Case No.

58
Forceps Extraction

Identity

Name
Age
MR No.
Date
Address
Sarai

: Mrs. E
: 24 years old
: 82 82 19
: May 13th, 2013
: Kandang Asam Padang

Chief Complain
A 24 years old patient was admitted to
the Obstetric Emergency Room of Dr.
M. Djamil Central General Hospital on
May 13th, 2013 at 10.50 am, referred
from Lubuk Buaya Primary Health care
with diagnosed G1P0A0L0 term
pregnancy 34-36 weeks + Severe
Preeclampsia

Anamnesis
Before admitted, patient control to Lubuk
Buaya Primary Health Care and found her
blood pressure was 150/90 mmHg, the
result from urine examination proteinury
+3, therefore she was referred to Dr. M.
Djamil Central General Hospital with IVFD
(500ml RL without SM regiment) but
without urinary catheter
No history of blurred vision, headache or
epigastrial pain.

Anamnesis
Feeling of pain from waist region which referred to the groin was
absent.
Bloody show leakage from the vagina was absent.
Fluid leakage from the vagina was absent.
No massive vaginal bleeding.
Amenorrhea since 9 months ago.
First date of last menstrual period : was forgotten
Estimation date of delivery : cant be predicted
Fetal movement was felt since 4 months ago.
No complain of nausea, vomiting and vaginal bleeding neither
during early pregnancy nor late pregnancy.
Prenatal care to midwife in 4 times, at 3, 5, 7, and 9 of month
pregnancy
Menstruation History : menarche at 13 years old, irregular cycle
in last 3 months, once a 25-35 days which last for 4 to 6 days,
each cycle with the amount of 2-3 times pad change/day without
menstrual pain

Previous Illness History

There wasnt previous history of
heart, lung, liver, kidney, DM,
hypertension, and allergic
reaction to the drugs.

Family Illness History

There wasnt history of
hereditary disease, contagious
and physicological illness in the

 Marriage history : once in 2012

History of pregnancy/abortion/delivery :
1/0/0
1. Present

History of family planning : (-)

History of immunization : TT twice at 6 and
7 month pregnancy
History of education : Senior High School
History of occupation : housewife

Physical Examination :
GA Cons
BP
PR RR T
Mdt CMC
160/100 86x 20x 37
urine : 200 cc
Proteinury +3
Patella reflex +/+ Normal
D/ G1P0A0L0 preterm pregnancy 34-36
weeks + Severe Preeclampsia

Management
Initial dose MgSO4 regiment
10.50 am : started initial dose of
MgSO4 regimen
11.05 am : finished initial dose of
MgSO4
regimen
followed
by
maintenance dose

Physical Examination :
GA Cons
BP PR RR T
Mdt CMC
150/90 84x 20x 37
Body Height
: 156 cm
Present Body weght : 62 kg
Before Pregnancy Body Weight
: 54
kg
BMI
: 22,2 kg/m2
Upper Arm Circumferrence : 24 cm

Physical Examination :

Eyes
: Conjunctiva wasnt anemic,
Sclera wasnt icteric
Neck
: JVP 5-2 cmH2O,
thyroid gland no enlargement
Chest
: H/L normal
Abdomen : OR (obstetric record)
Genitalia : OR (obstetric record)
Extremity : Edema -/-,
Physiological Reflex +/+,
Pathological Reflex -/-

Obstetric Record :
Abdomen:
Inspection :
Enlarge accordance with preterm pregnancy 34-36 weeks, mediana
line hyperpigmentation (+), scar (-)
Palpation :
L1 : Uterine fundal was palpable 4 finger below Xyphoideus processus
A soft, large, and nodular mass was palpable
L2 : A hard and resistance structure was felt on the left side
The numerous, small, and irregular struvture were felt on the right side
L3 : A round, hard mass was felt floating
L4 : Wasnt examined
Uterine Fundal Height : 28 cm
EFW : 2325 gram
Uterine contraction : (-)

Percussion : Tympani
Auscultation
: Peristaltic sound was normal
Fetal Heart Sound : 130-140 bpm

Genitalia : I : V/U within normal limit

 D/ G1P0A0L0 preterm pregnancy 34-36

weeks + Severe Preeclampsia in
maintenance dose of SM
Fetal alive singleton intrauterine
head presentation

Management
Control GA, VS, FHR, liquid balance, urine volume,
patellar reflex
Informed consent
Complete Laboratory examination ( liver function,
kidney and hemostasis )
Continue SM in maintenance dose
Severe PE team : ophthalmologist, internist,
cardiology

