CASE 1

G2P1A0, 24 years old, 37-38 weeks of gestation according to USG, not in labor, with
single alive intrauterine fetus, head presentation and anemic

1. IDENTITY
1. Name : Mrs. TY
2. Age : 24 years old
3. Ethnicity : Java
4. Religion : Moeslim
5. Occupation : Housewife
6. Education : Junior high school
7. Date of admission : April 8th 2017

2. HISTORY
1. Chief complaint :
Patient come to control her pregnancy.
2. History of present illness :
Patient came to Ob-Gyn clinic of Atma Jaya Hospital with
complain of yellow discharge from the vagina 1 day before
admission with smell and itch. She also felt abdominal discomfort
since 5 days before admission to the hospital. She also felt the
contraction with low intensity about 3 times per 10 minutes
irregularly. She denied any other complaints such as bleeding,
fever, urinary discomfort, and fatigue.
3. History of past illness :
1. History of hypertension : Denied
2. History of diabetes mellitus : Denied
3. History of allergy : Denied
4. History of epilepsy : Denied
5. History of hematologic disease : Denied
6. History of urinary tract/kidney disease : Denied
7. History of trauma : Denied
8. History of surgery : Denied
9. History of chronic disease : Denied
4. Family History :
1. History of hypertension : Denied
2. History of diabetes mellitus : Denied
3. History of allergy : Denied
5. History of menstrual cycle :
1. Menarche : 14 years old
2. Menstrual cycle : 28 days, regularly, with duration of
5 days, changed 2-3 pads a day
(40-60 cc), dysmenorrhea (-).
3. First day of last menstrual cycle : September 20th 2016
6. Marital history :
She married once, 6 years with current husband.
7. Contraception history: The patient use injected contraception every 3 months with the
last used 1 years ago.
8. History of Antenatal Care:
Patient had antenatal care with 5 visits, 1 at midwife, 1 at
primary health care, and 3 at hospital. .
9. Obstetric history:

No Years Gestational Labor Sex Birth Breast

Age History Weight Feeding
1 5 years 9 months Normal femal 2800 +/+
old delivery e
2 present 37-38 weeks

1. PHYSICAL EXAMINATION
1. General condition : Appeared mildly ill
2. Level of consciousness : Compos mentis
3. Vital signs
4. Blood pressure : 140/100 mmHg
5. Heart rate : 80 beats per minutes
6. Respiratory rate : 24 breaths per minutes
7. Body temperature : 37 C
1. Weight : 54 kg
2. Height : 155 cm
3. BMI : 22.5 kg/m2
4. General examination
1. Eyes : Anemic conjunctiva -/- ; icteric sclera -/-
2. Mouth : Wet oral mucosal membrane
3. Thorax
1. Heart : Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
2. Lung : Vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
3. Mammae : Areola hyper pigmentation +/+, nipple retraction -/-,
breast milk +/+
4. Abdomen
1. Inspection : Convex, striae gravidarum (+), linea nigra (+)
2. Auscultation : Bowel sounds (+), 6 times per minute.
3. Palpation : Supple, tenderness (-)
5. Extremities : warm, CRT < 2 seconds, edema (-/-/-/-),
physiologic reflex (+/+/+/+), pathologic reflex
(-/-/-/-)
1. Obstetric Examination
1. Estimated due date : 27 Mei 2017
1. Fundal height : 33 cm
2. Fetal weight examination : 3410 gram
3. Uterine contraction : positive
4. Fetal heart rate : 130 x/menit
5. Leopold maneuver
1. Leopold I : Buttock
2. Leopold II : Back on the right side
3. Leopold III : Head
4. Leopold IV : Divergent
1. Vaginal toucher :
1. Vulva and vaginal within normal limit, anteflexion position, dilatation 3cm, cervical
effacement 50%, consistency: thick and soft, amnion sac intact, with back
presentation.
1. Inspeculo : fluksus -, erosion -, stoll cell -, tissue -, cicatrix -.
6. Rectal toucher : not performed

1. CARDIOTOCOGRAPHY :
Baseline : 135 bpm
Variable : minimal
Acceleration : (+) 1 times in 20 minute
Deceleration : (-)
Fetal movement : (+) 1 time in 20 minutes
His : (+) 2 times in 20 minutes
Result : NST Reassuring
 1. LABORATORY EXAMINATION

Types Results Units Normal Value

Hematology
Hemoglobin 9,1 g/dL 12 16
Hematocrit 28 % 37 47
Leucocytes 12,8 Thousands/uL 4 10
Platelets 315 Thousands/uL 140 400
Erythrocytes 4,3 Millions/uL 4,20 5,2
MCV 66,0 fL 79 93,3
MCH 21,2 pg 26,7 31,9
MCHC 32,0 g/dL 32,3 35,9

Virology
HBsAg (-) Negative

1. WORKING DIAGNOSIS
 G2P1A0, 24 years old, 37-38 weeks of gestation according to USG, not
in labor, with single alive intrauterine fetus, head presentation and
anemic

1. PLANNING
1. Check for CBC
2. Give Oxygen via Nasal Kanul 4L/minutes
3. RL 500 cc loading 200
4. Sleep on left position
5. Repeat CTG afer 2 hours if the CTG is reactive observation the labor and give
management with :
6. NaCl 100 cc + 1 amp Buscopan high preassure
7. RL 500cc + 5 units Oxyosin start 8tpm/min increase 4 tpm/min every
30 minutes until the contraction is adequate. Max 40tpm/min
8. Give 1 bag of PRC
9. Prepare for vaginal spontaneous labor

1. FINAL DIAGNOSIS
Mother : P2A0, 24 years old, post partus maturus with spontaneous vaginal
delivery with rupture perineum grade I + anemia
Baby : Term shemale neonate, 38-39 weeks of gestational age according
to New Ballard Score, birth weight 2940 gram, 49 cm, APGAR score 7/9.
Diagnosed as healthy neonate.

1. TREATMENT AFTER DELIVERY

1. Observation of vital signs
1. Observation vaginal bleeding and uterine contraction
2. RL 500 cc + okcytocin 20 IU
1. Cefadroxil 3 x 200 mg tab PO
2. Mefenamic acid 3 x 500 mg tab PO
3. Methergin 3 x 0,125 mg tab PO
 4. Sangobion 2 x 1 tab PO
5. Moloco B12 3 x 1 tab PO

1. TAKE HOME MEDICINE

1. Cefadroxil 3 x 500 mg tab PO
1. Mefenamic acid 3 x 500 mg tab PO
2. Methergin 3 x 0,125 mg tab PO
3. Moloco B12 3 x 1 tab PO
4. Kalk 1x 1 tab PO