revisi Mr akbar 12 mei 2014 kala I fase aktif macet + retensio plasenta dan IUGR

Supervisor: dr. Agus Thoriq, SpOGDM: Akbar

Case Resume :No. Case Total

Pathology Delivery 2

1.

2.

G4P2A1L2 41 weeks head presentation with hypertension gestasional + IUGRG2P1A0L1 40-41 weeks head presentation with protracted active phase 1st stage of laborNormal Delivery -

IDENTITYName : Mrs. S

Age : 26 yo

Address : Monjok

No. RM : 538430

Hozpitalised on 12.15 WITA, 11th May 2014

• G4P2A1L2 41 weeks head presentation with Hypertension gestasional + IUGR

CASE 1

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

11/05/14

12.15 WITA

Patient came to VK IRD confessed abdominal pain since 06.00 WITA at 11/05/14, water came out from her vagina (-), bloody slim (-), fetal movement (+),.

No history of DM, history of, asthma (+), history of HT (+). History of food allergic (+).

LMP : 30-07-2013EDD : 06-05-2014

History of ANC : 3 x in PosyanduLast ANC: 20/03/2014, result: BP: 130/80 mmHg, FHB (+), head presentation,

History of USG: 1 x Male, S/L/, 26-27 weeks, plasenta in corpus posterior (14/02/2014)

General status:GC: wellGCS: E4V5M6BP: 150/100 mmHgPR: 84 bpmRR: 22 rpm T: 370 C

Eye : anemis (-), icteric (-)Thorax :Cor : S1S2 single reguler, murmur (-), gallop (-)Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-).Abdomen : scar (-), striae livida (+), linea nigra (+), Extremity : edema (-/-), warm acral (-/-)Nutrition status : Body Height : 134 cmBody weight : 48 kgObstetrical status:L1: breechL2: back on the right sideL3: headL4: 4/5UFH: 25 cm EFW: 2170UC: 2x10’~20”FHB: 12-12-12 (144x/min)

G4P2A1L2 41 weeks head presentation with 1st stage latent phase Hypertension gestasional + IUGR

• Obs mother & fetal well being

• Obs. Progress of labor


History of Family Planning: injectionNext Family Planning: -History of obstetry:1.Aterm, spontan, traditional birth attendan, 3300 gram female, 14 yo2.Aterm , spontan, 3300 gram, female 9 yo3.Abortus4.This

Chronologist: (-)

VT : Ø 2 cm , eff 15%, amnion (+), head presentation, denom unclear, ↓HI, unpalpable small part of fetal

Lab ResultHb : 11,7 x 106/ µLWBC : 13,23 x 103/ µLPLT : 376x 103/ µLHCT : 34,1 %HBsAg : (-) non reactiveProteinuria : (-)


12.45 WITA

Abdominal pain + UC: 2x10’~20”FHB : 12-12-12 (144)


• Obs mother & fetal well being

• Obs. Progress of labor

13.15

WITA

Abdominal pain + UC: 3x10’~35”FHB:13-12-13 (160)


Dm pro ctg, GP advice CTG, consult result of ctg to GP, GP advice recutitation intrauterine


14.00 Abdominal pain ++Mothers confessed, water leaked out from her vagina

UC: 3x10’~45”FHB : 12-12-12 ( 144)VT:Ø 5cm , amnion (-), head presentation, denom unclear, ↓HII, unpalpable small part of fetal

G4P2A1L2 41 weeks head presentation active phase first stage of labor with Hypertension gestasional + IUGR

Observation progress of labor

14.30 Abdominal pain ++ UC: 3x10’~45”FHB : 12-12-11 ( 140)



15.00 Abdominal pain ++ UC: 3x10’~45”FHB : 12-12-11 ( 140)



TIME SUBJECTIVE OBJECTIVE ASSESMENT PLANNING

15.25

WITA

Mothers want to bearing down UC: 3x10’~45”FHB : 12-12-12 ( 144)Inspeksi : Bulging of perineum, opening vulva (diameter of head ± 5cm), anus pressure,

2nd stage of labor

Conduct of labor

15.30WITA

Baby was born spontaneously, male, AS: 6-8, BW/BL = 2000 gr/46 cm, anus +, anomaly kongenital -


15.30 Patient confessed abdominal pain

UC (+) 3rd stage of labor

• Management active of 3rd stage

• Placenta was born spontan, complete, weight 400 gr, bleeding 150 cc

17.30 GC: wellGCS: E4V5M6BP: 120/80 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C

UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)

2 hours post partum

•Obs. Mother well being

•Suggest mother to eat and drink

Baby in NICU


07.00(12/05/14)

GC: wellGCS: E4V5M6BP: 150/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,80 C

UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)Lochea rubra (+)

Baby in NICUGC : wellPR : 132 bpmRR : 44 bpmT : 36,2ºC

1 day post partum

•Obs. Mother well being

•Suggest mother to eat and drink

Baby

3

3

3

3

3

2

17

3

4

3

3

3

3

19

Conclusion:

• Baby aterm (38-40)• Baby IUGR because < 10 Percentil• Risk Factor:

hypertension

IDENTITYName : Mrs. MAge : 26 yoAddress : Batu layar

Hozpitalised on 17.30 WITA, 11th May 2014

• G2P1A0L1 40-41 weeks head presentation with protracted active phase 1st stage of labor

CASE 2

Time Subjective Objective Assesment Planning

11/05/2014

17.30 WITA

Patient referred from Meninting PHC with G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor. Patient confessed abdominal pain since 07.00 WITA (11/05/2014), water came out from her vagina since 07.00 WITA, bloody slim (+), fetal movement (+)No history of DM, HT, asthma. No history of allergic reaction to medicine or food.

