7/24/2019 Contoh Laporan Jaga obstetri

1/8

LAPORAN OBSTETRI PATOLOGI

1. G2P1A0 32 years old fullterm pre!a!"y f#rst stae of la$or % ol#o&ydram!#o! % 'a#led of O(yto"#! )r#ps

*esarea! Se"t#o! % I+) #!sert#o! ,-

G2P1A0 32 years old admitted on January 13 th2016 at 02.30 am, referred by Obstetrician with dianose G2P1A0fullterm of !renancy not in labour yet, "ntrauterine fetal sinleton ali#e ce!halic !resentation $ oliohydramnion.Planned for O%&.

#story/

&he mother didn't felt labor !ain

&here was no bloody show

&here was no water dischare

(he felt the baby's mo#ement

&here was no history of cardiac, !ulmonary, li#er, renal, hy!ertension and diabetic diseases

A)% * + times at Obstetrician

-P * -ay , 201/ % * ebruary , 2016

-arriae * Once for 10 years %ontrace!tion * 1 monthly contrace!ti#e inection, last ta4en 1 years ao

P1 * 2005, (!ontaneus #erte deli#ery at (haron clinic, 78 3300 r, 7 9: cm, ali#e

Ge!eral e(am#!at#o!s/General %ondition * ood, conscious7lood !ressure * 120;50 mm %%onuncti#e * anemic ?@ (clera * icteric ?@

7/24/2019 Contoh Laporan Jaga obstetri

2/8

7/24/2019 Contoh Laporan Jaga obstetri

3/8

At 0:.9/ am 0+.00 am B% * rarely

7/24/2019 Contoh Laporan Jaga obstetri

4/8

"ntrauterine fetal sinleton ali#e ce!halic !resentation $ oliohydramnion

a!aeme!t /

%esarean (ection

%ounselin, informed consent

%ounselin contrace!tion"B contrace!ti#e

7lood was !re!ared Obser#ation of #ital sin, B%,

7/24/2019 Contoh Laporan Jaga obstetri

5/8

Perut * "ns!e4si * datar Pal!asi * teraba massa !adat setini 2 ari atas simfisis !ubis, !ermu4aan

4asar, )&?@Per4usi * 8 ?@Aus4ultasi * 7B ?$ )ormal

Status G#!e9olo#s /

"ns!e4si * lu4sus ?@, fluor ?@, #ul#a tida4 ada 4elainan"ns!e4ulo * lu4sus ?@, fluor ?@, #aina tida4 ada 4elainan, Punca4 #aina ?@P * lu4sus ?@, fluor ?@, #ul#a;#aina tida4 ada 4elainan, tida4 teraba !ortio%ut * @A;P bilateral * @%a#um oulasi &ida4 menonol

La$orator#um /

7/24/2019 Contoh Laporan Jaga obstetri

6/8

Abdomen * "* datar P* Pal!asi* teraba massa !adat setini 2 ari atas simfisis !ubis, !ermu4aan 4asar,

)&?@P* 8 ?@A* 7B?$ )ormal

tremitas * hanat, edema ?@A * P3A1 90 tahun Post

7/24/2019 Contoh Laporan Jaga obstetri

7/8

A * P3A1 90 tahun Post

7/24/2019 Contoh Laporan Jaga obstetri

8/8

Jam 1/.00& * +0;60 mm