MR 22-8-2014
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Transcript of MR 22-8-2014
![Page 1: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/1.jpg)
Morning Report19 Oktober 2014
Kasus Obstetri Fisiologis : Kasus Obstetri Patologis : Kasus Ginekologi:
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• G3P2A0 parturien aterm kala I fase laten• G3P0A2 parturien 36 minggu kala I fase
laten• G2P1A0 parturien preterm 34-35
minggu kala I fase laten+KPSW• G3P2A0 Parturien aterm Kala I Fase
Laten
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Kasus 1Kasus Patologis
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Identitas Pasien Tgl Masuk : 18
Oktober2014 Jam : 14.30 Nama Pasien : Ny. M Nama Suami : Tn. P Pekerjaan : IRT Alamat : Kopo Pendidikan : SD Tinggi Badan : 162 cm Berat Badan : 60,5 kg Rujukan : RS
Limijati DPJP : dr.R, Sp.OG
Usia : 34 tahun Usia : 37 tahun Pekerjaan Suami : PNS
![Page 5: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/5.jpg)
Anamnesis Keluhan Utama : Mulas Anamnesis Khusus : Seorang wanita G3P2A0 gravida 39 minggu
datang dengan rujukan dari RSL dengan keluhan mulas sejak kemarin malam.
Malam hari sebelum dibawa ke RSI, pasien megeluh mulas-mulas (17-10-2014).
Siang hari SMRS keluar cairan kecoklatan dari jalan lahir, (-) bau, gatal, dan darah.
![Page 6: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/6.jpg)
Perkawinan
Lama Kehamila
n
Penolong
Persalinan JK BBL Usia Keadaan
1 8 bulan Bidan Normal (KPSW)
Laki laki
1900 gram 9 tahun
Sehat
1 6 bulan Sp.OG Normal (TORCH)
Perempuan
500 gram 2008 TORCH
1 Hamil ini
![Page 7: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/7.jpg)
Anamnesis Tambahan HPHT : 18 Januari 2014 Siklus haid: 30 hari Riwayat Menstruasi :
teratur Riwayat PNC : 1 bulan
sekali ke dokter Sp.OG Riwayat KB : IUD RPD : - RPK : - Riwayat operasi : - Golongan darah : O Riwayat Obstetri :
G3P2A0 Lama pernikahan : 9
tahun
![Page 8: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/8.jpg)
Pemeriksaan Fisik
Keadaan Umum : baik, CM, sakit sedang
Tanda-tanda Vital Tensi : 110/70 mmHg Nadi : 90x/m Respirasi : 18x/m Suhu : 36,6 oC
Kepala : dbn Thorax : dbn Abdomen : dbn Ekstremitas : oedem tungkai bawah
+/+
![Page 9: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/9.jpg)
Status Obstetrikus Pemeriksaan Luar :
TFU : 33 cm LP : 101 cm Letak : kepala His : (+) BJA : 12-11-12 TBBA : 3200 gram
Pemeriksaan Panggul : -
Laboratorium : - Pemeriksaan Dalam : -
![Page 10: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/10.jpg)
Diagnosis :
G3P2A0 gravida 39 minggu kala I fase laten
Janin intrauterine tunggal hidup letak kepala
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Usul pemeriksaan
![Page 12: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/12.jpg)
Tindakan Rawat Observasi TTV, DJJ, His INFUS D5% Persiapan partus spontan
![Page 13: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/13.jpg)
Follow up 14.30 Pasien datang
TTV Tensi : 110/70 Nadi : 90x/m Respirasi : 18x/m Suhu : 36,6 oC DJJ: 12-12-12
10.00 pasien diantar ke OK 10.35 pasien dibaringkan di meja operasi 10.47 pasien dianaestesi 10.55 SC dimulai 10.57 Bayi lahir 10.58 plasenta lahir 11.13 operasi selesai
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PP: T: 120/80 S: 36.6 N: 90 R: 22 TFU: 2 jari dibawah umbilikus
2 jam PP T: 110/70 S: 36,4 N: 80 R: 20 TFU: 2 jari dibawah umbilikus
![Page 15: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/15.jpg)
Bayi lahir pk. 10.57 Bayi laki-laki, BB 2500g, PB 49cm, APGAR 1’:8; 5’:10
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Prognosis Quo ad vitam : ad
bonam Quo ad functionam : ad
bonam
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Kasus 2Kasus fisiologis
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Identitas Pasien Tgl Masuk : 19 Oktober 2014 Jam : 4.00 Nama Pasien : Ny. P Nama Suami : Tn. D Pekerjaan : IRT Alamat : Ciwidey Pendidikan : SD Tinggi Badan: 165 cm Berat Badan: 54kg DPJP: dr. R, Sp.OG
Usia : 22 tahun Usia : 24 tahun Pekerjaan Suami:
Buruh
![Page 19: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/19.jpg)
Anamnesis Keluhan Utama : keluar cairan dari jalan
lahir sejak malam Anamnesis Khusus : Seorang wanita G1P0A0 parturien 39-40
minggu, datang dengan keluhan keluar cairan sekonyong-konyong dari jalan lahir, cairan jernih, tidak berbau & gatal, darah (+), mules (+), sejak malam SMRS.
