Case 1

Name : Mrs. SA
Age : 31 yo
Address : Lingsar
Admitted : 17 May 2017
RM : 138200
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E
17/5/ Patient came from obstetric outpatien General Status G2P0A1L0 38- Monitoring:
2017 clinic confessed water leaked out GC : well 39w S/L/IU head - Obs Mother and
14.00 from her womb since 17.00 WITA. BP : 120/80 mmHg presentation, fetal condition
(16/5/2017). The color was clear with PR: 80 tpm history of PROM - Obs the
no smell, abdominal pain (-), Bloody RR: 20 tpm >12 hours + LHM progression of
slime (-), FM (+) Tax: 36.5 C labor
Weight: 47 kg
History of DM (-), HT (-), asthma (-), High: 137 cm Therapy:
allergic (-) Injection ampicilin
History DM in family (-), HT (-), Localis status 2 gr/iv, continue
asthma (-), allergic (-) Eye : an (-), ict (-) with oral ampicillin
Pulmo : ves (+/+), rh (-/-), wh (-/-) 3x500 mg for 7
History of menarche 15 y.o, routin Cor : S1S2 single regular, murmur days
LMP: 20-08-2016 (-), gallop(-)
EDD: 27-05-2017 Abdomen:
Scar (-), striae gravidarum (+), linea DM co to GP, GP co
History of ANC: 10x in Posyandu, 1x gravidarum (+) to Spv, advice:
in GH RSUDP NTB Extremity: oedema (-/-) warm (+/+) Therapy based
Last ANC: 17-5-2017 on NTB GH
Result: S: Amnion fluid leaked from Obs status: Guideline on
her womb, BP 120/80 mmHg, BW 47 L1 : breech PROM
kg, GA 38-39w , UFH 33cm, head L2 : back on left side Drip oxytocin
presentation L3 : head
L4: 4/5
History of USG: 2X in Obstetrician
Last USG: 17-5-2017 UFH: 29 cm
Result: S/L/IU head presentation/ FHB :12-13-12 (148x/m)
BPD 34-35w/ AC 34-35w/ FL 35-36
w/2603gr UC: -
VT : VT: 1 cm, eff 10 %, amnion
Obstretic history (-), head palpable HI,denominator
1. Abortus (Mei 2016) unclear, impalpable small part and
2. this umbilical cord
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History of Contraception: - PE:

Planning of Contraception: Injection Promontorium not palpable
3 months Arcus pubis >90
Spina ischiadica not prominent
Os coccygeus mobile

Lab result (17/5/2017):

Hb: 12
RBC: 3,95
HCT: 35,5
WBC: 8,01
PLT: 168
HbsAg (-)
GDS: 73
PPT: 15,1
APTT: 29,4
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
18.00 Abdominal Pain (-) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 80 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 8 dpm
T: 36,6 C history of PROM
UC : - >12 hours + LHM
FHB : 12-12-12

18.30 Abdominal Pain (-) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 78 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 12 dpm
T: 36,7 C history of PROM
UC : - >12 hours + LHM
FHB : 12-12-11

19.00 Abdominal Pain (-) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 78 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 16 dpm
T: 36,6 C history of PROM
UC : - >12 hours + LHM
FHB : 12-12-12
19.30 Abdominal pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 78 bpm S/L/IU head - Obs Mother and fetal condition
RR: 19 tpm presentation, - Drip oxytocin 20 dpm
T: 36,5 C history of PROM
UC : 2 x 10 ~ 15 >12 hours + LHM
FHB : 11-12-11

20.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 78 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 24 dpm
T: 36,5 C history of PROM
UC : 2 x 10 ~ 15 >12 hours + LHM
FHB : 12-11-12
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
20.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 80 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 28 dpm
T: 36,6 C history of PROM
UC : 3 x 10 ~ 20 >12 hours + LHM
FHB : 12-12-12

21.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 32 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11

21.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 36 dpm
T: 36,45C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-12
22.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
22.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
23.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 80 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,6 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-12-12

23.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11

24.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Flash 1 Drip oxytocin finished
T: 36,45C history of PROM - Drip oxytocin 40 dpm
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-12
00.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
01.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
01.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 80 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,6 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-12-12

02.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11

02.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,45C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-12
03.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
03.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
04.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 80 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,6 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-12-12

04.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11

05.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Drip oxytocin 40 dpm
T: 36,45C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-12
VT: 1 cm, eff 10 %, amnion (-),
head palpable HI,denominator
unclear, impalpable small part and
umbilical cord
05.30 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation, - Flash 2 Drip oxytocin finished
T: 36,4 C history of PROM - Co. SPV: Pro SC
UC : 3 x 10 ~ 25 >12 hours + LHM
FHB : 12-11-11
06.00 Abdominal Pain (+) BP: 100/70 mmHg G2P0A1L0 38-39w Monitoring:
FM (+) PR: 76 bpm S/L/IU head - Obs Mother and fetal condition
RR: 20 tpm presentation,
T: 36,4 C history of PROM
UC : 3 x 10 ~ 25 >12 hours + LHM