MORNING REPORT 4th September 2012

Supervisor : dr. I Made Putra Juliawan SpOG Medical Students : Yan, Rifka, Agung, Tari, Metha, Santhi, Rona

CASE RESUME

NORMAL LABOR
PATHOLOGIC LABOR
1. G4P1A2H1 39 - 40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor.

Case Report
Name

: Mrs. R Age : 34 years old Address : Batu Rimpang, Narmada, Lombok Barat Admitted : September 3th, 2012 at 11.00 WITA

Time 03/09/12 11.00 (at VK IRD)

Subject Patient came to Emergency Unit of NTB GH, referred from Narmada PHC with G4P1A2H1 39 - 40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor. Patient confessed abdominal pain since 00.00 (03/09/2012). Blood slim (+), history rupture of membrane (-). FM (+). History of DM (-), HT (-), asthma (-). LMP : 30/11/2011 EDD : 07/09/2012 History ANC : > 4x at Posyandu Last ANC : 09/08/2012 History USG : never

Object General status GC : well GCS: CM (E4V5M6) BP : 120/70 mmHg HR: 100 tpm RR: 16 tpm T: 36,2C Local status Eye : an (-/-), ict (-/-) Pulmo: ves (+/+), rh (-/-), wh (-/) Cor : S1S2 single regular M(-), G (-) Abd : striae gravidarum (+), linea nigra (+), scar (-) Ext : edema (-/-), warm acral (+/+) Obstetric status L1 : breech L2 : back on the right side L3 : head L4 : 4/5 UC : 2x/10 ~ 35 UFH: 33 cm EFW : 3410 gram FHB : 12.12.12 (144x/minute) VT : 4 cm, eff. 50%, Amnion (+), head palpable HI, denom unclear, impalpable small part of fetal & umbilical cord.

Assessment G4P1A2H1 39 - 40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor.

Planning - Obs. Mother and fetal well being. - Obs. Progress of labor - Observation inpartu with partograph - Lab. Evaluation CBC & HbsAg - DM co SPV pro amniotomi, advice: Acc amniotomi if CTG reactive, evaluate 2 hours post amniotomi - DM do CTG. Result : CTG reactive - GP do amniotomi

History of family planning : Injection 3 month Next family planning: Injection 3 month
Obstetric History: 1. , 3300 gr, bidan, 12 yo 2. Abortus 3 month 3. Abortus 3 month 4. This

Time

Subject Chronologist in Narmada PHC: 03/09/2012, 10.00 WITA S: Patient came confessed abdominal pain. Patient referred from midwife sembung village. LMP : 30/11/2012 EDD : 7/09/2012 O: General status : GC : well, Consciousness : CM BP : 100/70 mmHg HR : 80 x/minute RR : 20 x/minute T : 36,8 C Obstetric status: L1 : breech TFU: 34 cm L2 : back on the right side L3 : head L4 : 4/5 UC : (+) 3x/10 - 25 FHR : (+) 111111 (132x/minute) VT : 5 cm, eff. 50%, Amnion (+) , head palpable HI, denom : ROA, impalpable small part of fetal & umbilical cord. A: G4P1A2L1 40 weeks S/L/IU head presentation, condition mother and fetal well with active phase 1st stage of labor. P: - Obs. Mother and fetal well being. - Inf RL 2 flash - Inf D5 28 tpm 1 flash

Object Pelvic evaluation : Spina ischiadica not prominent Os coccigeous mobile Pubic arch > 900 Lab result in 11.46 (03/09/2012) Hb = 10,8 g/dl RBC = 3,68 10^6/L WBC = 9.0 10^3/L Plt = 365 10^3/L Hct = 35,5 % HbSAg = (-)

Assessment

Planning

Time 13.00

Subject Patient confessed abdominal pain.

Object General status GC : well Consciousness : CM (E4V5M6) BP : 120/70 mmHg HR: 96 bpm RR: 20 bpm T : 36,2C Obstetric status UC : 2x/10 35 FHB : 12-12-12 (144 bpm)

Assessment

Planning -Obs. Mother and fetal well being. -Obs. Progress of labor

15.00 Patient confessed abdominal pain.

General status GC : well BP : 120/80 mmHg PR: 88 bpm RR: 20 bpm T : 36,7C Obstetric status UC : 3x/10 ~ 35 FHB : 12.11.12 (140 bpm) VT : 4cm, eff. 50%, Amnion (-) , head palpable HI,denom : ROA, impalpable small part of fetal & umbilical cord.

G4P1A2H1 39 - 40 weeks S/L/IU head prsentation with arrested active phase 1st stage of labor

- Obs. Mother and fetal well being. -Obs. Progress of labor - DM co to SPV. pro CS. Advice : Acc CS at 21.00. Continue obs. Mother and fetal well being & progress of labor.

Time 17.00

Subject Patient confessed abdominal pain.

Object General status GC : well Consciousness : CM (E4V5M6) BP : 110/70 mmHg HR: 88 bpm RR: 20 bpm T : 36, 7C Obstetric status UC : 3x/10 30 FHB : 11-11-11 (132 bpm)

Assessment

Planning -Obs. Mother and fetal well being. -Obs. Progress of labor

18.00 Patient confessed abdominal pain.

General status GC : well Consciousness : CM (E4V5M6) BP : 120/70 mmHg HR: 96 bpm RR: 24 bpm T : 36, 8 C Obstetric status UC : 3x/10 35 FHB : 11-12-11 (136 bpm)

- Obs. Mother and fetal well being. - Obs. Progress of labor

Time 17.00

Subject Patient confessed abdominal pain.

Object General status GC : well BP : 120/80 mmHg PR: 88 bpm RR: 20 bpm T : 36,7C Obstetric status UC : 3x/10 ~ 35 FHB : 11.11.12 (136 bpm) VT : 5 cm, eff. 50%, Amnion (-) , head palpable HI,denom : ROA, impalpable small part of fetal & umbilical cord.

Assessment G4P1A2H1 39 - 40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor

Planning Prepare CS 21.00 - Insert DC. - Inj. Ampicillin 2g/IV. - CIE patient tp CS and use IUD, patient acc. - Check BT, CT

22.20

CS began Baby was born (22.45, 03/09/2012). Male. 3400 g. 51 cm. AS 7-9. Anus (+). Congenital anomaly (-). Placenta was born. Spontaneously at 22.43,Complete. Bleeding 400cc CS finish at 23.00 (03/09/2012)

Time 04/09/201 2 01.00

Subject Patient confessed wound pain

Object GC : well Cons : Compos Mentis BP : 110/70 mmHg PR : 96 bpm RR : 24 bpm T : 36 0 C Active bleeding : (-) Lochia rubra : (+) UFH : at umbilicus UC : (+) well UO : 50 cc/hours

Assessment 2 hours post CS

Planning Observed mother and baby well being Suggest mother to take a rest, eat and drink, mobilisation.

07.00

Patient confessed wound pain

GC : well Cons : Compos Mentis BP: 110/80 mmHg PR : 88 bpm RR : 24 bpm T : 36,8 oC UFH : 2 fingers below umbilicus UC : (+) well Active bleeding : (-) Lochia rubra : (+) UO : 50 cc/hours
Baby in NICU : GC : well PR : 132 bpm RR : 44 bpm T : 36,2OC

One day post CS

Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.