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MORNING REPORT September 23th 2011

Supervisor : dr. Mahayasa, SpOG


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

Cases resume :

Normal Labor

Phatologic Labor

Name Age Address


Time

: Mrs. F : 20 years old : Taliwang, KSB

CTH

: September 23th 2011 At wita 11.30

Subject

Object

Assesment

Planning

11.30

Patient referred from Beru Village PHC with G1P0A0H0 36 weeks with twins + anemia + severe preeclamsia. Abdominal pain (-), bloody slim (-), FM (+), history of rupture membrane (-). History of HT (-), DM (-), Asthma (-). LMP: 15-01-2011 EDD: 22-10-2011 History of ANC : History of ANC : > 4x, midwife Last ANC : August History for USG : 23/9/2011 Result: Fetal life /twins/IU with breechbreech presentation. History of family planning : Next family planning : -

General Condition : well Consciousness : CM BP : 140/80mmHg PR : 84x/minute RR: 20 x/minute T : 37,2C 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 : Fetal I: L1 : head UFH: 36 cms, L2 : fetal back on right side L3 : breech L4 : 4/5 Fetal II: L1 : head UFH: 36 cms, L2 : fetal back on right side L3 : breech L4 : 4/5

G1P0A0H0 35-36 weeks/G/L-L/IU with mild preeclamsia + moderate anemia

Observe mother & fetal well being DL, HbSAg , UL checked Coass consult to GP pro transfusi. Advice : ACC Transfusi 2 kolf Stop drip MgS04

Obstetrical history : This

Time

S
Chronologist : - Patient came to Beru village PHC at 15.00 (22/09/2011) confess limb edema. BP: 170/100mmHg PR: 84x/minute RR: 24x/minute T: UFH: 43 cm Back on the right side FHR: 145x/minute UC: (-) VT: not done Planning: IVFD D5% 20dpm -21.30 WITA FHR I: 153x/minute FHR II: 143x/minute Planning: O2 5 liter/minute Nifedipine 10 mgram Bolus MgSO4 10 cc Drip MgSO4 15cc in RL 28dpm Referred to NTB GH

O
His: (-) FHR : (+), I : 11-12-12 II: 11-12-11 VT : not done
Lab : DL:HGB : 6,1 WBC : 3,4 HCT : 40,4 MCV : 86 WBC : 17, 48 PLT : 370 HbSAg : UL:BJ : 10105 pH : 5,0 Nitrit : Protein : +2 Glukosa : Keton : Urobilinogen : Bilirubin : Blood : +2

Time

S
Abdominal pain

O
General Condition : well Consciousness : CM BP : 140/90 mmHg PR : 804x/minute RR: 20 x/minute T : 38,7C
Obstetrical status : His: (+), 2 x 10 25 FHR : (+), I : 11-12-12 II: 11-11-11 VT : 3 cms, eff 30%, amnion (+) , breech palpable HI, Unpalpable small part / umbilical cord.

A
G1P0A0H0 35-36 weeks/G/L-L/IU breech presentation with latent phase first stage of labor + mild preeclamsia + moderate anemia

P
Post tranfution jam 12.00 Observe mother & fetal well being GP consult to supervisor pro SC. Advice : ACC and prepare PRC. Inj. Xylomidon : Delladril 2:1 Prepare SC

23/9/2 011 21.00

Subject

Object

Assesment

Planning

22/9/2 011 22.30

SC began

22.45

First Baby was born, Female., A-S : 7-9, BW : 1900 g Anus (+), congenital anomaly (-).

22.47

Second Baby was born, Female., A-S : 7-9, BW : 2000 g Anus (+), congenital anomaly (-). Amnion fluid 10 cc, clear. Placenta was born manually, complete, bleeding 200cc Placenta weight : 420 gr

23.05

SC Finished

Subject

Object

Assesment

Planning

24/9/ 2011 01.30

(-)

GC : well cons : E4V5M6 BP : 110/70 mmHg PR : 80x/minute RR : 20 x/minute T : 36,7 C UFH : in umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 30 cc/hours

2 hour Post SC

Observe mother and baby well being KIE mother to take a rest

24/9/ 2011 07.00

Wound pain

GC : well cons : E4V5M6 BP : 100/70 mmHg PR : 88 x/minute RR : 20 x/minute T : 36,5 C UFH : in umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 25 cc/hours Baby in NICU : PR : 138x/minute RR : 33 x/minute T : 36,8C

1 day post SC

Observe mother and baby well being KIE mother to take a rest