Laboratory Finding
Laboratory finding
Hemoglobine
Leucocyte
Hematocrit
Trombocyte
MCV
MCH
MCHC
PT
APTT
GDS
Total bilirubin
Bilirubin direk
Bilirubin indirek
SGOT
SGPT

Routine blood testing

11,8 gr/dl
14.300/mm3
36 %
237.000/mm3
89 um3
29,7 pg
33,3 g/dl
10,4
40,4
77 mg/dl
0,45 mg/dl
0,15 mg/dl
0,3
24
16

Normal value for 3rd

TM
9,5-15,0
5.916.9
28.040.0
146429
8199
2932
32-36
10,0-13,6
29,2-39,4
0,00-200,00
0,10-1,20
0-0,2
0,00-0,00
0,00-31,00
0,00-34,00

PARAMETER

RESULT

REFERENCE VALUE

Calcium

8,5 mg/dl

8,6-10,3

Potassium

4,1 mmol/L

3,5-5,1

Sodium

136 mmol/L

139-145

Chlorida

112 mmol/L

97-111

77 mg/dl

0,00-200,00

Total protein

5,6 g/dl

0,00-0,00

Albumin

2,8 g/dl

3,5-5,2

Globulin

2,8 g/dl

0,00-0,00

LDH

480 u/l

< 480

22 mg/dl

16,6 48,5

1 mg/dl

0,6 1,2

Random blood
glucose

Ureum
Creatinin

URINALISIS

RESULT

REFERENCE VALUE

Protein

+++

Glucose

Leucocyte

0-1

0-5

Eritrocyte

0-1

0-1

Cylinder

Crystal

Epitel

+ flat

Flat Epithel

Bilirubin

Urobilinogen

Internist

G 1P0A0L0 preterm pregnancy + severe

Preeclampsia in maintenance dose of SM +
Hypocalcemia + Hypoalbuminemia
Fetal alive singleton intrauterine head presentation
Th/ metil dopa 2x250 mg
Therapy according to Obgyn
Osteocal 1x1
Transfusion plasbumin 20 % 100 cc finished in 4
hours
Joint treatment with Renal and Hypertension
Internist Sub. Div.
Advice : Check Albumin post correction

Ophthalmologists
Theres mild eclampsia fundus appearance
Therapy according to Obgyn, joint treatment
Cardiologists
G 1P0A0L0 gravid preterm 34-36 weeks +
severe preeclampsia
Th/ metildopa 2x250 mg
Check electrolyte
Report to consultant on duty advice :
Expectative

FOLLOW UP 14-5-2013
A/
Feeling of pain from waist to region which referred to the groin
(-)
Fetal movement (+)
Blurred vision (-), epigastric pain (-), headache (-)
Physical Examination :
GA
Cons
BP
PR
RR
T
Mdt
CMC
130/80 88
20
37
Abd : uterine Contraction (-)
FHS : 130-138 bpm
Genitalia : I v/u was normal, vaginal bleeding (-)
D/ G1P0A0L0 preterm pregnancy 34-36 weeks + Severe Preeclampsia in
maintenance dose of SM
Fetal alive singleton intrauterine head presentation

Management :
Control GA, VS, FHR, liquid balance, urine
volume, patellar reflex
Therapy :
Methyldopa 3x250 mg
Dexamethasone 2x1
Continue SM in maintenance dose
Plan :
Expectative

Cardiologists
severe preeclampsia on G 1P0A0L0 gravid
preterm 34-36 weeks
Problem : blood pressure was in controlled
Control vital sign
Ophthalmologists
Theres still found mild eclampsia fundus
appearance
Therapy according to Obgyn
Report to consultant on duty advice :
Expectative

FOLLOW UP 15-5-2013
05.00 am
A/
Feeling of pain from waist to region which referred to the groin
(+)
Fetal movement (+)
Blurred vision (-), epigastric pain (-), headache (-)
Physical Examination :
GA
Cons
BP
PR
RR
T
Mdt
CMC
150/90 80
20
37
Abd : uterine Contraction : +/Seldom/Weak
FHS : 136-146 bpm
Genitalia : I v/u was normal, vaginal bleeding (-)
Inspeculo :
vagina : tumor (-), laceration (-), fluxus (-)
Portio : NP, equal to thumb size, tumor (-), laceration (-), fluxus (-),
OUE opened 1 cm

D/ G1P0A0L0 preterm pregnancy 34-36 weeks +

partus prematurus imminens + Severe
Preeclampsia in maintenance dose of SM
Fetal alive singleton intrauterine head presentation
Management :
Control GA, VS, FHR, liquid balance, urine volume,
patellar reflex
Tocolitic Nifedipine 3x10 mg
Continue SM in maintenance dose
Plan :
Expectative

