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    Pelatihan Poned

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    Indah Noor Hayati
    The patient is a 30-year-old woman who came to the hospital at 16:30 complaining of frequent abdominal tightness for the past 11 hours. She is 9 months pregnant. Examination showed the fetus in cephalic presentation and 3 cm cervical dilation. The patient underwent an emergency c-section at 18:05 due to fetal distress and post-term pregnancy. A 3,445 gram baby girl was delivered with Apgar scores of 6/7/8. The placenta was delivered manually with 500cc of total blood loss. Post-op, the patient was shaking but stable, and was prescribed IV fluids, antibiotics, and pain medications.

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    Pelatihan Poned

    Uploaded by

    Indah Noor Hayati
    11 views8 pages
    The patient is a 30-year-old woman who came to the hospital at 16:30 complaining of frequent abdominal tightness for the past 11 hours. She is 9 months pregnant. Examination showed the fetus in cephalic presentation and 3 cm cervical dilation. The patient underwent an emergency c-section at 18:05 due to fetal distress and post-term pregnancy. A 3,445 gram baby girl was delivered with Apgar scores of 6/7/8. The placenta was delivered manually with 500cc of total blood loss. Post-op, the patient was shaking but stable, and was prescribed IV fluids, antibiotics, and pain medications.

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    The patient is a 30-year-old woman who came to the hospital at 16:30 complaining of frequent abdominal tightness for the past 11 hours. She is 9 months pregnant. Examination showed the fetus in cephalic presentation and 3 cm cervical dilation. The patient underwent an emergency c-section at 18:05 due to fetal distress and post-term pregnancy. A 3,445 gram baby girl was delivered with Apgar scores of 6/7/8. The placenta was delivered manually with 500cc of total blood loss. Post-op, the patient was shaking but stable, and was prescribed IV fluids, antibiotics, and pain medications.

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    11 views8 pages

    Pelatihan Poned

    Uploaded by

    Indah Noor Hayati
    The patient is a 30-year-old woman who came to the hospital at 16:30 complaining of frequent abdominal tightness for the past 11 hours. She is 9 months pregnant. Examination showed the fetus in cephalic presentation and 3 cm cervical dilation. The patient underwent an emergency c-section at 18:05 due to fetal distress and post-term pregnancy. A 3,445 gram baby girl was delivered with Apgar scores of 6/7/8. The placenta was delivered manually with 500cc of total blood loss. Post-op, the patient was shaking but stable, and was prescribed IV fluids, antibiotics, and pain medications.

    Copyright:

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    of 8

    LAPORAN JAGA

    PONED
    1. Ny. Murni/ 30 thn / MRS tgl 9
    September 2019, pukul 16.30 wita
    R/ persalinan :
    1. 2013 / aterm/SptBK/Bidan/L/BB:
    3700 gr/hidup
    2. Hamil ini

    R/Pernikahan : 1x / 23 tahun
    R/ ANC :
    R/ KB : (-)
    7x BPM, 5x SpOG
    R/ Menstruasi :
    R/ penyakit :
    menstruasi pertama kali usia 12 thn, HT (-), DM (-), ALERGI (-),
    lamanya 7 hari, teratur ASMA (-)
    HPHT :01-12-2018 RPK :
    TP : 8-9-2019 HT (-), DM (-), ALERGI (-),
    ASMA (-)
    UK : 40-41 mg
    TB : 154 cm
    BB : 65 kg
    BMI : 27,4
    normal
    S: px datang sendiri, L2 : Pu-Ka
    mengaku hamil 9 bln,
    L3 : pres-kep
    perut sering kencang2
    sejak 11 jam sblm mrs. L4 : Kep blm masuk
    Keluar air2 tidak ada, TBJ : 3000 gr,
    lender darah (+)
    His 3x 10’/40”, Djj : 78x/m
    O : KU baik TD : 120/80
    mmHg, N : 72 x/m, RR: VT : pembukaan 3 cm/ ket
    18 x/m, T :36 c (+)/preskep/H1,
    palpasi
    L1 : TFU : 3 jari di
    bawah prx, (31 cm)
    A : G2P1A0 uk 40-41 mg +JTHIU + letkep + inpartu kala I
    fase laten +post date + abnormal NST (fetal bradikardia)
    + TBJ 3000
    P : inf. Rl 20 tpm
    Diet TKTP
    Cek Lab lengkap, EKG
    pro SC ( atas pertimbangan fetal bradikardia)
     Lab
    Hb 11,2
    Leukosit 15,6 rb/ul
    Hematokrit 33,7 %
    NST = kat III (Fetal
    bradikardia)
     Jam 18. 05 wita di lakukan tindakan sc kepada pasien
     Lahir bayi sc, jk perempuan, BB 3445 gr, Pb. 50 cm, As
    6/7/8
     Ketuban mekonial. Total perdarahan 500 cc
     Placenta lahir dengan manual plasenta.
    Jam 20.30 wita , post sc

     S : Pasien turun dari OK ke VK, os menggigil


     O : ku baik, kesadaran CM, TD : 110/70 HR : 84 x/menit
    RR : 18 x/m, kontraksi uterus baik, TFU sepusat,
    perdarahan normal

     A : P2A0 post sc H0 a/I fetal distress + post date


     P : - IVFD RL + OXY 2 amp 20 tpm s/d 24 jam post sc
    - Inj. Ceftriaxon 2 x 1 gr ( 3 hari)
    - Inj. As. Tranexamat 3x500 mg
    - Inj keterolac 3x30 mg
    - Inj furamin 3x1 amp
    - Rawat luka 3 hari
    - observasi KU/ Keluhan/ Perdarahan
    - cek darah / 4 jam post sc

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