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Case Report

Mrs.ZA, 32 yo, from Belencong,


Hospitalization on 05.20, 24/06/2012

G3P2A0H2, 41 wk, S/A/IU, breech presentation, laten phase 1st


stage of labor + history rupture of membrane
Time Subject Object Assessment Planning
Chronology in Gunungsari ZA score : 3
PHC: Multigravida (1)
24/06/2012, 04.10 History of breech presentation
S: Patient 9 month pregnant : never (1)
Gestation age: >39 weeks (0)
came confessed rupture of
EFW : < 3176 g (2)
membrane (+) since 03.00
2 cm (0)
(24/06/2012). Abdominal
Station : < -3 (0)
pain (+).
O: General status : GC well, Lab result in 15.56,
BP 110/80 mmHg, HR 82 14/06/2012
x/minute, RR 21 x/minute, T Hb = 10,5 g/dl
36,4 C. LMP 10/09/2012. Rbc = 3,99
EDD 17/06/2012/ Leu = 22,95
Obstetric status: Plt = 315
L1 : head TFU: 41cm Hct = 32,4%
AC: -, EFW: - HbSAg = (-)
L2 : back on the right side
L3 : breech
L4 : -
UC : (+) 1x/10-20
FHR : (+) 140/minutes
VT : 2 cm, eff. 25%,
Amnion (-) , breech palpable
HI,denom: sacrum,
impalpable small part of fetal
& umbilical cord.

- A: G3P2A0L2 41 wk S/L/IU,
breech presentation with
PROM + breech site.

P: - Inj. Ampicillin 1g/IV (04.15 )


- Set infuse RL 20 tpm
(08.40).
Time Subject Object Assessment Planning
10.15 Abdominal pain (+). GC: well Breech presentation, -Obs. Mother and fetal
(at VK BP : 100/70 mmHg laten phase 1st stage well being.
Teratai) PR : 80 x/minute of labor + history -Obs. Progress of
RR : 20 x/minute rupture of labor.
T : 36,2 C membrane. -CTG, result reactive.

UC : 2x10 ~ 20
FHB: 12.11.11 (136x/minute).

11.20 Patient want to bearing down Seen breech in vulva. Breech presentation -Lead mother to
(+). UC : 3x10 ~ 35 2nd stage of labor + bearing down.
FHB: 12.11.12 (140x/minute). history rupture of
membrane. Amnion fluid: clear

- - Baby was born (11.25).


Female. 2800 gram. BL
47 cm. AS 6-8. Anus
(+). Congenital
anomaly (-).

Lovset and Manuver


Mauriceau-Smellie-Veit

Placenta was born


spontan. Complete.
300gram.

Leukia 100cc
Time Subject Object Assessment Planning
14.00 - GC : well 2 hours post partum. -Obs. Mother and baby
BP : 110/70 mmHg well being.
PR : 84 x/minute -CIE mother to breast
RR : 18 x/minute feeding.
T : 36,7 C -CIE mother to eat and
UFH : 2 finger below umbilicus drink.
Lochea: (+)

Baby room in:


PR : 140 x/minute
RR : 48 x/minute
T : 36,3 C

25/06/12 - GC : well 1 day post partum. -Obs. Mother and baby


07.30 BP : 110/70 mmHg well being.
PR : 80 x/minute -CIE mother to breast
RR : 20 x/minute feeding.
T : 36,5 C -CIE mother to eat and
UFH : 2 finger below umbilicus drink.
Lochea: (+)

Baby room in:


PR : 144 x/minute
RR : 44x/minute
T : 36,2 C

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