Morning Report

10 January 2009

Supervisor : dr. A. Rusdhy A.H, SpOG

Medical Student: 1. Ghea 2.Hadian 3.Heru 4.Miftah
Cases resume : 1. 2. 3. 4. Normal labor Breech presentation Hipertention in pregnancy + oligohidramnion

3 1 1 1. 3

Name / Age Address

Time 23.30

: Mrs. Ni Ketut Sutatni/ 42 years old : Lingsar

Subject Object General status : General condition: weak Conciousness: CM BP: 70/50mmHg RR: 24 x/mnt PR: 120 x/mnt T: 36 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Abdomen: distensi (-), pain (-), siffting dullness (-), UFH: 3 finger above simfisis. Extremitas: cold Inspection: active bleeding (-) Inspeculo: fluxus (+), smell (+), livide (+) VT: CD (+), CUAF size and consistensi ~ 8-10 week. APCD : normal

CTH Time
Assesment

: 31 January 2009 : 23.30

Planning Observation vital sign IVFD RL O2 4 l/mnt Laboratorium examination Trendelenburg position VT to prevent compressed to umbilical cord Report to supervisor proposed SC. Advice: Observation and resusitation, if until 17.00 condition still same prepare SC

Patient came to emergency care unit with pregnancy 3 month and confess bleeding pervaginam Chronologis: Patient confess bleeding pervaginam since 2 days ago( 29-1-09) after she fall down in his hause. .

G2P1A0H1 A/S/L breech presentation (footling) active phase of 1st stage of labor + history of vaginal discharge + umbilical cord palpable

LMP: 26-4-09 EDD: 2-2-09

History of pregnancy 1. male, aterm, spt, 3800 g, 7 years 2. this History of family planing: Injection 3 month since 7 years ago. Last injection 2 years ago. Planing for family planing: Injection per 3 month

Name / Age Address

Time

: Mrs. Isal / 45 years old : Lingsar

Subject Object Z-A score: 6 oParitas : 1 oHistory of breech presentation: 0 oEstimate Fetal Weight : 2 oOld of pregnacy: 0 oStation : 1 oCervix dilatation : 2 lab result: Hb: 10,4 g% WBC: 12.000/mm3 PLT:234.000/mm3 HCT:32 % HBsAg (-)

CTH

: 22 January 2009 : 20.00

Planning

Time
Assesment

Time 16.30

Subject Mother confess abdominal discomfort and want to bearing down

Object General status : well UC: 3x/10 ~40 FHB: 16-16-17

Assesment G2P1A0H1 A/S/L breech presentation (footling) active phase of 1st stage of labor + history of vaginal discharge + umbilical cord palpable

Planning KIE mother not to bearing down Trandelenburg position VT to prevent compression to umbilical cord

17.00

Mother confess abdominal discomfort more often and want to bearing down.

General status: well UC: 4x/10 ~ 45 FHB: 15-16-16 Insection: right foot seen in vulva more appear than before VT : DC complete cm, eff 100 % AM (-), foot n umbilical cord palpable, breech palpable descensus HIII.

G2P1A0H1 A/S/L breech presentation (footling) 2nd stage of labor + history of vaginal discharge + umbilical cord palpable

conducted mother to labor

17.15

Baby was born with manual aid, male, AS: 3-5, W: 3100 g, L: 50 cm. placenta was born spontaneusly, complete.

19.15

General status: well BP: 110/70 mmHg PR: 84 x/mnt UC: well UFH: 2 finger under umbilicus Active bleeding (-)

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