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REPORT

MAY 28st 2012

Supervisor: dr. Agus Thoriq,Sp.OG

Medical Students:Rani, Hasaniah, Heri, Fadil, Zihni, Ayu

CASE RESUME

NORMAL LABORG5P4A0H3Preterm, S/L/IU, with PPROM

1

PATHOLOGIC LABOR 1

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Name : Mrs. MRM: 034361Age : 38 Years Old

Address : Arong-arong, MataramHospital Admission: May 28th 2012

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

May 28st201215.00

Patient referred from DasanAgung PHC with PROM. Patientconfessed history rupture ofmembrane (+) at 06.00, clear,odorless. Abdominal pain (-),bloody slim (+). FM (+). History

of DM (-), HT (-), asthma (-).

LMP : /11/2011

EDD : /8/2012

History of ANC : >4x at PHC

Last ANC : 16/4/2012

History USG: (+) at Sp.OG. EDD:27/7/12

History of family planning : -

Next family planning : spiral

Obstetric status :

1. Aterm, male, TBA, 6 months,

+2. Aterm, female, midwife,

spontan, 2700g, 18 yo

3. Aterm, male, midwife,spontan, 2900g, 14 yo

4. Aterm, female, midwife,spontan, 2800g, 11 yo

5. this

General statusGC/GCS: well/E4V5M6BP: 120/70 mmHgRR: 22 tpmHR: 84 bpmt: 36,4 0C

Eyes: anemis -/- , icteric -/-Cor: S1S2 single murmur(-),gallop (-)Pulmo: ves (+/+), Wheezing (-/-),Rhonki (-/-).Abdomen: striae gravidarum (+),linea nigra (+)Lower extremity: oedem (-/-),warm acral (+/+)

Obstetric statusUFH: 25 cm EFW:2015gL1: breechL2: back on the right sideL3: headL4: 4/5His: (-)DJJ: 11-11-12 (136 bpm)VT: 1 cm, eff 10%, amn (-)clear, head palpable at H1,denominator unknown,unpalpable small part offetal/umbilical cord

G5P4A0H3Preterm, S/L/IU,with PPROM

obs mohter andfetal well being.Consult to SpOG:conservativeBed rest totalObs. Rectal temp.

Inj. Ampicillin 2g/ivInj. Dexamethason10mg/ivPro USGmove to melati

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TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

Chronologist :

28/05/2012 - 09.00

Subjective: Patient 8 months ofpregnancy confess rupture ofmembrane at 06.00, clear and

odorless, abdominal pain -(28/5/2012).FM (+).

Objective:

GC: well

BP: 130/80 mmHg RR: -

HR: - T: -

Obstetrical status:

UFH: 27cm,

Assessment: PROM

11.00

Refer to Mataram GH

Laboratory examination:Hb: 13,6HCT: 39,4RBC: 4,28WBC: 7,97PLT: 384

HBsAg: -

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TIME SUBJECTIVE OBJECTIVE ASSESMENT PLANNING

21.00 Patient confess abdominal pain General statusGC/cons: well/CMBP: 120/60 mmHgRR: 20 tpmHR: 80 bpmT: 36,7 0C

His: (+) 2-4x/10 30DJJ: 11-11-12 (136 bpm)Bloody slim (+)VT: 3 cm, eff 50%, amn (-),head palpable at H1, denominatorunknown, unpalpable small partof fetal/umbilical cord

Latent phase 1ststage of labor withhistory of rupturemembrane

Move to TerataiObs. Mother andfetal beingObs. Progress oflabor

21.45 Patient wants to bearing down General statusGC/cons: well/CM

His: (+) 4x/10 40DJJ: 12-12-13 (144 bpm)VT: complete, amn (-) clear,head palpable HIII, denominatorunknown, unpalpable small part

of fetal/umbilical cord

Doranteknusvulkaperjol

2nd stage of labor

Conduct mother tobearing down

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TIME SUBJECTIVE OBJECTIVE ASSESMENT PLANNING

21.50 Baby was born spontaneus, life,female, 1900 gram, BL : 45 cm, A-S: 7-9. Ballard score 22 (33),anus(+), anomaly kongenital (-)Plasenta was born spontaneus,complete, 500 gram. Lochea 100

cc

23.50 Patient still weak GC: wellBP: 130/90HR: 80RR: 20T: 37UC: good (+)UHF: 1 finger below

umbilicusActive vaginal bleeding: -

2 h post partum Continue observation GS

07.00 Patient still weak GC: wellBP: 110/60HR: 100RR: 18T: 36,4

UC: good (+)UHF: 2 finger belowumbilicusActive vaginal bleeding: -

Baby in NICUHR: 124x/mntRR:40x/mntT: 36,1

1 day post partum Obs. Mother well beingCIE patient to mobilisationMefenamat Acid 500mg 3x1Amoxicillin 500mg3x1