LMP : 01/08/2013EDD: 07/05/2014

Examination:General condition : WellGCS : E4V5M6

BP : 110/90 mmHgPR : 90 x/mRR : 21 x/mTemp : 36,8 ◦C

General StatusEyes : an-/-, ict -/-Cor : s1s2 single, m -, g –Pulmo : Ves +/+, rh -/-, whz -/-Abdomen : scar (-), striae gravidaum (+), linea nigra (+)Ext : oedem-/-, warm +/+

Status Obstetric L1 : breechL2 : back on the right sideL3 : headL4 : 4/5

G2P1A0L1 40-41 weeks S/L/IU head presentation with protracted active phase 1st stage of labor

Observation mother well being

CIE mother and family IVFD RL 20 tpmDM co to GP pro obs.

Sign of labor,inj ceftriaxon 1 gr/iv and ctg, GP advice obs. Sign of labor , inj ceftriaxon 1gr /iv and ctg


History of ANC : 5 x at PHCLast ANC: 10/05/2014, result: BP: 110/80 mmHg, UFH : 31cm, head presentation,40-41 weeks, FHB (+)

History of USG : -

History of Family Planning: - Next Family Planning: injection

History of obstetry:1.Male, spontan, midwife, aterm, 2800 gram, 5 yo2.This

UFH : 30 cm EFW : 2945 gramFHR: 13-13-13 (154)UC : 3x10’~30”VT : Ø 4 cm, eff 50%, amnion (-),clear, head palpable ↓HII, denom unclear, unpalpable small part of fetus

Lab ResultHb : 10,7 x 106/ µLWBC : 22,65 x 103/ µLPLT : 252 x 103/ µLHCT : 33,5 %HBsAg : (-) non reactive


11/05/2014

(07.30)

Chronologist at Meninting PHC

S: Patient pregnant 9 month come to Meninting PHC confessed abdominal pain and water leak from her vagina since 07.00 wita (11/05/2014)O:GC : WellGCS : E4V5M6

BP : 110/80 mmHgPR : 88 bpmRR : 20 x/mTemp : 36,5 ◦C

UFH : 31 cmFHB: 12-12-11( 136)UC : 2x10’~25”VT: Ø 2 cm, eff. 25 %, amnion (+) clear, head palpable ↓HI, denominator unclear, unpalpable small part of fetal & umbilical cord.


11.30Wita

(11-05-2014)

A: G2P1A0L1 40-411 weeks S/L/IU head presentation with inpartu latent phase 1st stage of labor + history of ROM P: •Obs. Mother and fetal well being•Obs. Progress of labor

S: abdominal pain more frequently

O: GC : wellBP:100/80PR : 88 bpmRR : 20 x/mTemp : 36,5◦CHis : 3x10’~30”FHB: 12-12-12 (144) VT : Ø 5 cm, eff. 50 %, amnion (+) clear, head palpable ↓HII, denominator unclear, unpalpable small part of fetal & umbilical cord


15.30

A: inpartu active phase first stage of labor

P: continue observation

S: -O:GC : wellBP:100/80PR : 88 bpmRR : 20 x/mTemp : 36,5◦CHis : 3x10’~35”FHB: 12-12-12 (144)VT : Ø 6 cm, eff. 50 %, amnion (+) clear, head palpable ↓HII, denominator unclear, unpalpable small part of fetal & umbilical cordA: inpartu protracted first stage laborP: inj ampicilin, infus RL, prepare for referred to NTB GH


16.30 S:-O: GC : wellBP:100/80PR : 88 bpmRR : 20 x/mTemp : 36,5◦CHis : 4x10’~35”FHB: 12-12-12 (144)A: Inpartu protracted 1st stage of laborP: change infus RL with D5


18.00WITA

Abdominal pain + UC : 3x10’ ~35”FHB : 12-12-12 (144)


Obs. Sign of laborConsult result of ctg,GP advice continue observation


18.30 WITA



Obs. Progress of labor

19.00 WITA




19.30 WITA

Abdominal pain ++ UC : 3x10’ ~40”FHB : 12-12-12 (144)




19.40 WITA

Mothers want to bearing down

Inspection:Bulging of perineum,

opening vulva, anus presure

G2P1A0L1 40-41 weeks S/L/IU head presentation with 2nd stage of labor

Conduct labor

19.45WITA

Baby was born , male, AS: 5-7, BW/BL = 3550gr/50 cm, anus +, anomaly kongenital -


19.45 UC + 3rd stage of labor Management active of 3rd stage

20.00 UC + 3rd stage of labor Placenta was not bornInjection 2nd oxytocinCateter urine

20.15 UC + Retensio plasenta

Placenta was born manual, uncomplete,± 300 gram.Bleeding ± 500cc,Pro usg on Monday (12/05/2014)


22.30WITA


UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)

2 hours post partum with rest plasenta

Obs. Mother well beingSuggest mother to eat and drinkPro USG

Baby in NICU


07.00 WITA (12-05-2014)


UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)Lochea rubra (+)

Baby in NICUGC : wellPR : 134 bpmRR : 44 bpmT : 36,2ºCUse O2, IVFD D10%

One day post partum

•Obs. Mother well being•Suggest mother to eat and drink

• Pro kuretase if USG (+) rest plasenta

THANK YOU

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revisi Mr akbar 12 mei 2014 kala I fase aktif macet + retensio plasenta dan IUGR