mr lili stengah gemeli belum jadi

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  • 7/28/2019 Mr Lili Stengah Gemeli Belum Jadi

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    Supervisor : dr. I Made P. Mahayase, Sp.OG

    Medical Students:

    Dian, Ita, Tomi, Lili, Ika, Elin

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    G1P0A0H0 38-39 weeks/G/L-L/IU Breech presentation andHead Presentation with active phase 1st stage of labor withsevere preeclamsia + history ruptur of membran

  • 7/28/2019 Mr Lili Stengah Gemeli Belum Jadi

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    s

    Name : Mrs. R CTH : September 11th, 2011

    Age : 25 years old at . 22.10 Wita

    Address : Kr. Jasi, Lingsar

    Time Subject Object Assesment Planning

    11/09

    2011

    22.10

    Patient reffered from Gerung GH

    with G1P0A0H0 39 weeks/G/L-L/IU

    Breech-Head Presentation withactive phase 1st stage of labor and

    severe preeclamsia. Abdominal pain

    (+). Bloody slim (+). History rupture

    of membrane (+). FM (+). History of

    DM (-), HT (-), Astma (-).

    LMP : 14-12-2010

    EDD : 21-09-2011

    History of ANC : > 4x, posyandu

    Last ANC : -

    History of family planning : -

    Next family planning : IUD

    Obstetrical history :

    I. This.

    Chronologis at Kediri PHC:11/09/2011

    19.00

    Patient come to Kediri PHC with 9

    month pregnancy, and Gemeli (USG,

    20-06-2011). Confessed abdominal

    pain, History ruptur of membran

    since 10/09/2011, at 14.00 WITA.

    FM (+), epigastric pain (-), dizzines (-

    ), bllured vision (-)

    GC : Well GCS ; E4V5M6

    GC : Well GCS ; E4V5M6

    BP : 160/85 mmHg PR : 104 bpm

    T : 37,C RR : 22 tpmGeneral status :

    Eye : an (-), icteric (-)

    Thorax :

    C ; S1/S2 single reguler, murmur (-),

    gallop (-).

    P ; ves (+/+), wh (-), rh (-)

    A: : scar (-), striae (+)

    Extremity : edema +/+

    Obstetrical Status :

    UFH: 35 cm, Breech presentation, head

    presentation

    UC : 3 x 10 35

    FHR : 1. 140 bpm 2. 144 bpm

    VT 5 cms, eff 50%, amnion (-) clearly,

    foot palpable HII, unpalpable

    umbilical cord

    Lab ; (-)

    WBC : 14.500

    RBC : 4,31

    HCT : 36,7%

    PLT : 277.000

    HGB 10,7 g/dL

    Protein : +2

    HbsAg : (+)

    G1P0A0H0 39

    weeks/G/L-L/IU Head

    Presentation + breechpresentation with

    active phase 1st stage

    of labor, severe

    preeclamsia and

    history rupture of

    membrane

    Obs. mother and fetal

    well being

    Lab : DL, HbsAg Coass co GP: pro SC

    GP co to supervisor

    pro Sc

    ACC

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    Time Subject Object Assesment Planning

    Contd

    A : G1P0A0 39 weeks/G/L-L/IU head

    presentation with active phase 1st

    stage of labor and stage of labor and

    severe preeclamsia

    P :

    -Nipedifin 3x10 mg

    -Bolus and drip MgSO4

    -Obs mother and fetal well being

    By anamnesis

    Chronologist at GH of Gerung

    Cont therapy from Kediri PHC

    mother and fetal well being

    KIE family, DC

    Patient sent to GH of NTB

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    00.45 SC began

    Female, 3200 gr, AS 7-

    9, congenital anomali (-

    ), anus (+). Female,

    1950, AS 5-7,

    congenital anomali (+),anus (+)

    Amnion clear.

    Placenta was born

    manual.

    Bleeding 200cc

    02.45 - GC : well cons : E4V5M6

    BP : 130/70 mmHg PR :

    100 x/minute

    RR : 20 x/minute

    T : 37 C

    UFH : 2 finger below

    umbilicus

    Uterine consistency firm

    Operation wound good

    Active bleeding (-)

    Urine output: 600 cc

    2 hours post SC Obs mother and baby

    07.00

    (12-9-

    2011)

    - GC : well cons : E4V5M6

    BP : 130/80 mmHg PR :

    100 x/minute

    RR : 20 x/minute

    T : 37 C

    UFH : 2 finger below

    umbilicus

    Uterine consistency firm

    Operation wound good

    Active bleeding (-)

    1st day post SC Obs mother and baby