CASE NO

Identity
Patient Husband
Name : Mrs. Z Name : Mr. N
Age : 41 years old Age : 47 years old
MR : 01.21.46.32 Education : Senior High School
Education : Junior High School Occupation : Farmer
Occupation : Housewife Address : Sijunjung
Address : Sawah laweh Sijunjung
Admission date : 25-03-2024
 Clinical Data
March 26th 2024 at 01.00
Anamnesis
Patient came alone to emergency room at PONEK M
Djamil Hospital accompanied by her family with chief
complained pelvic pain to groin since 4 hours ago before
admitted
• Pelvic pain to groin since 4 hours ago
• Bloody show from the vagina (+) 2 hours ago
• Fluid leakage from vagina (-)
• Vaginal bleeding from vagina (-)
• Amenorrhea since 9 months ago
• LMP : July 8th, 2023 EDD : April 15th, 2024
• Fetal movement was felt since 5 months ago
• History of menstrual : menarche 13 years old, regular 28
days cycle, duration 4-6 days, 2-3 pad changes per day,
menstrual pain (-)
• History early pregnancy : nausea (+) vomit (-) bleeding
(-)
• History late pregnancy : nausea (-) vomit (-) bleeding (-)
• Antenatal care : Control to midwife every month since
month of pregnancy 1 months of pregnancy, never
control to obstetrician during pregnancy. There are no
abnormalities were found.
Previous illness history :
• DM, hypertension, lung, kidney, liver was normal
Family illness history :
• There were no history of congenital, psychiatric
and contagious disease
Marriage history once, by 1999
History of pregnancy/abortion/delivery: 6/0/5
1. 2000/male/2500/aterm/Normal /midwife/alive
2. 2002/male/3000/aterm/Normal/midwife/alive
3. 2006/male/3400/aterm/Normal/midwife/alive
4. 2010/female/2300/aterm/Normal
Delivery/midwife/alive
5. 2014/female/3000 g/ aterm/Normal
Delivery/midwife/alive
6. current pregnancy
 Physical examination

GA Cons BP HR RR T UFH : 28 cm;

mdrt CMC 125/77 88 20 36, Uterine contraction : 2-3x/20-30’’/10’/ strong
Fetal heart rate : 138- 145 x/i
Weight Before pregnancy: 48 kg
During pregnancy : 55 kg Genitalia
Height : 148 cm I : V/U within normal limit, vaginal bleeding (-)
BMI : 21 (Normoweight)
VT : cervical dilatation 4 cm, amnion sac (+), head presentation, transverse
Generalist status: sagitalis suture at hodge I-II
Head : Normocephal
Eyes: Conjuctiva weren’t anemic, sclera weren’t icteric Pelvic Inlet:
Thorax: Pulmo: vesicular (+) whz (-/-), Rh (-/-)
Promontory : hard to define
Cor: HS regular, murmur (-) gallop (-)
Abdomen: describe in obstetric status Inominate line hard to define
Genitalia : describe in obstetric status Pelvic side wall: straight
Extremity: CRT <2”, oedema (-/-) Sacrum bone : convex
Ischiadic spine : slightly protrude
Obstetric status : Coccygeus bone: mobile
Head: Chloasma gravidarum (+) Arc of pubic : > 90
Mammae : Enlargement (+), hyperpigmentation areola mammae (+) colostrum
(-)
Pelvic outlet:
Abdomen : Inter tuberous distance could be passed through by normal adult fist
I : According to term of pregnancy. Striae gravidarum (+), linea
hyperpigmentation (+), cicatrix (-) Impression: wide pelvic
L1 : fundal uterine palpated three fingers below processus xypoideus, A large,
soft, nodular mass was palpated EFW : 2480 gr
L2 : big resistence of baby was palpated on left side, small parts of the baby
was palpated on right side
L3 : A hard, round mass was palpated, fixated
L4 : Divergen
Supportive examination Diagnosis
Laboratorium 26/03/2024 Diagnose :
Hb : 12.1 • G6P5A0L5 37 -38 weeks of term parturient active phase of first
Leuko : 7.910 stage
trombo : 267.000 • Fetal alive, singleton, intrauterine, head presentation
HT : 34
MCV : 85 Plan : vaginal delivery
MCH : 30
MCHC : 35 Instruction :
• Control progres of labor with partograph
CTG : 1st category

PONEK ultrasound 26/03/2024

• 37-38 weeks of term pregnancy according fetal
biometry
• Fetal alive, singleton, intra uterine, head
presentation
Admission Letter
Labor result 26-03-2024
Ponek ultrasound 25/03/2024
Ponek ultrasound 26/03/2024
USG
• Fetal alive, singleton, intra uterine, head presentation
• Fetal movement activity was good
• Fetal Biometri :
BPD : 8.57 cm EFW : 2944 gram
HC : 31.10 cm SDAU : 2,44
AC : 32.68 cm FHR : 122 bpm
FL : 7.22 cm AFI : 10.15cm