08.00 am
A/
Feeling of pain from waist to region which referred
to the groin (+)
Fetal movement (+)
Blurred vision (-), epigastric pain (-), headache (-)
Physical Examination :
GA
Cons
BP
PR
RR
T
Mdt
CMC
150/90
80
20
37
Abd : uterine Contraction : 2-3 x/35/Moderate
FHS : 140-150 bpm
Genitalia : I v/u was normal, vaginal bleeding (-)
VT : cervical dilatation was 2-3 cm
Amnionic sac (+)
Head palpable, sagital suture HI-II

D/ G1P0A0L0 preterm parturient 34-36 weeks first

stage of latent phase + Severe Preeclampsia in
maintenance dose of SM
Fetal alive singleton intrauterine head presentation
sagital suture HI-II
Management :
Control GA, VS, FHR, liquid balance, urine volume,
patellar reflex
Tocolitic Nifedipine 3x10 mg
Continue SM in maintenance dose
Plan :
Expectative

12.00 am
A/
Feeling of pain from waist to region which referred
to the groin (+)
Fetal movement (+)
Blurred vision (-), epigastric pain (-), headache (-)
Physical Examination :
GA
Cons
BP
PR
RR
T
Mdt
CMC
150/90
80
20
37
Abd : uterine Contraction : 3-4 x/40/Strong
FHS : 140-150 bpm
Genitalia : I v/u was normal, vaginal bleeding (-)
VT : cervical dilatation was 5-6 cm
Amnionic sac (+)
Head palpable, left transversal occiput H II-III

D/ G1P0A0L0 preterm parturient 34-36 weeks first stage

of active phase + Severe Preeclampsia in maintenance
dose of SM
Fetal alive singleton intrauterine head presentation left
transversal occiput H II-III
Management :
Control GA, VS, FHR, liquid balance, urine volume,
patellar reflex
Continue SM in maintenance dose
Re-evaluate in 4 hours time
Plan :
vaginal delivery
Assist stage II of labor with FE

01.30 pm
A/
Feeling of pain from waist to region which referred
to the groin (+)
Fetal movement (+)
Blurred vision (-), epigastric pain (-), headache (-)
Physical Examination :
GA
Cons
BP
PR
RR
T
Mdt
CMC
150/90
82
20
36,5
Abd : uterine Contraction : 3-4 x/45/Strong
FHS : 132-136 bpm
Genitalia : I v/u was normal, vaginal bleeding (-)
VT : cervical dilatation was 7-8 cm
Amnionic sac (+)
Head palpable, left anterior occiput H III+

D/ G1P0A0L0 preterm parturient 34-36 weeks first stage

of active phase + Severe Preeclampsia in
maintenance dose of SM
Fetal alive singleton intrauterine head presentation
left anterior occiput H III+
Management :
Control GA, VS, FHR, liquid balance, urine volume,
patellar reflex
Continue SM in maintenance dose
Re-evaluate in 2 hours time
Plan :
vaginal delivery
Assist stage II of labor with FE

03.00 pm
A/
Feeling of pain and let to bearing down
Fluid leakage spontaneusly from the vagina, clear
residue,
Fetal movement (+)
Blurred vision (-), epigastric pain (-), headache (-)
Physical Examination :
GA
Cons BP
PR
RR
T
Mdt
CMC 150/9082
20
37
Abd : uterine Contraction : 3-4 x/55/S
FHS : 128-132 bpm
Genitalia : I v/u was normal, vaginal bleeding (-)
VT : cervical dilatation was completed
Amnionic sac (+)
Head palpable, anterior occiput H III-IV

D/ G1P0A0L0 preterm parturient 34-36 weeks second

stage + Severe Preeclampsia in maintenance dose
of SM
Fetal alive singleton intrauterine head presentation
anterior occiput H III-IV
Management :
Control GA, VS, FHR, liquid balance, urine volume,
patellar reflex
Continue SM in maintenance dose
Plan :
vaginal delivery
Assist stage II of labor with FE

At 03.00 pm : Forceps Extraction was performed

At 03.15 pm :
A male baby was born by FE with 2450 gr in weight, 48 cm
in height and AS : 7/8
Placenta was born manually, 1 piece, complete. Size was 17
x 16 x 3 cm, weight approximately 500 gr. Umbilical cord
was approximately 55 cm in length with paracentral
insertion. Exploration of uterine cavity was performed.
Portio and uterine cavity were intact. Episiotomy wound
was repaired.
Blood loss during delivery 150 cc
D/ : P1A0L1 post FE on indication of severe PE
Both Mother Child were in care
A/ : stage IV monitoring