mr lili stengah gemeli belum jadi
TRANSCRIPT
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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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7/28/2019 Mr Lili Stengah Gemeli Belum Jadi
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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
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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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7/28/2019 Mr Lili Stengah Gemeli Belum Jadi
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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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7/28/2019 Mr Lili Stengah Gemeli Belum Jadi
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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