Placenta implanted in anterior corpus, Maturity grade II

Impression :
• 37-38 weeks of aterm pregnancy according fetal biometry
• Fetal alive, singleton, intra uterine, head presentation
• Placenta implanted in anterior corpus
 CTG (18-03-2024)

Baseline : 130 bpm

Variability : 5-20 bpm
Acceleration : (+)
Deceleration : (-)
Fetal movement. : (+)
Contraction : (+)
Impression : 1st Category
Perinatology Consultation
A/
G6P5A0L5 37-38 weeks of term parturient active
phase of first stage

P/
Please educate about the limitations of breathing
apparatus if fetal distress occurs in the baby
We will accompany the delivery and perform
newborn resuscitation for the baby to be born
 Follow Up
1.00 WIB 26/3/2024 04.45 WIB 26/3/2024
/ Pelvic pain to groin (+) S/ Mother wants to bear down
oody show from the vaginar (+)
uid leakage from vagina (-) O/GA Cons BP HR RR T
etal Movement (+) mdrt CMC 121/80 87 20 36,5
/GA Cons BP HR RR T Abdomen :
drt CMC 135/81 80 21 36,5 His 3-4x/40-45”/10’strong
bdomen : FHR : 150-158 x/i
is 2-3/ 20–30”/10 ‘strong
HR : 136-148 x/i Genitalia
enitalia Protruded perineal, opening of vulva and anal
T : cervical dilatation 4-5 cm, amnion sac (+), head presentation, VT : cervical dilatation complete, amnion sac (-), head presentation,
occiput right anterior at hodge II-III occiput anterior at hodge IV

/ G6P5A0L5 37 -38 weeks of term parturient active phase of first A/ G6P5A0L5 37 -38 weeks of term parturient second stage
age Fetal alive, singleton, intrauterine, head presentation, occiput anterior
etal alive, singleton, intrauterine, head presentation, occiput right at hodge IV
nterior at hodge II-III
I/ Follow up GA, VS, HIS, FHR
Follow up GA, VS, HIS, FHR
/ Following Delivery P/ Lead to bear down
At 26-03-2024, 04.45 → vaginal delivery was performed
A female baby was born at 05.05
BW : 2400 gram​
BL : 49 cm
A/S 8/9
Inj. Oxytocin 10 IU IM → Placenta was born complete with III stage active management
Process :
• G6P5A0L5 37-38 weeks of term parturient active phase of first stage → second stage
→ Vaginal delivery

Diagnose Post :
• P6A0L6 post vaginal delivery
• Mother and baby were in care

Instruction :
• Control GA, VS, UC, Vaginal bleeding
• paracetamol 3x500 mg
• cefixime 2x200 mg
• laboratory check 6 hours after delivery
• Follow up for IV stage
• Care in ward room
26-03-2024
/ Mother wants to bear down

O/GA Cons BP HR RR T
mdrt CMC 125/77 88 20 36,
Abdomen :
His 3-4x/40-45”/10’strong
FHR : 135-145 x/i

Genitalia
Protruded perineal, opening of vulva and anal
VT : cervical dilatation complete, amnion sac (-), head
presentation, occiput anterior at hodge IV
A/ G6P5A0L5 37 -38 weeks of term parturient second
stage
P/ Lead Delivery
A female baby was born at 05.05
BW : 2400 gram​
BL : 49 cm
A/S 8/9
Partograph
Documentation
Lubchenko Curve
Follow up four stage of labour
Time Hour BP HR RR Uterine Funfus Contraction Urine Bleeding

1 05.20 110/70 88x 36,5 2 finger below Normal - -

umbilicus

05.35 100/70 78x 2 finger below Normal 80cc- ¼ pad

umbilicus
05.50 110/80 80x 2 finger below Normal - -
umbilicus

06.05 110/70 85x 2 finger below Normal ½ pad

umbilicus

2 06.35 124/84 80x 36,7 2 finger below Normal ½ pad

umbilicus
07.05 120/88 88x 2 finger below Normal 100 cc ½ pad
umbilicus Clearly
yellow
 Follow Up 2 hour post vaginal delivery
26-03-2024, 07.05
S Post partum pain (+) P • Control GA, VS, UC, Vaginal bleeding
• paracetamol 3x650 mg
• laboratory check 6 hours after delivery
• Care in ward room
O GA Cons BP HR RR T
Moderate CMC 120/88 88 20 36.8 C

Abdomen :
Uterine fundal palpated 2 fingers below
umbilical, contraction (+)​

Gen : V/U normal, VB (-)

A • P6A0L6 post vaginal delivery

• Mother and baby were in care
Post Op Laboratory Result
Thankyou