SMRSI pasien sudah datang ke bidan dan diberikan obat perangsang melahirkan.
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Perkawinan
Lama Kehamil
an
Penolong Persalinan JK BBL Usia Keadaan
1 Hamil ini
![Page 21: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/21.jpg)
Anamnesis Tambahan HPHT : 16 Januari 2014 TTP : 23 Oktober 2014 Riwayat Menstruasi :
teratur, 28 hari, lamanya 5 hari, nyeri mens (-)
Riwayat PNC: bidan Riwayat KB : pil RPD : (-) RPK : (-) Riwayat operasi: -
Golongan darah : tidak
tahu Riwayat Obstetri :
G1P0A0 Lama pernikahan : 2
tahun
![Page 22: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/22.jpg)
Pemeriksaan Fisik
Keadaan Umum : baik, CM Tanda-tanda Vital
Tensi : 120/80 mmHg Nadi : 100x/m Respirasi : 20x/m Suhu : 36,7o C
Kepala : dbn Thorax : dbn Abdomen : cembung gravid Ekstremitas : oedem -/-
![Page 23: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/23.jpg)
Status Obstetrikus Pemeriksaan Luar :
TFU : 26 cm LP : 116 cm Letak : kepala, puka U His : - BJA : 13-13-13 TBBA : 2500 gram
Pemeriksaan Panggul : -
Laboratorium : -
Pemeriksaan Dalam : Inspekulo : Perabaan fornix: VT: tak
v/v: tak Pembukaan: 1 cm Ketuban: utuh Presentasi: kepala Hodge: I Portio: tebal kaku
![Page 24: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/24.jpg)
Diagnosis :
G3P0A2 parturien 36 minggu kala I fase laten
Janin intrauterine tunggal hidup letak kepala
![Page 25: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/25.jpg)
Tindakan Persiapan partus spontan pervaginam Observasi TTV, DJJ, dan his
![Page 26: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/26.jpg)
Usul pemeriksaan USG NST Hematologi Rutin BT & CT
![Page 27: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/27.jpg)
Follow up 11.02 pasien datang
Tensi : 100/70 mmHg Nadi : 92x/m Respirasi : 20x/m Suhu : 35,9o C DJJ: 13-13-13
Pembukaan I HI
![Page 28: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/28.jpg)
Prognosis Quo ad vitam : ad bonam Quo ad functionam: ad bonam
![Page 29: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/29.jpg)
Kasus 3Kasus Patologis
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Identitas Pasien Tgl Masuk : 19 Oktober
2014 Jam : Nama Pasien : Nama Suami : Pekerjaan : IRT Alamat : Pendidikan : Tinggi Badan : Berat Badan : Rujukan : DPJP :
Usia : Usia : Pekerjaan Suami:
![Page 31: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/31.jpg)
Anamnesis Keluhan Utama : Anamnesis Khusus : Seorang wanita G P A gravida minggu datang
dengan keluhan
![Page 32: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/32.jpg)
Perkawinan
Lama Kehamila
n
Penolong
Persalinan JK BBL Usia Keadaan
![Page 33: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/33.jpg)
Anamnesis Tambahan HPHT : TTP : Riwayat Menstruasi : Riwayat PNC : Riwayat KB : RPD : RPK : Riwayat operasi :
Golongan darah : Riwayat Obstetri : Lama pernikahan :
![Page 34: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/34.jpg)
Pemeriksaan Fisik
Keadaan Umum : baik, CM, sakit berat Tanda-tanda Vital
Tensi : 110/80 mmHg Nadi : 96x/m Respirasi : 20x/m Suhu : 36,5o C
Kepala : dbn Thorax : dbn Abdomen : dbn Ekstremitas : dbn
![Page 35: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/35.jpg)
Status Obstetrikus Pemeriksaan Luar :
TFU : 27 cm LP : 90 cm Letak : puka, w His : - BJA : 12-12-12 TBBA : 2170 gram
Pemeriksaan Panggul : -
Laboratorium:- Pemeriksaan Dalam :
V/V: tak Pembukaan 2cm Ketuban: Jernih Presentasi: kaki Hodge: I
![Page 36: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/36.jpg)
Diagnosis :
G2P1A0 parturien preterm 34-35 minggu kala I fase laten+KPSW
Janin intrauterine tunggal hidup letak sungsang
![Page 37: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/37.jpg)
Tindakan Rawat inap Observasi TTV,DJJ, His, tanda-tanda
infeksi intra uterin Antibiotik Ampicilin 4x 500 mg USG Kalmetason 5mg/12 jam
