MORNING REPORT October 8th 2011

Supervisor : dr. Juliawan, SpOG

Medical Students: Lili, Atun, Honest, Dhani, Niar, Ray, Irfan

Cases resume :

Normal Labor

Phatologic Labor

Name Age Address

Time

: Mrs. S : 30 years old : Bajur

CTH

: October 8nd 2011 At 11.40

Subject
Patient reffered from Mataram GH with G1P0A0H0 37 weeks S/L/IU with transverse lie + history rupture of membrane. Patient confessed rupture of membrane since 01.00 (08/10/2011). Abdominal pain (+) since 06.00, bloody slim (+) since 06.00, FM (+). History of DM (-), HT (-), asthma (-). LMP: 11/01/2011 EDD: 18/10/2011 History of ANC: > 7x, midwife Last ANC: 4/10/2011 History of family planning : Next family planning : injection for 3 months Obstetric History : 1. This Cronologist in Mataram GH (8/10/2011 at 10.15 am) S :Patient reffered from Bajur PHC with G1P0A0H0 37 weeks S/L/IU with transverse lie. Patient confessed abdominal pain since 06.00 (8/10/2011), rupture of membrane since 01.00

Object
General Condition : well Consciousness : CM BP : 120/90 mmHg PR : 86 x/minute RR: 20 x/minute T : 36,0C 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: L2: head at right side, breech at left side L3: small part of fetal (finger hand) L4: UFH : 23 cm FHR: 136x/minute UC : 3x10~35 VT : complete, amnion (-) denom, finger hand palpable, H II, unpalpable umbilical cord.

Assesment
G1P0A0H0 37 weeks S/L/IU with second stage of labor +transverse lie

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

08/10 /2011 11.40

Time

S
O : General Condition : well Consciousness : CM BP : 120/70 mmHg PR : 80 x/minute RR: 16 x/minute T : 36,8C Obstetrical status L1: L2: head at right side, breech at left side L3: small part of fetal (finger hand) L4: UFH : 23 cm FHR: 136x/minute UC : 2x10~20 VT : 6 cm, eff 75%, amnion (-), finger hand palpable, H II, unpalpable umbilical cord. A : G1P0A0H0 37 weeks S/L/IU with transverse lie + history rupture of membran P: Infuse RL (in Bajur PHC) Injection Ampicillin 1 gr (08.20 am in Bajur PHC) Co to Sp.OG Sp.OG keluar kota Reffered to NTB GH Laboratory result: HGB : 12,1 WBC : 13,2x 103 RBC : 3,98 x 106 HCT :38,1 PLT: 255.000 HbsAg: (-)

Time

P
SC began Baby was born, male, 2500 gr, AS 6-7 , transverse lie, amnion clear 250 cc , anus (+), congenital anomaly (-), Placenta was born manually, complete, bleeding 300 cc Intraoperative: uterus arkuatus SC finished

08/10/2 011 12.40

13.15

14.40

Wound pain operation

General condition : well BP: 120/80 mmHg PR: 78x/minute RR: 20x/minute T: 36,7 C UO : 280cc/2 hours UFH: 1 finger below umbilicus UC: (+) good Vaginal active bleeding (-)

2 hours post SC

Observe mother condition KIE mother to take a rest

Time

S
Wound pain operation

O
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 below umbilicus UC: (+) good Vaginal active bleeding (-) Baby in NICU PR : 140 x/minute RR : 38 x/minute T : 36C

A
1 day post SC

P
Observe mother condition KIE mother to take a rest

9/10/ 2011 09.00