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Case Summary: Prolonged Labor and SC

- Mrs. F, a 25-year-old woman (G1P0A0L0), was admitted to the hospital at 08:15 on August 23rd, 2011 for a prolonged second stage of labor at 41 weeks gestation with breech presentation. - Upon examination, she was found to have a uterine fundal height of 34cm, breech palpable in the fundus, and an estimated fetal weight of 3565 grams. Attempts were made to terminate the labor through external version and vacuum extraction, both of which failed. - She subsequently underwent a successful cesarean section at 11:25, delivering a 3200 gram male infant in good condition. Her post-operative condition

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Lili Suriani
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111 views6 pages

Case Summary: Prolonged Labor and SC

- Mrs. F, a 25-year-old woman (G1P0A0L0), was admitted to the hospital at 08:15 on August 23rd, 2011 for a prolonged second stage of labor at 41 weeks gestation with breech presentation. - Upon examination, she was found to have a uterine fundal height of 34cm, breech palpable in the fundus, and an estimated fetal weight of 3565 grams. Attempts were made to terminate the labor through external version and vacuum extraction, both of which failed. - She subsequently underwent a successful cesarean section at 11:25, delivering a 3200 gram male infant in good condition. Her post-operative condition

Uploaded by

Lili Suriani
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd

Resume of Case August 23th, 2011

Supervisor : dr. Juliawan, SpOG MS :Arif, Tya, Dinmas, Ita, Uyunk, Lili Phisiology : 0 Phatology: 1

Identitied
Name : Mrs. F Age : 25 years old MR : 253552 Adressed: Bengkel

Admitted to GH of NTB on August 23th, 2011 at 08.15

Time 08.15 (23/8/ 2011)

Subject Patient reffered from Bengkel PHC with G1P0A0L0 41weeks/S/L/IU head presentation + prolonged 2nd stage of labor. Abdominal pain since 20.00 WITA (22-08-2011) came to GH of NTB. History rupture of membrane (+), abdominal pain (+) , bloody slim (+), FM (+). History of HT (-), DM (-), Asthma (-) LMP : 9-11-2010 EDD : 16-08-2011 History of ANC : > 4 x at Polindes History of family planning : Next family planning : IUD History of obstetric 1. This Chronologist : 23-08-2011 04.00 WITA S : patient came to Bengkel PHC with G1P0A0L0 41weeks/S/L/IU head presentation + prolonged 2nd stage of labor at 04.00 (23-8-2011). Abdominal pain since 20.00 WITA (22-08-2011) Blood slim (+), FM (+), history ruptur of membrane (+) at 20.00 WITA (22-082011). History of DM (-), HT (-), Asthma ().

Object General status: General condition : well Cons : CM BP : 140/80 mmHg PR : 80 bpm RR : 20 x/minute T : 37C Localis status Head : an (-/-) ict (-/-) Pulmo : Ves (+/+), Rh (-/), Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 30 cm L2 : back on the right L3 : head L4 : 3/5 UC : EFW : 3565 gram FHB : 11.12.11 VT : complete, amn (-) clear, head palpable, HII , caput (+) ,unpalpable small part or umbilical cord,

Assestment G1P0A0L0 41 weeks/S/L/IU head presentation neglected 2nd stage of labor

Planning - Obs. Mother and fetal well being -DL and HBsAg Report to GP (09.00 wita): -Pro rehidration, Adv : - Rehidration -Inj Ampisilin 1 gr/IV GP report to Supervisor Adv: - Try termination with EV if failure, pro SC

O: 04.00 WITA GC : well GCS : E4V5M6 TD : 140/80 mmHg PR : 84x/minute Temp : 37C RR : 20x/minute Abdominal palpation : UFH 34cm, breech palpable in fundus. Right back. EFW 3565 gr FHB (+) VT : 8 cm, amn (+), eff 75%, head palpable, HII unpalpable small part or umbilical cord 06.00 WITA FHB (+) VT : complete, amn (-) clear, head palpable, HII unpalpable small part or umbilical cord, prepare to GH NTB 08.00 WITA Sent to GH of NTB with prolonged 2nd stage of labor + Bayi Besar A: G1P0A0L0 41weeks/S/L/IU head presentation + prolonged 2nd stage of labor + Bayi Besar P: Reffered to GH

Lab exam : WBC : 25.000 RBC : 4,36 HGB :10,2 PLT : 348.000 Hct : 34,1 Mcv: 25,2 Mch : 25,5 HBsAg : +

Time 10.30 wita

A G1P0A0L0 41 weeks/S/L/IU head presentation neglected 2nd stage of labor

P EV beganVacum failur

11.00 wita

Co to Supervisor Adv: -Acc SC -CIE Os & Family -Rehidrasi D.C -Cepotaxim 2 gr/IV

11.25 wita 12.15 wita

SC began Baby was born, Male, BW ; 3200 gr, BL: 47 cm, A-S ; 7-9, anus (+), congenital anomaly (-), amnion clear 30 cc, bleeding 100 cc Baby was sent to NICU Placenta was born spontan, completely. bleeding 100 cc

12.20

Time 13.00

S -

O Mother GC : well BP ; 130/80mmHg PR : 70 bpm RR : 19 x T : 36,5C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 250 cc

A 1 hour post SC

P Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

14.00

Mother GC : well BP ; 130/80mmHg PR : 84 bpm RR : 20 x T : 37,1C UC (+) hard, palpable in umbilical. Active bleeding (-) UO : 500 cc

2 hour post SC

Obs vital sign and active bleeding CIE mother to eat and drink if not fomit

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