LETAK SUNGSANG

1. SUG, 29 yo WAW

Complained labor pain (+) since 10.00 pm (30/08/2014) , watery vaginal discharge (-), FM (+) good. Known breech pres since 08/07/2014 ~ 33 wks GA (USG at O&G).

LMP: 25/11/2013EDD: 02/09/2014 PNC: Midwife, O&G

Obstetric History:1. ♂, 3500 g, SVD, midwife, 11 yo2. ♀, 3500 g, SVD, midwife, 8 yo3. ♂, 3500 g, SVD, midwife, 2 yo4.Current pregnancy

Married: 2x: I~8 yrs II~2 yrsContraception: OCP ~ stop August 2013

W/H: 67/152Present St:BP: 120/70 RR: 20P : 88 Tax: 36,7

General St :Eyes : anemic -/-Thorax cor : S1S2 sgl, reg, m (-) pulmo : ves +/+, rh -/-, wh -/-Ext : warm +/+ Oedem -/- +/+ -/- Obstetric St:Abd: FH 38 cm ω, AC 97 cm UC (+) 3x/10’~40-45’’ FHB (+) 138 bpm

VT (SDW) 08.30 amCD 8 cm, Eff 75%, AM (+)Buttock palp, Sacrum Left Anterior, ↓H IIUnpalp small parts/umb cord

G4P3003 39-40 wks, S/L, Breech Prest, 1st stage of labor

EFW: 3592 g ZA: 4

Pdx:-

Tx:•Exp Vaginal Delivery•IVFD RL 20 dpm

Mx: •C, VS, FHB, UC, Progress of labor

CIE

OBSTETRIC EMERGENCY ROOMLETAK SUNGSANG

1. SUG, 29 yo WAW

at 09.25 amPatient urge to bear down, spontaneously ROM

LAB:WBC: 14,6 PLT: 266HGB: 11,2 BT: 1’00HCT: 40,4 CT: 8’30”

USG:Fetus, S/L, breech prest, FHB (+), FM (+)BPD: 96,0 ~ 39W6D AVE 39W3DAC: 348,2 ~ 39W3D EFW: 3592 gFL: 79,3 ~ 40W3D EDD: 2/09/14Placenta Fundus Corpus Anterior grd IIIAFI 8,2

Obstetric St:Abd: UC (+) 4-5x/10’~40-45’’ FHB (+) 142 bpmVT (WAW) 09.25 am CD complete, AM (-) Buttock palp, Sacrum Transverse, ↓HIII+

2nd stage of labor

Tx: Lovset Mauriceau

At 09.33 amborn baby, ♂, 3900 g,

AS 7-8

OBSTETRIC EMERGENCY ROOMDUTY ON : SUNDAY, AUGUST 31st 2014