MORNING REPORT October 2nd 2011

Supervisor : dr. Juliawan, SpOG

Medical Students: Lili, Ika, Maria, Noval, Fida

Cases resume :

Normal Labor

Phatologic Labor

Name Age Address

Time

: Mrs. M A : 36 years old : Dasan Agung Baru

CTH

: October 2nd 2011 At 18.10

Subject

Object

Assesment

Planning

02/10 /2011 18.10

Patient came to NTB GH confessed rupture of membrane since 17.30 (02/10/2011). Abdominal pain (-), bloody slim (-), FM (+). History of DM (-), HT (-), asthma (-). LMP: 29-01-2011 EDD: 05-11-2011 History of ANC: > 4x, SpOG Last ANC: September 24th 2011 USG: > 4x History of family planning : Next family planning : Obstetric History : 1. Abortus 2. This

General Condition : well Consciousness : CM BP : 120/70 mmHg PR : 96 x/minute RR: 20 x/minute T : 36,5C Status Generalis: Eye : palor (-/-), icteric (-/-) Thorax : Cor : S1S2 single reguler (murmur -), (gallop -) Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra(+) Extremity : edema (-), warm acral (+) Obstetrical status L1: head at right side, UFH : 31 cm L2: breech at left side L3: small part of fetal L4: FHR: 144x/minute UC : (-) VT : (-), forniks palpable

G2P0A1H0 35-36 weeks S/L/IU with transverse lie + history of rupture membrane

Obs. Mother and fetal well being Check DL, HbsAg Coass to GP: pro injection Ampisilin 2 gr/iv & pro SC GP : acc injection Ampisilin 2 gr/iv GP consult to SPV advice: pro SC SPV acc SC

Time

S
Laboratory result: HGB : 11,5 WBC : 13,59 x 103 RBC : 4,23 x 106 HCT :37,1 PLT: 277.000 HbsAg: (-)

02/10 /2011 21.55

SC began

22.00

Baby was born, female, 1750 gr, AS 3-5, Ballard score : , transverse lie, amnion clear 250 cc , anus (+), congenital anomaly (-), Placenta was born manually, complete, bleeding 450 cc Intraoperative: mioma multiple

22.30

SC finished

Time

O
General condition : well
BP: 110/60 mmHg PR: 92x/minute RR: 20x/minute T: 36,8 C UO : 33 cc/hours UFH: 2 finger under umbilicus UC: (+) good Vaginal active bleeding (-)

A
2 hours post SC

P
Observe mother condition KIE mother to take a rest

03/10 /2011 00.30

07.00

Wound pain operation

General condition : well BP: 120/70 mmHg PR: 88 x/minute RR: 20 x/minute T: 36,5 C UO : cc/hours UFH: 2 finger under umbilicus UC: (+) good Vaginal active bleeding (-) Baby in NICU PR : 110 x/minute RR : 32 x/minute T : 35,6C

1 day post SC

Observe mother condition KIE mother to take a rest

Identitied
Name Age MR Adress : Mrs. LS : 27 years old : 256113 : Kediri

Admitted to GH of NTB on October 3rd, 2011 at 04.45

Time 03.55 03.10.2011

Subject Patient reffered from Gerung Hospital with G2P1A0L1 T/S/L/IU head presentation + prolonged active phase 1st stage of labor. + fetal distress. FM (+). Abdominal pain (+) since 05.00 (2/10/2011), bloody slim (+) at 20.00 (2/10/2011). History rupture of membrane (+) since 22.30 (2/10/2011). History of HT (-), DM (-), Asthma (-) LMP : forgot EDD : History of ANC : > 4 x at Polindes History of family planning : injection for 3 month Next family planning : injection for 3 month History of obstetric 1. This Chronologist : S : patient came to Gerung Hospital at 16.30 (2/10/2011) with G2P1A0L1 T/S/L/IU head presentation, confessed abdominal pain since 05.00 (2/10/2011). history of rupture membrane (-) History of DM (-), HT (-), Asthma (-).

Object General status: General condition : well Cons : CM BP : 110/80 mmHg PR : 80 bpm RR : 20 x/minute T : 36C Generalis status Eye : an (-/-) ict (-/-) Pulmo : Ves (+/+), Rh (-/-), Wh (-/-) Cor : normal Abd : striae gravidarum Ext : edema (-/-) Obstetrics status L1 : breech UFC : 40 cm L2 : back on the left L3 : head L4 : 3/5 UC : 3x10~25 EFW : 4495 gram FHB : 10.9.10 VT : 9cm eff 90%, amn (-) clear, head palpable, HII , caput (+) ,moulage (+),unpalpable small part or umbilical cord,

Assestment G2P1A0L1 aterm/S/L/IU head presentation neglected active phase 1st stage of labor

Planning - Obs. Mother and fetal well being -DL and HBsAg - GP report to Supervisor Adv: pro SC

Time

Subject O: General condition :in pain Cons : CM BP : 110/70 mmHg PR : 86 bpm RR : 18 x/minute T : 36C Obstetrics status L1 : breech UFC : 35 cm L2 : back on the right L3 : head L4 : 3/5 UC : 3x10~25 EFW : 3720 gram FHB : 12-12-11 VT : 5cm eff 50%, amn (+), head palpable, HI , unpalpable small part or umbilical cord, 22.00 WITA FHB (+) 11-12-12 (140 bpm) UC: 2x10~30 VT : 6cm eff 50%, amn (+), head palpable, HI unpalpable small part or umbilical cord, 22.30 WITA rupture of membran (+), clear O: VT: 8cm 75%, amn (-) clear, HI unpalpable small part or umbilical cord,

Object Lab exam : WBC : 22.73 RBC : 3.99 HGB :10 PLT : 256.000 Hct : 33,8 HBsAg : (-) GDS: 167

Assestment

Planning

Time 01.00 UC: 3x10~25; FHB: 9-9-9 (102)bpm VT : 8cm eff 75%, amn (+), head palpable, HI unpalpable small part or umbilical cord A: prolonged active phase of 1st stage 03.00 patient reffered P: O2 nasal 5 lpm IVFD RL Sugest mother to lay to left 05.50 06.00

Subject

Object

Assestment

Planning

SC began Baby was born. female, 3100 grams, BL: 50cm. A-S 6-7. Anus (+), kongenital anomali (-), amnion meconeal. Baby was sent to NICU Plasenta was born manually, complete, 500 gr

06.45

SC finished

Time

Subject

Object

Assestment

Planning

3/10/2011 08.00

General condition : well BP: 120/70 mmHg PR: 92 x/minute RR: 20 x/minute T: 36,5C UO : 32 cc/hours UFH: 1 finger under umbilicus UC: (+) good Vaginal active bleeding (-) Baby in NICU PR : 140 x/minute RR : 40 x/minute T : 36,6 C

1 hours post SC

Observe mother condition KIE mother to take a rest