Case No.

PATIENT’S ID PATIENT HUSBAND’S ID

Name : Mrs. YW Name : Mr. W

Age : 21 years old Age : 28 years old
Address : Pasar Usang Address : Pasar Usang
MR No. : 01.04.03.83 Occupation : Enterpreneur
Admission date : Feb 14th, 2019
Education : junior high
school
Occupation : house wife
 ANAMNESIS
A 21 years old patient admitted to Delivery room Dr. M. Djamil
Central General Hospital Padang on Feb 14th, 2019, at 04.40
a.m referred from Public Health Care of Pasar Usang with
diagnose G1P0A0L0 term parturient 39 - 40 weeks laten phase
of first stage + HBsAg (+).
 PRESENT ILLNESS HISTORY
•Previously , patient control to Pasar Usang Public Health Care with
chief complaint pelvic pain to the groin since 6 hours before
admision. From examination in Pasar Usang Public Health Care,
patient was diagnose with G1P0A0L0 term parturient 39 - 40 weeks
laten phase of first stage + HBsAg (+), then patient was referred to
delivery room of Dr. M. Djamil Central General Hospital with IV line
and urinary catether inserted
•Bloody show from the vagina was (+) since 6 hours before
admission.
•Fluid leakage from the vagina was absent
•Massive bleeding from the vagina was absent
•Amenorrhea since 9 months ago.
•First date of last menstrual period was May 12th 2018
•Estimation date of delivery on February 19th 2019
•Fetal movement was felt since 4 months ago
PRESENT ILLNESS HISTORY
• No complain of nausea, vomiting, and vaginal
bleeding neither during early pregnancy nor late
pregnancy
• Prenatal care :
• prenatal care to midwife since 3 month of pregnancy.
never controlled to obstetrician.
• during prenatal care, patient was known with HbsAg (+)
but the patient never check up to obstetrician
• Menstruation history: menarche at 13 years old,
regular cycle once for every 28 days, 2-3 times pad
change/day without menstrual pain
Previous Illness History
There is no history of heart, lung, liver, kidney, DM,
hypertension, and allergic reaction to the drugs.

Family Illness History

There was no history of hereditary disease and

physicological illness in the family.
Marital status : married once in 2018

Obstetrics status : pregnancy / abortion / delivery : 1 / 0/ 0

1. Present

History of family planning : (-)

Immunization : (-)
Educational background : junior high school
Occupation : Housewife
Habbits : smoke (-), alcohol (-), drugs (-)
PHYSICAL EXAMINATION
•Vital sign :
•GA Cons BP PR RR T BB TB
•Mdt CMC 100/70 88 20 AF 65 155
•Body Weight before pregnancy : 50 kg
•Body Weight : 65 kg
•Body Height: 155 cm
•Body Mass Index: 20,8 (normoweight)
•Upper Arm Circumference : 24 cm
Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric
•Chest : areola hyperpigmentation (+), breast enlargement (+)
H/L normal
•Abdomen : OR (obstetric record)
•Genitalia : OR (obstetric record)
•Extremity : Edema -/-,
Physiological Reflex +/+,
Pathological Reflex -/-
Abdomen :

I : Enlarge accordance to term pregnancy, striae gravidarum (+), midline hiperpimentation (+),
cicatrix (-) .

Pa :

L1 uterine fundal was palpable at 3 finger below xyphoid process,

a large, soft, nodular mass was palpated

L2 a hard and resistance structure was felt on the left side,

numerous small part of the baby was felt on the right side

L3 a round, hard, fixated mass was palpable

L4 Divergent

Uterine fundal height : 33 cm EFW : 3255 grams

Uterine contraction : 1-2x/15”/Mild

Pe : Tympani

Au : Peristaltic sound was normal, FHR :140-150 x/minutes

Genitalia :
Inspection : V/U normal, vaginal bleeding (-)
VT : dilatation of servix was 3-4cm,
efficement 90%, soft, median
amniotic sac (+),
fetal Head was palpable at hodge II-III.
• Inlet pelvic size : Adequate for vaginal delivery
Promontorium wasn’t palpable,
Inominate line wasn’t palpable
Pelvic side wall was stright
Ischial spines wasn’t protrude
Sacral bone was well curved
Sacrococcygeal bone was mobile
Pubic arch>90

• Outlet pelvic size :

Inter tuberous distance could accommodate an adult fist (>10,5 cm)

• Inlet & outlet : Normal Pelvic size

 • Fetal alive, singleton, intrauterine, head presentation
• Fetal movement was good
USG • Biometrics :
• BPD : 9.37cm
• AC : 32.39 cm
• FL : 7.33 cm
• EFW : 3094 gr

• Plasenta was Implanted at posterior corpus, maturation gr II

• fetal heart rate was 145 bpm
• Impresion :
• 37-38 weeks of pregnancy ,
• fetal alive
• head presentation
CTG
Interpretasi CTG
• Baseline : 140 - 150 bpm
• Variability : 5-15 bpm
• Acceleration : (+)
• Deceleration : (-)
• Fetal Movement : (+)
• Contraction : (+)
 Impression : 1st category
Laboratory Evaluation on February 14th 2019:
Parameter Results Normal Range Unit
Hemoglobin 13.2 12-16 g/dl
Leukosit 10.160 5.000-10.000 103/mm3
150.000-
Trombosit 161.000 103/mm3
400.000
Hematokrit 39 37.00-43.00 %
PT 9.6 9.4-12.8 Second
APTT 30.7 28.0-37.8 second
• HbsAg • reactive
• Non
• HIV
reactive
Diagnose
G1P0A0L0 first stage of latent phase 39-40 weeks of term pregnancy +
HbsAg (+)
Fetal alive singleton intrauterine head presentation Hodge II-III
Action :
 Control,GA, VS,uterine contraction,FHR.
 Informed consent
 IVFD RL 20 tpm
 Ceftriaxon 2 gr (IV)  Profilasis
 Consult Perinatology
 Consult anesthesia and OR

Plan: LSCS
At 6.45 am : LSCS was performed

A male baby was born by LSCS, with :

3200 grams in body weight, 48 cm in height, APGAR score 8/9
Placenta was delivered by mild traction on the umbilical cord,
complete, 1 piece, 17 x 16 x3 cm in size, ± 600 g in weight, the
umbilical cord was ± 50 cm
Estimated blood lose during operation ± 150 cc

Diagnosis :
•P1A0L1 post LSCS due to on indication HbSAg (+)
•Mother and baby were in care

Management :
•Control GA, vaginal bleeding, contraction,
•IVFD RL + oxytocin : metergin (1:1)  28 gtt/minute
•Pronalges Supp II /if needed

Plan :
Routine blood test post operation
Laboratory Evaluation post op:
Parameter Results Normal Range Unit
Hemoglobin 11.60-13.90 g/dl
Leukosit 5.700-13.600 103/mm3
174.000-
Trombosit 103/mm3
391.000
Hematokrit 31.00-41.00 %
THANK YOU