Rika Yulia ( Arrest of Descent)

7/30/2019 Rika Yulia ( Arrest of Descent)

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Arrest of descent oi CPD


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Patients ID

Name : Mrs. RY

Age : 30 years oldAddress : Kel. Indarung

MR Number : 83 23 98

Time of admission : June 19th, 2013


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Anamnesis

A 30 years old patient was admitted to the

Emergency Room of Dr. M. Djamil Central General

Hospital on June 19th, 2013 at 6.00 am with chief

complain feeling pain from waist region which

referred to the groin since 2 hours ago


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Present Illness History

Pain from waist region which referred to the groin wasfelt since 2 hours ago

Bloody show from the vagina was (+) since 2 hours

ago

There was no fluid leakage from the vagina There was no massive vaginal bleeding

Amenorrhea since 9 months ago

First date of last menstrual period was forgotten

Estimation date of delivery was hard to determine


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The fetal movement was felt since 5 months ago.

No complain of nausea, vomitus, or vaginal bleeding

during early nor late pregnancy

Prenatal care to midwife 3 times(2,4 and 8 month)

pregnancy age Menstruation history: Menarche at 13 years old, the

cycle was irreguler, once a month, 5-7 days in duration

with 2-3x pad change/day, menstrual pain (-)


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Previous Illness History

There was no history of cardiac disease, lung disease,

liver disease, renal disease, diabetes mellitus,

hypertension, nor allergy.

There was no history of any hereditary, contagious, or

psychiatric disorder.

Familial Illness History


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Marriage history: married once in 2002Educational history : senior high school graduateOccupational history : housewife

Obstetric history : Pregnancy/Abortion/Delivery: 3/0/21. In 2008, male, 2600g, term, spontaneous, midwife,

alive2. In 2006, male, 2500g, term, spontaneous, midwife,

alive3. Present

History of family planning : (-)Immunization : (-)


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Physical Examination

GA Cons BP HR RR T BW BH BMI

Mdt CMC 110/70 80 20 36.7 50 155 22,4(normoweight)

BW after pregnancy: 62 kg

Eyes : conjunctiva was not anemic,

sclera was not icteric

Neck : JVP 5-2 cmH2O, no enlargement of thyroid

glandThorax : Heart & lung were in normal limit

Extremity: oedema -/-


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Obstetric Record

Abdomen

Inspection : Seemed enlarged in accordance with term

pregnancy, cicatrix (-)

Palpation :

L1 : Uterine fundus was palpated at 3 fingers bellowproccesus xyphoideus, a large soft nodular mass

was palpated

L2 : The hardest resistance was felt on the right side,

Small multiple structures were felt in the leftside

L3 : A Round hard mass was palpated, not fixated

L4 : Convergen


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Fundal height : 32 cm, EBW : 2945 gr,

Uterine contraction : 2-3x/ 30/ S

Percussion : tympany

Auscultation : peristaltic sound was normalFHR : 140-146 bpm


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Genitalia

Inspection : V/U was normal, Vaginal

bleeding (-) Vaginal Touche

2-3 cm, effacement 80%

Amnionic sac was (-) clear residue

Head was palpated tranverse sagitalis suturaHI-II

Inner and Outer Pelvic Size Examination: no contracted

pelvis


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Laboratory Finding

Parameter Result Normal

Haemoglobin 10.6 9,5-14

Leukocyte 7600 5000-15000

Thrombocyte 224 150-400 x103

Hematocrit 32 37-43

Eritrocyte 3.7 4-5 jt


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USG


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CTG


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Diagnosis :G3P2A0L2 Term parturient First stage Laten phase

Fetal alive, singleton, intrauterine, head presentation

tranverse sagitalis sutura HI-II

Management :

Control general condition, vital signs, FHR, uterine

contraction Informed consent

Routine blood check

Examine 4 hours later

Plan:

Vaginal Delivery

f


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Progress of Labour

10.00 am

(4 h after)

02.00 pm 03.00 pm

Anamnestic feeling pain from waist to groin

with increase in intensity , fetal

movement (+).

feeling pain from waist to groin

with increase in intensity , fetal

movement (+).

Finished lead to bare down. feeling

pain from waist to groin with

increase in intensity ,fluid leakage

(+) fetal movement (+).

Physical

Examination

VS : normal limit

Abd : His 3-4/42/moderate,

FHR 128-136 bpm

Gen :

I : v/u normal

VT : 5-6 cm

Amniotic sac (-), clearresidu

Head was palpated

tranverse sagitalis sutura

HI-II

VS : normal limit

Abd : His 4-5/50/strong,

FHR 126-134 bpm

Gen :

I : v/u normal

VT : complete


Head was palpated left

tranverse occiput HI-II

VS : normal limit

Abd : His 4-5/50/strong,

FHR 130-138 bpm

Gen :

I : v/u normal

VT : complete


Head was palpated left

tranverse occiput HII-III

Diagnostic G3P2A0L2 term parturient 1st

stage active phase

Fetal live singleton intrauterin head

presentation left tranverse occiputHI-II

G3P2A0L2 term parturient 2nd

stage

Fetal live singleton intrauterin

head presentation left tranverseocciput HI-II

G3P2A0L2 term parturient 2nd

stage

Fetal live singleton intrauterin head

presentation left occiput tranverseHII-III + Arrest of Descent due to

CPD

Advice Control general condition, vital

signs, FHR, uterine contraction


Control general condition, vital


lead to bare down , lying to left

side


Control general condition, vital


Informed consent

Antibiotic

Councelling contraception

Planning Vaginal delivery Vaginal delivery Emergency Cesarean Section


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June 19th, 2013

03.30 p.m.

TPPCS was performed

A male baby was born by TPPCS, with :

3600g of body weight, 50 cm in height, APGAR score 7/8

Placenta was born with a slight pull on the umbilical cord, it

was born intact, single, & weighing 500 gr with a size of

17x17x3 cm. The umbilical cord length was 60 cm with

paracentral insertion.

Insertion IUD was performed.

Bleeding during procedure was 250 cc


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Diagnosis : P3A0L3 post TPPCS on indication arrest of descent

due to CPD

Mother & Baby in care

Management : Post surgery observation


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Thank You..


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Documents

Rika Yulia ( Arrest of Descent)