![Page 38: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/38.jpg)
Usul pemeriksaan Hematologi rutin BT & CT NST USG
![Page 39: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/39.jpg)
Prognosis Quo ad vitam : ad bonam Quo ad functionam : ad bonam
![Page 40: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/40.jpg)
Kasus 4
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Identitas Pasien Tgl Masuk : 22 Agustus
2014 Jam : 17.15 Nama Pasien : Ny. H Nama Suami : Tn. H Pekerjaan : Wiraswasta Alamat : Bandung Pendidikan : SMA Tinggi Badan : 150 cm Berat Badan : 80 kg Rujukan : - DPJP : dr. Erik, Sp.OG
Usia : 35 tahun Usia : 38 tahun Pekerjaan Suami:
Wiraswasta
![Page 42: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/42.jpg)
Anamnesis Keluhan Utama : Keluar cairan dari jalan lahir Anamnesis Khusus : Seorang wanita G3P2A0 datang dengan keluhan
keluar cairan dari jalan lahir pukul 12 siang tadi, berwarna bening, hingga ganti celana sebanyak 1x. Darah (-), lendir (+) bening, tidak gatal. Mules (-) pergerakan anak aktif.
![Page 43: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/43.jpg)
Perkawinan
Lama Kehamila
n
Penolong
Persalinan JK BBL Usia Keadaan
1 36 minggu Sp. OG Pervagina
m, vakumLaki-laki 2500 g
7 tahu
nSehat
1 26 minggu Sp. OG SC IUFD
1 Hamil ini
![Page 44: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/44.jpg)
Anamnesis Tambahan HPHT : Lupa TTP : - Riwayat Menstruasi :
teratur, 28 hari, lamanya 4 hari
Riwayat PNC : bidan Riwayat KB : pil &
suntik, terhenti setelah melahirkan anak ke-2
RPD : - RPK : Ayah, Ibu HT Riwayat operasi : -
Golongan darah : B Riwayat Obstetri :
G3P2A0 Lama pernikahan : 8
thn
![Page 45: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/45.jpg)
Pemeriksaan Fisik
Keadaan Umum : baik, CM Tanda-tanda Vital
Tensi : 110/70 mmHg Nadi : 72 x/m Respirasi : 20x/m Suhu : 36,3
Kepala : dbn Thorax : dbn Abdomen : dbn Ekstremitas : dbn
![Page 46: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/46.jpg)
Status Obstetrikus Pemeriksaan Luar :
TFU : 32 cm LP : 13 cm Letak : U His : - BJA : 12-12-12 TBBA : 3100 gram
Pemeriksaan Panggul : -
Laboratorium : - Pemeriksaan Dalam :
V/V: tak Pembukaan: 2-3 cm Ketuban: jernih Presentasi: kepala Hodge: II
![Page 47: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/47.jpg)
Diagnosis :
G3P2A0 Parturien aterm Kala I Fase Laten
Janin hidup tunggal intrauterin letak kepala
![Page 48: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/48.jpg)
Usul pemeriksaan Hematologi rutin BT CT NST USG
![Page 49: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/49.jpg)
Tindakan Persiapan partus spontan pervaginam Observasi TTV, DJJ, His, pembukaan
![Page 50: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/50.jpg)
Prognosis Quo ad vitam : ad bonam Quo ad functionam : ad bonam
![Page 51: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/51.jpg)
Kasus 4Kasus patologis
![Page 52: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/52.jpg)
Identitas Pasien Tgl Masuk : 22 Agustus
2014 Jam : 20.35 Nama Pasien : Ny. T Nama Suami : Tn. H Pekerjaan : Dosen Alamat : Bandung Pendidikan : S2 Tinggi Badan : 156 cm Berat Badan : 80 kg Rujukan : - DPJP : dr. Erik, Sp.OG
Usia : 35 tahun Usia : 36 tahun Pekerjaan Suami:
Wiraswasta
![Page 53: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/53.jpg)
Anamnesis Keluhan Utama : Mules Anamnesis Khusus : Seorang wanita G2P1A0 datang dengan keluhan
mules sejak 11 jam yang lalu. Hilang timbul namun sejak 6 jam yang lalu terus menerus. Mulas 3-4x/10 menit durasi 1 menit. Darah (+), cairan (+) merembes
USG terakhir (20/8/2014): Bayi laki-laki, tunggal, hidup, intrauterine, TBBA 3000 gram
![Page 54: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/54.jpg)
Perkawinan
Lama Kehamila
n
Penolong
Persalinan JK BBL Usia Keadaan
1 9 bulan Dr. Sp. OG Spontan Laki-
