18 Maret 2014 Serotinus Drip

8/12/2019 18 Maret 2014 Serotinus Drip

1/12

Supervisor : dr. Edy Prasetyo, SpOG

Medical Student:

Novi, Suwika, Hery

.

Cases resume :

1 Pathologies 1

-

Normal Labor/ 12


2/12

Name: Mrs. S

Age: 25 yo

Adress: Aramanis

No RM: 098169

Admitted: 17thMarch 2014 at13.00 WITA


3/12

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


4/12

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 : +


5/12


6/12

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


7/12


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.


8/12


9/12


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


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


10/12


11/12


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


12/12



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

Documents

18 Maret 2014 Serotinus Drip