CASE REPORT

NO
Identity
 Name : Mrs. N
 Age : 31 years old
 No. RM : 00 54 60 77
 Date : December 26th, 2018

Husband Identity
 Name : Mr. R
 Age : 34 years old
 Occupation: Civil employee

 Addres : Padang
Anamnesis :

A 31 years old patient admitted to the

Emergency Delivery Room of Dr. M. Djamil
Central General Hospital Padang on December
27th, 2018 at 06.00 AM, reffered from private
hospital in Padang with G4P2A1L2 latent
phase of first stage term parturient + twice
previous CS
Present Illness History
 Feeling pain from waist to the groin since 4 hours ago

 Bloody show from the vagina since 4 hours ago

 Fluid leakage from the vagina was absent

 Massive bleeding from the vagina was absent

 Amenorrhea since 9 months ago

 LMP: forgotten EDD: can’t be calculated

 Fetal movement was identified since 5 months ago.

 No complain of nausea, vomiting and vaginal bleeding

neither during early pregnancy nor late pregnancy.
 Prenatal care to Obsteritian 6x (3,5,6,7,8,9 month ).

 Menstruation history : Menarche at 13 years old,

irregullar cycle, last for 5 to 7 days each cycle with the
amount of 2-3 times pad change/day without menstrual
pain
Previous Illness History :
 There wasn’t previous history of heart, lung, liver,
kidney, DM, hypertension and allergy

Family Illness History :

 There wasn’t history of hereditary disease, contagious
and physicological illness in the family
Marriage history : once at 2011
History of pregnancy/abortion/delivery: 4/1/2
1. 2012/ female/2900/SC o.i contracted pelvic/
Obstetrician /alive
2. 2014/ abortus incomplete / curretage
3. 2015/female/3100gram/SC o.i previous CS +
contracted pelvis/Obstetrician/alive
4. Present

History of family planning : (-)

History of immunization : (-)
 Graduate : bachelor
 Occupation : civil employee
Physical Examination

 GA : Moderate
 consiousness : CMC
 BP : 120/80 mmHg
 HR : 96 x/min
 RR : 21 x/min
 Temperatur : 37,1° C
 Body height : 142 cm LILA : 25 cm
 Body weight : 50 kg
 BMI : 24,79 kg/m2 (normoweight)
 Eyes : conjunctiva wasn’t anemic,
sclera wasn’t icteric
 Neck : JVP 5-2 cmH2O, tyroid gland
no enlargement
 Chest : H/L normal
 Abdoment : obstetric record
 Genitalia : obstetric record
 Extremity : oedem -/-, RF +/+, RP -/-
Obstetric record
Abdoment
 Inspection : Abdomen seem enlarge according to term pregnancy,
striae gravidarum (+), hyperpigmentation of midline (+), sicatrix
(+) Pfannensteil
 Palpation

L1: Uterine fundal height was 3 fingers below xyphoideus

processus. A large, soft, nodular mass was palpable
L2: Greatest resistance was palpable on the left side.
Numerous small, irregular structure were felt on the right
side
L3 : A hard, round, mass was palpable, not fixated
L4 : Not performed
His: 3-4x/35”/moderate
Auscultation : FHR : 130-140x/mnt
Genitalia
 Inspection : V/U normal, vaginal bleeding (-)

VT :  2-3cm, portio medial, thin, soft

Amnionic sac (+)
Head presentation, palpable at Hodge I
Denominoator can not be determined

UFH: 33 cm; EBW: 3.100 gr;

Inlet pelvic size
Promontorium was palpable, diagonal conjugate
10cm
Inominate line was palpable >1/3 part on both side
Pelvic sidewalls was straight
Ischial spines was slightly protrude
Sacral bone was curved
Sacrococcygeal bone was mobile
Pubic arch < 90˚

Outlet pelvic size:

Intertuberous distance could not accommodate an
adult fist (<10.5cm)

Inlet & outlet : Contracted pelvic

CTG
 Base Line : 140
 Variability : 5-15
 Aceleration: (+)
 Deseleration: (-)
 Contraction: (+)
 Fetal movement: (+)

Impresion : 1st Category

 ULTRASOUND

• Fetal alive singleton intrauterine, head presentation

• Fetus movement was good
• Biometric :
BPD : 90,9 mm
AC : 330,6 mm
FL : 69,1 mm
• EFW : 3.005 gr
• SDP : 6,28
• Placental implanted at anterior corpus gr II
Impression :
36-37 weeks of pregnancy
Fetal alive
Laboratorium
 Hb : 10,0 gr/dl (12-14)
 Leukocyte : 8.660 /mm3 (5-10)
 Hematocryte : 32 % (37-43)
 Trombocyte : 330.000/mm3 (150-400)
 PT : 10,5 (10,0-13,6)
 APTT : 37,0 ( 29,2-39,40)
 HbsAg : Non reactive
 Anti HIV : Non reactive
Diagnose :
G4P2A1L2 latent phase of first stage term parturient +
twice previous CS
Fetal alive singleton intrauterine, head presentation H I

Management :
• Control GA, VS, His, FHR
• Informed consent
• Profilaksis antibiotic : Ceftriaxone Inj 2 gr
• Consult Perinatology & Anastesiologist

Plan :
CS emergency
27/12/2018 ( 7.30 PM )
LSCS was performed
A male baby was born
FW : 3000 gr
FL : 48 cm
A/S : 8/9
Placenta was delivered by slight traction, complete, size 17x 15x 2,5
cm, weight 600 gr, umbilical cord’s length 48 cm, paracentralis
insertion
IUD was inserted at uterine fundal. Blood loss during surgery 250 cc

Diagnose :
P3A1L3 post LSCS o.i twice previous CS + IUD
insertion
Mother-child were in care
Plan :
Control GA, VS, Contraction, vaginal bleeding
IVFD RL + Oxytocin 10IU + Methylergometrine 0,2
mg  20dpm
Pronalges Supp II If Need
Cefixime 2x200 mg (PO)
Paracetamol 3x500 mg (PO)
Routine blood check 6 hours after surgery