laki 35007
tahun
Sehat
1 Hamil ini
![Page 55: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/55.jpg)
Anamnesis Tambahan HPHT : 20 november
2013 TTP : 27 Agustus 2014 Riwayat Menstruasi :
teratur, 28 hari, lamanya 4 hari
Riwayat PNC : dr. Sp. OG
Riwayat KB : IUD RPD : - RPK : - Riwayat operasi : -
Golongan darah : B Riwayat Obstetri :
G2P1A0 Lama pernikahan : 1
thn
![Page 56: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/56.jpg)
Pemeriksaan Fisik
Keadaan Umum : baik, CM Tanda-tanda Vital
Tensi : 120/80 mmHg Nadi : 100 x/m Respirasi : 28x/m Suhu : 36,3
Kepala : dbn Thorax : dbn Abdomen : dbn Ekstremitas : dbn
![Page 57: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/57.jpg)
Status Obstetrikus Pemeriksaan Luar :
TFU : 32 cm LP : 103 cm Letak : U His : 3-4x/10’ durasi 1’ BJA : 12-12-12 TBBA : 3100 gram
Pemeriksaan Panggul : -
Laboratorium : - Pemeriksaan Dalam :
V/V: tak Pembukaan 4-5cm Ketuban: utuh Presentasi: kepala Hodge: II
![Page 58: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/58.jpg)
Diagnosis :
G2P1A0 Parturien 39-40 minggu Kala I Fase Aktif + KPSW
![Page 59: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/59.jpg)
Usul pemeriksaan Hematologi rutin BT CT
![Page 60: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/60.jpg)
Tindakan Persiapan partus spontan pervaginam Observasi TTV, DJJ, His, pembukaan
![Page 61: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/61.jpg)
Prognosis Quo ad vitam : ad bonam Quo ad functionam : ad
bonam
![Page 62: MR 22-8-2014](https://reader035.fdocuments.us/reader035/viewer/2022062309/55cf9145550346f57b8c27bc/html5/thumbnails/62.jpg)
Kasus 5Kasus patologis
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Identitas Pasien Tgl Masuk : 23 Agustus
2014 Jam : 04.12 Nama Pasien : Ny. R Nama Suami : Tn. H Pekerjaan : Wiraswasta Alamat : Bandung Pendidikan : SMA Tinggi Badan : 158 cm Berat Badan : 66 kg Rujukan : - DPJP : dr. Robiyanto,
Sp.OG
Usia : 35 tahun Usia : 36 tahun Pekerjaan Suami:
Wiraswasta
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Anamnesis Keluhan Utama : Mules Anamnesis Khusus : Seorang wanita G1P0A0 mengaku hamil 9 bulan
datang dengan keluhan mules-mules. Mules dirasakan 3x10 menit, durasi 1 menit. Terasa air keluar merembes dari jalan lahir, pukul 3.00. Bening, tidak amis, darah (-), dengan volume kira-kira 200cc. Sakit kepala (-), penglihatan kabur (-).
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Perkawinan
Lama Kehamila
n
Penolong
Persalinan JK BBL Usia Keadaan
1 Hamil ini
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Anamnesis Tambahan HPHT : 28 november
2013 TTP : 4 September
2014 Riwayat Menstruasi :
teratur, 28 hari, lamanya 3 hari
Riwayat PNC : dr. Sp. OG
Riwayat KB : - RPD : - RPK : -
Riwayat operasi : - Golongan darah : A Riwayat Obstetri :
G1P0A0 Lama pernikahan : 1
thn
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Pemeriksaan Fisik
Keadaan Umum : baik, CM Tanda-tanda Vital
Tensi : 130/90 mmHg Nadi : 112 x/m Respirasi : 20x/m Suhu : 36,1O C
Kepala : dbn Thorax : dbn Abdomen : dbn Ekstremitas : dbn
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Status Obstetrikus Pemeriksaan Luar :
TFU : 30 cm LP : 98 cm Letak : U His : 3x/10’ durasi 1’ BJA : 12-12-12 TBBA : 2790 gram
Pemeriksaan Panggul : -
Laboratorium : - Pemeriksaan Dalam :
V/V: tak Pembukaan 3-4 cm Ketuban: utuh Presentasi: kepala Hodge: I
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Diagnosis :
G1P0A0 parturien aterm kala I fase laten
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Usul pemeriksaan Hematologi rutin BT CT NST
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Tindakan Persiapan partus spontan pervaginam Observasi TTV, DJJ, His, pembukaan
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Prognosis Quo ad vitam : ad bonam Quo ad functionam : ad
bonam