MORNING REPORT April 16th 2011

Supervisor : dr. M. MAhayasa, SpOG

Medical Students: Rangga, Nata, yuyun

Cases resume :

Normal Labor Phatologic Labor

1 6

Name Age Address

Time

: Mrs. R : 43 years old : Bengkel Timur, LA

CTH

: October 13th 2011 At 10.05 wita

Subject
Patient referred from Poli Hamil with G3P2A0L2 40 weeks S/L/IU + Footling presentation + latent phase first stage of labor. Patient confessed abdominal pain, since yesterday, Blood slym (-). History rupture of membrane (-). FM (+). History of DM (-), HT (-), asthma (-). LMP : 03/01/2011 EDD : 10/10/2011 History of ANC : > 4 x, midwife Last ANC : October 2011 History of USG : (+) in Oct 13th baby : footling presentation, calcification (+), advice : SC cito History of family planning : IUD Next family planning : IUD Obstetrical history : I. Male, term, spontaneous, midwife, 3700 gr, 7 yo II. Female, term, SC (transverse lie), SpOG, 3300 gr, 5 yo III. this Chronologist : (-)

Object
General Condition : well Consciousness : CM BP : 110/70 mmHg PR : 84 x/minute RR: 20 x/minute T : 36,8C MH/MW : 163 cm/79 kg Generalis status : Eye : palor (-), icteric (-) Thorax : Cor : S1S2 Single Reguler Murmur (-), Gallop (-) Pulmo : Vesikuler (+/+), Wheezing (-/-), Ronkhi (-/-). Abdomen : scar post SC (+), striae (+), linea nigra(+) Extremity : edema (-), warm acral (+) Obstetrical status : L1 : head, UFH: 31 cms, AC : 109 cm L2 : fetal back on right side L3 : breech L4 : EFW : 3379 gr UC : (+), 2 x 10 20 FHR : (+), 12-12-11 (140 x/minute) VT : 1 cms, eff 10%, amnion (+), head palpable, denom unclear, H I, unpalpable small part of fetal or umbilical cord

Assesment
G3P2A0L2 40 weeks S/L/IU + Footling presentation + latent phase first stage of labor

Planning
Observe mother & fetal well being CBC, HbSAg checked Supervisor advice : pro SC

11/10 /2011 10.05

Time

S
Lab : DL : HGB : 12,5 RBC : 4,76 HCT : 41,3 WBC : 10 PLT : 203 HbSAg : (-)

12.45

SC preparation

Time

13/10 /2011 13.22

SC began Baby was born, Male, A-S : 6-8 BW/BL : 3600 gr/53 cm Anus (+), congenital anomali (-) Amnion cloudy Placenta was born manually, placental weight : 500 gr Bleeding 300 cc Intraoperation : Baby in tranverse lie Endometriosis at corpus uteri anterior dextra et sinistra SC Finished

13.55

Subject

Object

Assesment

Planning

15.55

(-)

GC : well cons : E4V5M6 BP : 110/60 mmHg PR : 86 tpm RR : 20 tpm T : 36,3 C UFH : umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 45 cc/hours GC : well cons : E4V5M6 BP : 120/70 mmHg PR : 84 x/minute RR : 20 x/minute T : 36 C UFH : 2 fingers below umbilicus Uterine consistency firm Operation wound good Active bleeding (-)

2 hour Post SC

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

13/10 /2011 07.00

Wound pain

1 day post SC

Observe mother and baby well being Suggest mother to take a rest Baby & mother treat together

Baby in NICU : PR : 124 x/minute RR : 48 x/minute T : 36,9C