Case

• Name : Mrs. A
• Age : 36 yo
• Address : Lingsar, Lobar
• Admitted : April, 19th 2017
• RM : 59 13 79
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

19/04/ Patient referred from Sigerongan General status: G5P4AH2 32-33 DM planning:
17 PHC with G5P4A0H2 32 weeks GC: well weeks G/L-L/IU Diagnostic:
12:56 G/L-L/IU . Patient confessed Cons : E4V5M6 breech • USG
pm abdominal pain since 05.00 am, BP: 110/80 mmHg presentation- • CTG
water leaked out from her womb PR: 84 bpm head presentation
(-). Bloody slime (-), FM (+). RR: 18 tpm with latent phase Therapy:
Headache (-), Blurred vision (-), T: 360c of labor • Obs mother and fetal
epigastric pai n (-) No history of Eye : palor (-), icteric (-) well being
DM, HT, asthma. Thorax : • Pro C section
Cor : S1S2 single reguler (murmur -
LMP: 10/09/2016 ), (gallop -) SPV advice :
EDD: 17//06/2017 Pulmo : vesikuler (+/+), wheezing (- - Obs progress of
GW: 32 w /-), labor
Ronkhi (-/-). - Inj antibiotic
History of ANC: 8x at Posyandu Abdomen : scar (-), striae (+), linea
Last ANC: 16/4/2017  Twins nigra (+)
History of USG: 1x at Sp.OG Extremity : edema (+/+), warm acral
Last: 18/04/17 (+/+)
Result  Twins, 1577/1519 gram
Obstetrical status:
History of family planning: IUD L1: breech
Next family planning: IUD L2: back on the left side and the
right side
Obstetrical history: L3: Head
I. Male/ Aterm/house/ UFH: 34 cm
normal/death UC: 3x10’ 30”
II. Male/aterm/normal/house/de FHB1: 13-13-13 (156 x/min)
ath FHB2: 13-13-14 (160x/min)
VT: Ø3 cm, eff 50%, amnion (+),
head palpable ↓HI, inpalpable small
part of fetal or umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

19/04/ History of family planning: Injection 3 Laboratory exam (19/04/2017):

2017 months HGB: 11,6
Next family planning: : IUD RBC: 4,14
HCT: 36
Obstetrical history: WBC: 10,75
1. this PLT: 193
GDS 101
Hbs Ag non reaktif
PPT 11,3
APTT 23,2
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronology at Sigerongan PHC (19- GC: well A/ G5P4A0H2 32 P/

04-2017) GCS: E4V5M6 weeks G/L/IU • Inform mother
BP: 120/180 mmHg breech
about the
Patient 9 month pregnant confessed HR: 82 tpm presentation,
abdominal pain spread to the flank (- RR: 21 tpm mother and fetal examination
) since 08.00 (19/04/2017), bloody Tax: 36,5°C well being with result
slime (-), water leaked out from her UFH : 38 cm laten phase of • Lying to the
womb (+) since 05.00, fetal I. Breech presentation – back on labor + gemeli left side
movement (+). the right side • Suggest
II. Breech presentation – back on
mother to eat
the left side
FHB: 148 bpm / 146 bpm and drink
A/ G5P4A0H2 32 weeks G/L/IU VT : Ø 2cm, eff 25%, amnion (+), • IVFD RL 20
breech presentation, mother and breech presentation, HII, not tpm
fetal well being with laten phase of palpable small part & umbilical cord • Refer to NTB
labor + gemeli UC : 3x10’ 40” GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

P/
• Inform mother about the
examination result
• Lying to the left side
• Suggest mother to eat and drink
• IVFD RL 20 tpm
• Refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.30 Abdominal pain (+), BP : 110/70 mmHg G5P4A0H2 32-33 DM planning :

Water leak from her womb HR: 80 tpm weeks G/L-L/IU •Obs mother and fetal well being
(-) RR: 20 tpm breech presentation-
Tax: 36.7◦ C head presentation
UC : 4x10’ 40” with active phase of
FHB1: 13-13-13 (156 labor
x/min)
FHB2: 13-13-14
(160x/min)
VT : Ø 6 cm, eff 75%,
amnion (+) head
palpable ↓HI, inpalpable
small part of fetal or
umbilical cord

14.50 Abdominal pain (+), Water GC: well 2nd phase of labor DM Planning :
leak from her womb (+) Cons : E4V5M6 - Try to conduct the labor
mother want to bearing FHB1: 12-12-13 (156
down x/min) - If failed, pro C section
FHB2: 11-12-11
UC: 4x10’ 45”
VT : Ø complete
dilatation, amnion (-)
clear, head palpable
↓HIII, palpable small part
of fetal or umbilical cord

15:30 1st baby was born until Baby was born, female, AS 7-9,
shoulder, the head can 1850 gram, 43 cm, Anus (+),
not descend congenital anomaly (-)
VT : head of 2nd baby
palpable Baby was born, female, AS 6-8,