocin drip Flash I
started at 8 dpm

UC : FHB : 13-14-13 (160x/mnt)

20.00

Water leaked out from her

womb (+) Abdominal pain (+)

BP : 100/80 mmHg
PR: 87 bpm
RR: 19 bpm
T: 36,7C

PLANNING

UC : 1x10~10
FHB : 13-12-13 (152x/mnt)
VT : 1 cm, eff 10%, amnion (-)
clear, head presentation,
denominator unclear, HI, small
part or umbilical cord unpalpable.

DM co to GP to SPV,
advice:
-Oxytocin drip Flash I
started at 8 dpm
-CTG

20.30

Water leaked out from her

womb (+) Abdominal pain (+)

FHB: 12-12-12
UC: 1x10~10

Oxytocin drip 12 dpm

21.00

Water leaked out from her

womb (+) Abdominal pain (+)

FHB: 12-12-12
UC: 1x10~20

Oxytocin drip 16 dpm

TIME

30SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

21.30

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 13-12-13

Oxytocin drip 20 dpm

22.00

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 12-12-13

Oxytocin drip 24 dpm

22.30

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 12-12-13

Oxytocin drip 28 dpm

23.00

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 12-12-12

Oxytocin drip 32 dpm

23.30

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 12-12-11

Oxytocin drip 36 dpm

00.00

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 12-12-12

Oxytocin drip 40 dpm

02.30

Water leaked out from her

womb (+) Abdominal pain (+)

UC : 1x10~10
FHB : 12-12-11

Flash II
Oxytocin drip 40 dpm
Sugest mother to eat
and drink
Sugest mother to lay
down to the left side

TIME

SUBJECTIVE

06.00

Water leaked out from her

womb (+) Abdominal pain (+)

OBJECTIVE
BP : 100/80 mmHg
PR: 82 bpm
RR: 20 bpm
T: 36,8C
UC : 2x10~15
FHB : 12-12-11 (140x/mnt)
VT : 1 cm, eff 10%,
amnion (-) clear, head
presentation, denominator
unclear, HI, small part or
umbilical cord unpalpable.

08.30

Water leaked out from her

womb (+) Abdominal pain (+)

ASSESTMENT
G1P0A0H0 38-39
weeks S/L/IU head
presentation with
PROM > 12 hours and
failure of oxytocin drip
induction

PLANNING
DM Planning:
Pro termination with C-section
CTG
DM co to GP co to SPV, advice:
Pro termination with C-section

Patient moved to operation room

FHB: 12-12-13
UC: 2x10~15

The baby was born at 09.05 female

with BW 3500 gram, BL cm, HC
cm, Apgar Score 7-9, anus (+), there
is no congenital anomaly

09.05

Plasenta was born complete at

09.08, bleeding 350 cc
11.00

Pain from operation wound

(+), flatus (-), other confession
(-)

GC: well
GCS: CM
BP: 100/80 mmHg
PR: 90 bpm
RR: 20 x/min
T: 36,20C
TFU: 1 finger bellow
umbilicus
UO: 250 cc

2 hours post partum

Observe mother well being

Observe UFH, bleeding, and urine
output

TIME
06.00

SUBJECTIVE
Pain from operation wound
(+), flatus (-), other confession
(-), defecation (-)

OBJECTIVE
GC: well
GCS: CM
BP: 100/80 mmHg
PR: 90 bpm
RR: 20 x/min
T: 36,20C
TFU: 1 finger bellow
umbilicus
UO: 1000 cc

ASSESTMENT
1 day post partum

PLANNING
Observe mother well being
Observe UFH, bleeding, and urine
output
Suggest mother to mobillisation