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MISHAEL OCTAVIANY JIREH


406162089
TARUMANAGARA UNIVERSITY

EXAMINER : dr. Cipta Pramana, SpOG(K)

CASE STUDY EXAM

G2P1A0 , 25 years old, 38 weeks gestational age.


Single fetus intrauterine.
Breech presentation, fetal back on the left.
1st stage of labor.

MEDICAL RECORD :
 Patient’s complaints :
His 3x per 10 minutes, bloody show (+), amniotic fluid (-).
 Past medical history :
Appendectomy at 12 years old.
Hypertension (-), DM (-), Heart disease (-), Asthma (-), Hepatitis (-).
 Menstruation history :
First age of menarche is 12 years old, menstrual cycle 28 days, 7 days period,
replace tampon 2 times a day.
Dysmenorrhea (-), menorrhagia (-).
First day of last menstruation : February 7th, 2017.
Day of estimated birth : November 7th, 2017.
 Marriage history :
Married once at 21 years old.
 Pregnancy history :
First child was born on 2015, premature, female, birthweight 2000gr, helped by
midwife.
 Antenatal care history :
ANC 4 times at primary health care and the result was normal.
TT immunization : twice.
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MISHAEL OCTAVIANY JIREH
406162089
TARUMANAGARA UNIVERSITY

EXAMINER : dr. Cipta Pramana, SpOG(K)

PHYSICAL EXAMINATION :
Consciousness : Compos mentis.
Vital signs :
 Blood pressure : 120/80 mmHg.
 Heart rate : 80x/minute.
 Respiratory rate : 20x/minute
 Body temperature : 360C
Body mass index : normal.

Systemic examination : normal.


 Eyes : anemic conjunctiva (-/-), jaundice sclera (-/-).
 Cor and pulmo : normal.
 Extremities : upper and lower extremities  edema (-/-).

Obstetric examination :
 Fundal height : 32 cm.
 HIS : 3 times per 10 minutes.
 Leopold I : palpable mass with hard consistency, round-shaped, bouncy.
 Leopold II : palpable elongated mass on the left of mother’s abdomen.
 Leopold III : palpable mass with soft-consistency, round-shaped, not bouncy.
 Leopold IV : not engaged.
 Fetal heart rate : 12-12-12
 Abdominal thickness : normal.
 Vaginal touche :
 Cervix dilation 3cm.
 Amniotic sac (+).
 Breech presentation, H1.
 Pelvic examination :
Linea terminalis = <1/3 circle.
Conjugata diagonalis = 12,5cm.
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MISHAEL OCTAVIANY JIREH
406162089
TARUMANAGARA UNIVERSITY

EXAMINER : dr. Cipta Pramana, SpOG(K)

Pelvic side wall = parallel.


Sacrum curvature = normal.
Spina ischiadica = not protrude.
Os. Coccyges mobility = normal.
Pubic arch = >900C.

LABORATORY TEST :
NORMAL VALUE RESULT
Hemoglobin 11,7-15,5 g/dL 12
Leukocyte 3,6-11 /L 8
Thrombocyte 150-400 /L 120

DIAGNOSIS :
G2P1A0 , 25 years old, 38 weeks gestational age.
Single fetus intrauterine.
Breech presentation, fetal back on the left.
Not engaged.
1st stage of labor.
ACTION :
Observations of 10.
External version.
RESULT :
Resistance (+)
Observation of 10 = all in a good condition.
DIAGNOSIS :
G2P1A0 , 25 years old, 38 weeks gestational age.
Single fetus intrauterine.
Breech presentation, fetal back on the left.
Not engaged.
1st stage of labor.
Failed external rotation without complication.
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MISHAEL OCTAVIANY JIREH
406162089
TARUMANAGARA UNIVERSITY

EXAMINER : dr. Cipta Pramana, SpOG(K)

ACTION :
Observations of 10.
Wait for vaginal delivery.
RESULT :
Cervix dilation = 10 cm (complete)
Descent of lower part = H3+
DIAGNOSIS :
G2P1A0 , 25 years old, 38 weeks gestational age.
Single fetus intrauterine.
Breech presentation, fetal back on the left.
Not engaged.
2nd stage of labor.
ACTION :
Lead the patient to push.
Vaginal delivery with 3 options :
 Spontaneous : Bracht maneuver.
The indications for this Bracht maneuver are small baby, complete breech.
 Partial extraction : Classic, Muller, Lovset, Mauriceau maneuver.
 Full extraction : Bottom extraction, foot extraction.
Full extraction is to ease 2nd stage of labor.
The indications for full extraction are fetal distress, imminent uterine rupture,
obstructed of 2nd stage labor, descent of lower part is H3+.

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