Download - 18 Maret 2014 Serotinus Drip
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Supervisor : dr. Edy Prasetyo, SpOG
Medical Student:
Novi, Suwika, Hery
.
Cases resume :
1 Pathologies 1
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Normal Labor/ 12
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Name: Mrs. S
Age: 25 yo
Adress: Aramanis
No RM: 098169
Admitted: 17thMarch 2014 at13.00 WITA
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Time Subjective Objective Assestment Planning
17/03/
201413.00
WITA
Patient came to poly
Obstetric with G1P0A0L041-42 wks S/L/IU head
presentation mother and
fetal well being.
Patient confessed postdate, abdominal pain (-)
and history rupture of
membrane (-). Bloody slim
(-). FM (+).
History of DM (-), HT (-),
Asthma (-).
LMP : 29/05/2013
EDD : 05/03/2014
History of ANC : >9x, at
Posyandu
Last ANC : 17/02/2014,
result : BP: 110/70, BW: 64,TFU 32 cm, 41-42 weeks.
History of USG: 2x Klinicand hospital
Last USG : (17-03-2014)Result : Fetal S/L/IU head
presentation, placenta
fundus anterior grade III
clasification, amnion less.
General status :
GC : well GCS : E4V5M6 BP : 110/70 mmHg
RR : 22x/mnt
Pulse : 86 x/mnt
T : 36,8 C
Eyes : an (-/-) ikt (-/-)
Cor : S1S2 single regular,
M (-), G (-)
Pulmo : vesiculer (+/+), rh(-/-), wh (-/-)
Abd : scar (-), striae (+)
Extremity edema (-/-),
warm (+/+)
Obstetric status :
L1 : head UFH: 32 cmL2 : back on left side
L3 : breech L4 : 4/5
EFW : 3255 gr
FHB: 12-12-11 (140 x/min)UC : -
VT : 1 cm, effacement 10%,amnion (+), head palpable
HI, denominator unclear,impalpable small part and
umbilical cord.
G1P0A0L0 41-42
wks/S/L/IU headpresentation mother
and fetal in well
condition with
oligohidramnion
DM co to GP pro
CTG andtermination with
misoprostol
GP co to SPV
about result CTGSPV advice: CTG
reactive pro labor
induction with
oxytocin dripobservation
mother & fetal well
being
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Time Subjektive Objective Assessment Planning
Obstetrical history :
1. This
History of family planning:
Next family planning: -
Chronologist : -
PE:
Sacrum convexity normal
Spina ischiadica not
prominent
Os coccygeus mobile
Arcus pubis > 90
PS: 4
cerviks dilatation 1 cm= 1
Cerviks length 2 cm=1
cerviks consistency
moderate: 1
Cerviks position
posterior: 0Station H I: -2=1
Lab exam
HGB : 11,1
RBC: 4,35
Hct: 34,7
WBC : 13,1 PLT : 261
HBsAg : +
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Time Subjektive Objective Assestment Planning
14.30 UC: -
FHB: 12-11-12
(140 bpm)
CTG done. Result:
reactive
Oxytocin drip started
from 8 dpm
15.00 UC: -FHB: 12-11-12
(140 bpm)
Oxy drip: 12 dpm
15.30 UC: -
FHB: 12-12-12
(144 bpm)
Oxy drip: 16 dpm
16.00 UC: 1x10-20
FHB: 11-12-12
(140 bpm)
Oxy drip: 20 dpm
16.30 UC: 2x10-25
FHB: 12-12-12
(140 bpm)
Oxy drip: 24 dpm
17.00 GC : well GCS : E4V5M6
BP : 120/70 mmHg
RR : 20x/mnt
Pulse : 80x/mnt
T : 36,8 C
VT : 2 cm, effacement 10%,
amnion (+), head palpable HI,
denominator unclear, impalpable
small part and umbilical cord.
UC: 3x10-30
FHB: 13-13-13
G1P0A0L0 41-42
wks/S/L/IU head
presentation Laten
phase.
Oxy drip: 28 dpm
17.30 UC: 3x10-30
FHB: 13-12-13
Oxy drip: 32 dpm
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Time Subjektive Objective Assestment Planning
18.00 UC: 4x10-30
FHB: 12-12-12
144 bpm
Oxy drip: 36dpm , maintenance
18.30 UC: 4x10-30
FHB: 13-14-14
164 bpm
Oxy drip: 36 dpm
19.00 UC: 4x10-30
FHB: 13-14-14
164 bpm
Oxy drip: 36 dpm
DM do CTG
19.30 UC: 4x10-30
FHB: 13-14-14
164 bpm
Oxy drip: 36 dpm
DM co to GP about result CTG,
pro resusitation, GP advice : do
resusitation and then do CTG
again.GP co to SPV, SPV advice :
stop drip, SC tomorrow at 07.30
wita.
20.00 UC: 4x10-30
FHB: 13-14-14
164 bpm
-Stop drip oxy
- Do resusitation
21.00
GC : well GCS : E4V5M6 BP : 110/70 mmHg
RR : 21x/mnt
Pulse : 84 x/mnt
T : 36,7 C
VT : 2 cm, effacement 25%, amnion
(+), head palpable HI, denominator
unclear, impalpable small part and
umbilical cord.
UC: 4x10-30FHB: 13-13-14
G1P0A0L0 41-42wks/S/L/IU head
presentation with
arrested Laten phase.
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Time Subjektive Objective Assestment Planning
21.30 UC: 4x10-30FHB: 12-11-12
140 bpm
22.00 UC: 4x10-30FHB: 12-12-12
23.00 UC: 4x10-30FHB: 12-12-12
18/03/2014
00.00
UC: 4x10-30
FHB: 12-12-12
01.00 GC : well GCS : E4V5M6
BP : 110/80 mmHg
RR : 22x/mnt
Pulse : 80 x/mnt
T : 36,7 C
VT : 3 cm, effacement 25%,
amnion (+), head palpable HI, denominator unclear,
impalpable small part andumbilical cord.
UC: 4x10-30
FHB: 12-13-12
148 bpm
G1P0A0L0 41-
42 wks/S/L/IU
head
presentation
with Laten
phase
Obs. Mother andfetal well being
Obs. Progress of
labor
02.00 UC: 4x10-30
FHB: 12-12-12
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Time Subjektive Objective Assestment Planning
03.00 UC: 4x10-30
FHB: 12-12-12
140 bpm
04.00 UC: 4x10-30
FHB: 12-12-12
.
05.00 GC : well GCS : E4V5M6 BP : 110/80 mmHg
RR : 22x/mnt
Pulse : 80 x/mnt
T : 36,7 CVT : 4 cm, effacement 25%,
amnion (+), head palpable
HI, denominator unclear,
impalpable small part andumbilical cord.
UC: 4x10-30FHB: 12-13-12148 bpm
G1P0A0L0 41-42wks/S/L/IU head
presentationactive phase 1st
stage of labor.
Do CTGDM co to GP about
CTG result, GP
06.00 UC: 4x10-30
FHB: 12-12-12
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Time Subjektive Objective Assestment Planning
07.00 GC : well GCS : E4V5M6
BP : 110/80 mmHg
RR : 22x/mnt Pulse : 80 x/mnt
T : 36,7 C
UC: 4x10-30
FHB: 12-12-12140 bpm
Prepare to SC