MORNING REPORT September 23nd 2011

Supervisor : dr. Mahayasa, SpOG

Medical Students: Sindi, Ika, noval, Maria, elin, lili

Cases resume :

Normal Labor

Phatologic Labor

Name Age Address

Time

: Mrs. F : 20 years old : Lingsar

CTH

: September 22nd 2011 At 08.00 wita

Subject

Object

Assesment

Planning

23/9/ 2011 08.00

Patient came to Poli Hamil (RSUP NTB) with abdominal pain since 2 days ago, bloody slim (+), History of rupture membrane (-). DM (-), HT (), Asthma (-). LMP : 20/12/2010 EDD : 27/09/2011 History of ANC : > 4x Last ANC : History of USG : History of family planning : Next family planning : Obstetrical history : I. This

General Condition : well Consciousness : CM BP : 120/80 mmHg PR : 75 x/minute RR: 21 x/minute T : 36,5C Height: 140 cm 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 : breech, UFH: 39 cms, L2 : fetal back on right side L3 : Head L4 : 4/5 EFW : 4185 gram His: (+), 3 x 10 35 FHR : (+), 12-12-12 VT : 7 cms, eff 5%, amnion (+) , head palpable, LOA HI, Unpalpable small part / umbilical cord.

G1P0A0H0 38-39 weeks T/S/L/IU with active phase first stage of labor + macrosomia

Observe mother & fetal well being DL, HbSAg Injeksi Ampicilin 1 gr/IV Coass consult to GP pro Observe. GP consult to supervisor Advice : ACC observe

Time

S
Chronologist : -

O
PE: Sacrum convexity normal Spina ischiadica not prominent Os coccygeus mobile Arcus pubis > 90

Lab : DL:HGB : 10,8 RBC : 4,36 HCT : 36,4 WBC : 12, 9 PLT : 227 HbSAg : 09.10 (23/0 9/201 1)

History of rupture membrane (+)

UC: 3 x 10-35 FHR: 12.13.12 VT: CD 7 cm, eff 75%, amnion (-) clear, LOA, head palpable, H1,unpalpable smallpart and umbilical cord.

G1P0A0H0 38-39 weeks T/S/L/IU with active phase first stage of labor + history of rupture membrane + macrosomia

Co to dr.Punarbawa Sp.OG advice: observe

Time

O
UC: 3x10-35 FRH: 156 x/minute VT: CD 7 cm, eff 75%, amnion (-), clear, head palpable, maoulage 3 unpalpable small part of umbilical cord

A
G1P0A0H0 38-39 weeks T/S/L/IU with arrested active phase first stage of labor + history of rupture membrane+ macrosomia

P
Coass to supervisor: Pro SC Co dr. Punarbawa advice co dr.mahayasa, advice: observe

12.10

14.30

Dr.mahayasa Sp.OG called VK

UC: 3x10-35 FHR: 156 x/minute Advice dr.mahayasa, Sp.OG-observe and if any fetal distress or any complication to mother,,,call supervisor ACC SC on 21.30 WITA if mother and baby well

15.00

UC: 3x1035 FHR: 164x/minute BP:120/70 mmHg PR: 82x/minute RR: 20x/minute T: 37,9C

G1P0A0H0 38-39 weeks T/S/L/IU with arrested active phase first stage of labor + history of rupture membrane+ macrosomia + febris+ fetal distress

Coass to GD: Pro rescusitasion Pro paracetamol 3 dd 500mg Pro SC GD to supervisor advice: ACC rescusitation, paracetamol 3 dd 500mg, SC still on 21.30 WITA

Subject

Object

Assesment

Planning Observe

16.30

Abdominal pain (+)

FHR: 13.12.12 UC: 3x1040 BP: 110/80mmHg PR: 96x/minute RR: 20x/minute T: 37,9C

G1P0A0H0 38-39 weeks T/S/L/IU with arrested active phase first stage of labor + history of rupture membrane+ macrosomia+febris

17.00

Abdominal pain (+)

FHR: 13.12.12 UC: 3x1040 BP: 120/70 mmHg PR: 97x/minute RR: 20x/minute T: 37,9C

G1P0A0H0 38-39 weeks T/S/L/IU with arrested active phase first stage of labor + history of rupture membrane+ macrosomia+febris

Observe

17.30

Abdominal pain (+)

FHR: 13.13.12 UC: 3x10-40 BP: 110/80mmHg PR: 92x/minute RR: 20x/minute T: 37,9C Suspect bandle ring Catheter: gross hematuri (-)

G1P0A0H0 38-39 weeks T/S/L/IU with arrested active phase first stage of labor + history of rupture membrane+ macrosomia+febris + suspect RUI

Coass to GD: pro SC GD advice: observe

Subject

Object

Assesment

Planning

18.00

Abdominal pain (+)

UC: 3x10-40 FHR: 13.13.13 UC: 3x10-40 FHR: 170x/minute Suspect bandle ring (+) BP: 130/70 mmHg PR: 100x/minute RR: 20x/minute T: 37,9 G1P0A0H0 38-39 weeks T/S/L/IU with arrested active phase first stage of labor + history of rupture membrane+ macrosomia+febris + suspect RUI +fetal distress SC began Coass to GD: pro SC GD to supervisor advice ACC SC 20.00 WITA

19.00

Abdominal pain (+)

21.15

21.20

Baby was born male, 3000gram, AS: 5-7, amnion fluid clear, anus (+), congenital anomaly (-). Placenta was born manual, complete, bleeding 200cc. RUI (-)

observe

Subject

Object

Assesment

Planning

23.25

Wound operation pain (+)

BP: 120/70mmHg PR: 81x/minute RR: 20x/minute T: 37,2 C UC: (+) UFH:1 finger below umbilicus UO: 50 cc/hour Vaginal active bleeding (-) BP: 110/60mmHg PR: 80x/minute RR: 20x/minute T: 36,5 C UC: (+) UFH:1 finger below umbilicus UO: 70 cc/hour Vaginal active bleeding (-)

2 hours post SC

Observe

1 day post SC 07.00 Wound operation pain (+)

Observe Mefenamic acid 3 x 500mg Amoxicilin 3 x 500mg SF 1x1

Baby in NICU PR: 137x/minute RR: 37 x/minute T: 36,7C