NORMAL DELIVERY
CASE REPORT
HERTI MARNI
PADANG PANJANG GENERAL HOSPITAL
Identity
Name : Mrs. NY
Age : 23 Years old
No. MR : 10.48.13
Address : Ganting
Date : Oktober, 3th 2016
Chief Complaint
• A 23 years old patient was admitted to the ward room of
Padang Panjang General Hospital on Oktober, 3th 2016 at
04.00 am with chief complaint feeling of pain from waist
region which referred to the groin (+) since 10 hours before.
Present illness History
Feeling of pain from waist region
which referred to the groin (+) 10
hours before enterred SGH
Bloody show from the vagina (+)
Fluid leakage from the vagina (-)
No massive bleeding from vagina
Amenorrhea since 9 months ago
Menstrual history : menarche at 11 years old, regular cycle in 28 days, once a month, no menstrual
pain
First date of last menstruation was on January 4th 2016
Estimation date of delivery was on Oktober 10th 2016
Title
Fetal movement was felt since 4 months ago
No complain of nausea, vomiting and vaginal bleeding during late pregnancy
Antenatal care : control to midwife every month, to OG doctor twice, at 7
and 9 month of pregnancy
Previous Illness History :
There wasn’t previous history of heart, lung, liver,
kidney, DM, Hypertension, and allergy
Family Illness History :
There wasn’t history of hereditary disease, contagious
and psychological illness in the family
Marriage History : once in November 2015
History of pregnancy/abortion/delivery : 1/0/0
1. Present
History of family planning : none
History of immunization : TT, 2x at midwives
History of education : Senior high school graduate
Occupation : House wife
Physical Examinations
General appearrance : Moderate
Conciousness : Composmentis cooperative
Body Height : 150 cm
Body Weight : 60 kg
(before pregnant : 48 kg, BMI : 21,33 kg/m2)
normo weight
Nutrisional status : Good
Blood pressure : 110/70 mmHg
Heart rate : 84 x/menit
Respiration rate : 23 x/menit
Body Temperature : 37⁰C
General Examination
Eyes : Conjunctiva wasn’t anemic, sclera wasn’t icteric
Neck : JVP 5-2 cmH2O, thyroid gland no enlargement
Chest : H/L normal
Abdomen : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-
Obstetrical Record
Abdomen :
I : Enlarge equal to term pregnancy, cicatrix (-)
Pa :
L1 : Uterine fundal was palpable 3 fingers under proc. Xypoideus, large nodular mass
was palpated
L2 : A hard and resistance structure was felt on the left side.
Small parts of the baby were felt on the right side
L3 : A round hard mass was palpated, fixed
L4 : divergent
Uterine Fundal Height : 33 cm
Estimated fetal body weight : 3100 gr
Uterine contraction : 3-4x/45”/strong
Pe : Tympani
Au : Peristaltic sound was normal Fetal Heart Sound : 140-155 bpm
Obstetrical Record
Genitalia : I : V/U normal, bleeding from vagina(-
)
VT:
6cm , amniotic sac still intact, vertex left occiput anterior
position on HI-II.
Pelvic Assessment :
Promontorium unidentified
Linea inominata was palpable 1/3 part
Sidewalls was straight
Sacrum was smooth and well curved
Ischial spines difficult to palpate
sacrococcygeal joint was mobile
Pubic arch > 90˚
UPL : DIT is more than 4 knuckles
Clinical pelvimetry findings :
adequate for vaginal birth
Laboratory findings
Hemoglobin : 11,3 gr%
Leukosit : 11500 / mm3
Trombosit : 246.000/ mm3
Hematokrit : 34%
Diagnosis
G1P0A0L0 term pregnancy first stage, active phase
Fetal alive, singleton, intra uterine, head presentation, HI-II
Management :
Control of GA, VS, His, FHR
Informed consent
Re-examine in 4 hours
Plan : Normal labor
History of illness
On july 7th 2016 08.00am
S/ : - feeling pain in waist which referred to the groin (+)
- fetal movement (+)
O/ : VS in normal rate
Abd : UC 4-5x/45”/strong
FHR 147-150 bpm
Gen : V/U normal, Bloodyshow (+)
VT ø 10 cm, amniotic sac still intact, vertex
anterior on HIII+
A/: G1P0A0L0 term pregnancy second stage
Fetal alive, singleton, intra
uterine, head presentation, HIII+
P/ : Normal Delivery
Delivery Report
On July 7th 2016 09.00am
a male baby was born by normal delivery :
FW: 3360 gr
FL : 48 cm
A/S : 7/8
Placenta was born with slight traction on
umbilical, complete, 1 piece, size 17x16x3 cm,
weight 500 gr. Umbilical cord was 60 cm,
paracentral incertion.
Blood during delivery +/- 150 cc.
D/: P1A0L1 post spontaneous delivery
Baby and mother were in good condition
P/ Control fourth stage
Amoxicilin 3x500 mg po
Mefenamic acid 3x500 mg po
Vitamin C 3x50 mg po
SF 1x300 mg po
Table of monitoring 4th phase
Hours of Time BP Pulse Temp UF UC Bledder Blood
control
1 09.15 130/80 84x 36,70 1 jari bpst Baik - -
09.30 120/80 85x 1jari bpst Baik - -
09.45 120/80 86x 1 jari bpst Baik - -
10.00 120/80 80x 1 jari bpst Baik 100cc 1 duk
2 10.30 120/80 82x 36,70 2 jari bpst Baik - -
11.00 120/80 82x 2 jari bpst Baik - -
Time : 14.30 WIB
S : Fever (-), Colostrum (+/+), Urine (+), BAB (-), PPV (-)
O : SG Cons BP HR Br T
Mod Alert 120/80 80x/i 20x/i 37 0
Eye : Conjungtiva was not anemic, sclera was not icteric
Abdomen :
Insp : Looks a little bulge
Palp : UF 2 finger below the umbilical, contraction was good
Perk : Thympani
Ausk : Bowel movement (+) Normal
Genitalia :
Insp : V/U normal, lokhia rubra (+)
Diagnosis :
P1A0H1 post partus maturus spontan
Mother and Baby was in good condition
Plan :
Control SG, VS, PPV
Diet MB TKTP
Mobilisasi
Breast care
Vulva hygiene
Moved to ward
Therapy :
Amoxicillin 500 mg tab 3x1
Asam meffenamat 500 mg tab 3x1
Vit C tab 1x1 tab
SF 1 x 1 tab
October 4th 2016
S : Fever (-), Colostrum (+/+), Urine (+), BAB (-), PPV (-)
O : SG Cons BP HR Br T
Mod Alert 120/80 80x/i 20x/i 37 0
Eye : Conjungtiva was not anemic, sclera was not icteric
Abdomen :
Insp : Looks a little bulge
Palp : UF 2 finger below the umbilical, contraction was good
Perk : Thympani
Ausk : Bowel movement (+) Normal
Genitalia :
Insp : V/U normal, lokhia rubra (+)
Diagnosis :
P1A0H1 post partus maturus spontan Day 2
Mother and Baby was in good condition
Plan :
Control SG, VS, PPV
Diet MB TKTP
Mobilisasi
Breast care
Vulva hygiene
Home Care
Therapy :
Amoxicillin 500 mg tab 3x1
Asam meffenamat 500 mg tab 3x1
Vit C tab 1x1 tab
SF 1 x 1 tab
THANK YOU VERY
MUCH
