mr 231013 negelegted

8/13/2019 MR 231013 Negelegted

1/12


2/12

Case Resume :

No. Case Total

Pathology Delivery 1

1. G1P0A0L0 38-39 weeksS/L/IU with neglected active

phase 1ststage of labor

Normal Delivery 0


3/12

Name : Mrs. E

Age : 21 years old

Address : Gegelang, LingsarAdmitted : 23rd Oct 2013

No. RM : 091711

G1P0A0L0 38-39 weeks S/L/IU with neglected active

phase 1ststage of labor


4/12

s

Time Subject Object Assesment Planning

23/10/

2013

10.30

WITA

Patient referred from Narmada PHC

with G1P0A0L0 38-39 weeks S/L/IU

with latent phase 1 stage of labor pro

USG.Mother confessed abdominal pain

spread to flank since 07.00 (22/10/2013),

bloody slim (-), history of water leakage

(-), Fetal Movement (+). Nausea (-),

vomiting (-), headache (-), visual

diturbance (-).

No history of DM, HT, asthma. No

history of allergic reaction to medicine or

food.

LMP : 24 - 1 - 13

EDD: 1 11 - 13

History of ANC : 8x at Posyandu andPHC

Last ANC : 13-10-2013

History of USG : -

Last USG :

History of Family Planning : -

Next Family Planning : IUD

History of obstetry:1. This

Examination at VK Teratai Room:

General condition : Well

GCS : E4V5M6BP : 120/80 mmHg

PR : 88x/

RR : 20x/

Temp : 37,7C

General Status

Eyes : an-/-, ict -/-

Cor : s1s2single, m -, g

Pulmo : Ves +/+, rh -/-, whz -/-

Abdomen : striae gravidaum (+),

linea nigra (+)

Ext : oedem-/-, warm +/+

Status Obstetric

L1 : breech

L2 : back on the right side

L3 : head, in pelvic inlet

L4 : 4/5

UFH : 32 cm

EFW : 3.255 gram

FHR:20-21-19,reguler (160bpm)(FHR takicardi)

UC : 2 x /10~20

VT : 6 cm, eff 50%, Amnion (+),

head palpable HI, denominator

unclear, small part of

fetal/umbilical cord unpalpable

G1P0A0L0 38-39

weeks S/L/IU with

neglected active phase

1ststage of labor

Observation mother

and fetal well being

Lab. Check (CBC,

HBsAg, and Complete

Urine)

CTG

DM Co. to SPV, pro :

Inj. ceftriaxon 1g

Resusitation

intrauterin (RL :

D5% = 2 : 1)

SC

SPV Adv :

SPV Acc for SC,

Inj ceftriaxon 2g

Inj xilomidon 2cc

CIE patient and family

Pre OP SC


5/12


Chronology at Narmada PHC

22 /10/2013 at 00.30 WITA

S: Patient confessed abdominal pain

spread to flank since 07.00 (2/10/2013)

LMP : 24- 1- 2013

EDD: 1- 11- 2013

O:

General status :

GC well, con. CM, BP 130/80mmHg,

PR 80 x/minute, RR 20 x/minute, T 36.0

C. Oedema extremeties -/-.

Obstetric status:

L1: breech TFU: 30 cm

EFW: 2790 gram

L2 : back on the rightL3 : head

L4 : 4/5

UC : 2 x 10~ 35

FHR : 12- 11 -11 (140x/mnt)

VT : 1 cm, eff. 25 %, Amnion (+)

clear, head palpableHI, , denominator

unclear, impalpable small part of fetal &

umbilical cord.

G1P0A0L0 38-39

weeks S/L/IU with

latent phase 1 stage

of labor.


6/12


22/10/2013 at 07.30 WITA

S : -

O:

Obstetric status:

UC : 2-3 x 10~ 35-40

VT : : 2 cm, eff. 25 %, Amnion (+)

clear, head palpableHI, , denominatorunclear, impalpable small part of fetal &

umbilical cord

A: -

P: -

22/10/2013 at 01.00 WITA

S: -

O:

General status :

-.

Obstetric status:

UC : 3 x 10~ 35

FHR : -

VT : 2 cm, eff. 25 %, Amnion (+)

clear, head palpableHI, , denominator

unclear, impalpable small part of fetal &umbilical cord


7/12

Time Subjective Object Assesment Planning

23/10/2013 at 07.00 WITA

S: -

O:

General status :

-.Obstetric status:

UC : 2 x 10~ 35

FHR : -

VT : 2 cm, eff. 25 %, Amnion

(+) clear, head palpableHI, ,

denominator unclear, impalpable

small part of fetal & umbilical cord


8/12

FHR > 160 bpm


9/12

12.00

wita

Patient moved to OK Room - G1P0A0L0 38-39

weeks S/L/IU with


1ststage of labor



10/12

13.05

WITA

- G1P0A0L0 38-39

weeks S/L/IU with


1ststage of labor

SC Begin

13. 35

WITA

- - - Baby was born, male,

birth weight 3.300 g,

birth lenght 48 cm,

anus (+), congenitalanomaly (-), Apgar

Score 7-9

Amnion clear

Move Baby to NICU

15.35 Patient confessed dizzy (+) General StatusGeneral condition : Well


PR : 79x/

RR : 18x/

Temp : 36,8C

UC : +

UFH : 2 fingers below umbilicalUO : 500 ml

2 hours post SC

Observation patientgeneral condition,

urine output and vital

sign

Observation SC

wound

Move patient to Melati

room



11/12

24/10/13

07.30

Patient confessed dizzy (+) General Status

General condition : Well


PR : 88x/

RR : 22x/

Temp : 36,7C

UC : +

UFH : 2 fingers below umbilical

UO : 400 ml

Baby in NICU ;

PR: 144 bpm

RR: 42 x/m

Temp :36,8 C

1 day post SC Observation patient

general condition,

urine output and vital

sign

Observation SC

wound



12/12

THANK YOU...

mr 231013 negelegted

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