20-02-14 Letak Lintang + KPD

Supervisor: dr. Juliawan, SpOGDM: Ery, Heri, Mamat, Asri

Case Resume :No. Case Total

Pathology Delivery 1

1. G1P0A0 39 - 40 weeks S/L/IU transverse lie with PROM < 12 hNormal Delivery -

G1P0A0 39 - 40 weeks S/L/IU transverse lie with PROM < 12 h

Name : Mrs. AAge : 35 years oldAddress : LingsarAdmitted : 20 – 02 – 2014 No. RM : 098647

G1P0A0 39 - 40 weeks S/L/IU transverse lie with PROM < 12 h

Time Subjective Objective Assesment Planning

11.00 WITA

At DR Teratai

- General condition : WellGCS : E4V5M6

BP : 120/80 mmHgPR : 80 x/mRR : 20 x/mTemp : 36,0 ◦C

UFH : 26 cm transverse lieEFW : - gramFHR: 12-12-12, reguler (144 bpm)UC : -VT : -

G1P0A0 39 – 40 weeks S/L/IU transverse lie with PROM < 12 h

DM co to GP pro SC, GP co to SPV for SC SPV : acc SC

CIE patient and family

Prepare for SC

11.40 WITA

- - SC began

12.10 WITA

- - Baby was born, male, 2700 gr, 49 cm, AS- 7-9, anus (+), anomaly congenital (-)

12.15 WITA

- - Placenta was born, manually and complete

Time Subjective

Objective Assesment Planning

14.10 WITA

- General condition : well BP: 110/80 PR : 88 x / mRR : 20x/mT: 36,8UFH: 2 finger below umbilicusUC: (+) wellActive bleeding (-)

P1A0H1 2 hours post partum

Obs. General Condition,Vital sign

Obs. Mother and baby well being

21/02/2014

07.00 WITA

- General condition : well BP: 120/80 PR : 80 x / mRR : 20x/mT: 36,8UFH: 2 finger below umbilicusUC: (+) wellActive bleeding (-)

Babies roomingPR: 148 bpmRR: 50 x/mTemp :36,6 ◦C

1st day post partum

Obs. Mother and baby well being

CIE: explanation about result of examination, drink n eat, breast feeding, and mobilization