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CASE RESUME
NORMAL LABOR
PATHOLOGY
LABOR
TIME
SUBJECTIVE
OBJECTIVE
9/11/
2012
10.20
at
History of USG : 1 x
History of Family Planning :
Injectio
n
every
3
month
Next
Family
Planning
:
Injectio
n
every
3
month
Obstetrical History :
1. Aterm, Spontant, Midwife,
General Status :
GC : Well
BP : 120/80
PR : 96 bpm
RR : 24 tpm
T : 36,5 C
Local Status :
Eye : Anemis (-/-), Icteric (-/-)
Cor : S1S2 Single regular,
murmur (-), gallop (-)
Pulmo
:
Vesicular
(+/+),
wheeizing (-/-) ronkhi (-/-)
Abdomen : Scar (-), Striae
Gravidarum
(+),
Linea
nigra(+)
Extremity : Oedema :
Warm acral :
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : Head
L4 : 4/5
UFH : 26
EFW : 2325
UC : FHB : 11-11-11 (132 bpm)
VT : 1 cm, effacement 10%,
amnion (-), Head palpable,
H1, denominator unclear,
impalpable small part and
umbilical cord
ASSESSMENT
PLANNING
Observation
mother and fetal
well being
Ampicillin
injection
1
gr
Intravenous
Dexamethasone
12 mg/12 hours
USG
at
Pro
10/11/2012
TIME
9/11/
2012
10.20
SUBJECTIVE
OBJECTIVE
Lab Examination :
HB : 12,2 g/dl
RBC : 4,13 x 106/L
HCT : 41,0 %
WBC : 9,08 x 103/L
PLT : 339x 103/L
HbSAg : (-)
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
ASSESSME
NT
PLANNING
G3P2A0L2
36-37 weeks
S/L/IU head
presentation
with PROM
Observation
mother and
fetal well being
Ampicillin
injection 2g/iv
every 6 hours
Chronologist at PHC
7/11/
2012
13.0
0
General Status :
GC : Well
BP : 130/80
PR : 84 bpm
RR : 22 tpm
T : 36,5 C
Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : Head
L4 : 3/5
UFH : 27
EFW : 2460
UC : FHB : 11-10-11 (128 bpm)
VT : 1 cm, effacement
10%, amnion (-), Head
palpable,
H1,
denominator unclear,
impalpable smll part
and umbilical cord
TIME
10/1
1/20
12
09.0
0
SUBJECTIVE
OBJECTIVE
ASSESSME
NT
PLANNING
SPV adv :
do as aterm
PROM
Result :
Fetus : S/L/IU
Amnion : Enough
Placenta : at Fundus grade
III
Pregnancy age : 36 weeks
EFW : 2500 gr
13.00
CTG : reactive
GC : Well
BP : 130/80 mmHg
PR : 90 bpm
RR : 24 tpm
T : 36,5 C
UC : FHB : 11-10-11 (128 bpm)
VT : 1 cm, effacement 10%,
amnion (-), Head palpable,
H1, denominator unclear,
impalpable small part and
umbilical cord
Consult
to
DM
General
Doctor,
adv : Termination
with oxytosin drip
Oxytosin
Drip
Start at 8 dpm
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
10/11/1
2
13.30
14.00
14.30
UC : 2x10~15
FHB : 11-10-10 (124
bpm)
15.00
UC : 2 x 10 ~ 25
FHB : 11-10-11 (128
bpm)
15.30
UC : 2x 10 ~ 25
FHB : 11-11-11 (132
bpm)
16.00
UC : 2x 10 ~ 25
FHB : 10-11-11 (128
bpm)
16.30
UC : 2x 10 ~ 25
FHB : 10-11-11 (128
bpm)
17.00
UC : 2x 10 ~ 25
FHB : 11-11-11 (132
bpm)
GC : well
BP : 120/80 mmHg
PR : 88bpm
RR : 20 bpm
T : 36,8OC
17.30
UC : 2x 10 ~ 25
FHB : 11-11-10 (128
TIME
SUBJECTIVE
10/11/1
2
19.00
OBJECTIVE
ASSESSMENT
UC : 3x 10 ~35
FHB : 11-11-11 (132
bpm)
PLANNING
Drip oxytocin 1st flash
end, continue with
2nd flash
Drip oxytocin 40 dpm
19.30
UC : 3x 10 ~35
FHB : 10-11-11 (128
bpm)
20.00
UC : 3x 10 ~40
FHB : 10-11-11 (128
bpm)
20.30
UC : 3x 10 ~40
FHB : 11-11-10 (128
bpm)
21.00
UC : 3x 10 ~40
FHB : 11-10-11 (128
bpm)
GC : well
BP : 120/80 mmHg
PR : 92bpm
RR : 20 bpm
T : 36,9OC
21.30
UC : 3x 10 ~40
FHB : 11-10-11 (128
bpm)
22.00
UC : 3x 10 ~40
FHB : 11-11-11 (132
bpm)
VT
:
1
cm,
effacement
10%,
amnion
(-),
Head
TIME
SUBJECTIVE
OBJECTIVE
22.30
UC : 3x 10 ~40
FHB : 11-11-11
(136bpm)
23.00
UC : 3x 10 ~40
FHB : 11-11-10 (128
bpm)
VT : 1 cm,
effacement 10%,
amnion (-), Head
palpable, H1,
denominator unclear,
impalpable small part
and umbilical cord
11/11/1
2
06.00
07.00
GC : well
BP : 120/80 mmHg
PR : 88bpm
RR : 24 bpm
T : 36,7OC
ASSESSMENT
PLANNING
Drip oxytocin 40 dpm
Dm Consult to SPV :
SPV advice CS at
07.00 11/11/12
Prepared CS
Insert DC
Ampicillin 2 gr/IV
CS began
Baby was born, male,
BW : 2500 gram, BL:
45 cm, A-S : 7-9, anus
(+), congenital
anomaly (-),
Placenta was born
manually, complete
Bleeding : 500 cc
CS finished
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
11/11/1
2
10.00
GC: well
BP: 110/80 mmHg
PR: 104 bpm
RR: 24tpm
T: 37,2oC
UC : (+) well
UFH : 1 fingers below
umbilicus
2 hours post CS
12/11/1
2
07.00
GC : well
BP : 120/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,7OC
UC : (+) well
UFH : 2 fingers below
umbilicus
1 day post CS
Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC