Vous êtes sur la page 1sur 10

Morning Report

CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1. G3P2A0L2 36-37 weeks S/L/IU head presentation


with PROM >24 hours and drip failure
2. G1P0A0L0 39-40 week/S/L/IU footling breech
presentation active phase, first stage of labor +
prolapse umbilical cord + fetal distress
3. -

TIME

SUBJECTIVE

OBJECTIVE

9/11/
2012
10.20

Patient referred from Tanjung


Karang PHC with G3P2A0L2
36-37 weeks S/L/IU head
presentation, with PROM >24
hours and mother and fetal
well being. History ruptur of
membrane (+) since 13.00
7/11/2012. Bloody slim (-).
Abdominal pain (-). FM (+).
No History of DM, Asthma, or
HT.
LMP : 06-03-2012
EDD : 13-12-2012
History of ANC : 3x
Posyandu
Last ANC : 05/11/2012

at

History of USG : 1 x
History of Family Planning :
Injectio
n
every
3
month
Next
Family
Planning
:
Injectio
n
every
3
month
Obstetrical History :
1. Aterm, Spontant, Midwife,

General Status :
GC : Well
BP : 120/80
PR : 96 bpm
RR : 24 tpm
T : 36,5 C
Local Status :
Eye : Anemis (-/-), Icteric (-/-)
Cor : S1S2 Single regular,
murmur (-), gallop (-)
Pulmo
:
Vesicular
(+/+),
wheeizing (-/-) ronkhi (-/-)
Abdomen : Scar (-), Striae
Gravidarum
(+),
Linea
nigra(+)
Extremity : Oedema :
Warm acral :
Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : Head
L4 : 4/5
UFH : 26
EFW : 2325
UC : FHB : 11-11-11 (132 bpm)
VT : 1 cm, effacement 10%,
amnion (-), Head palpable,
H1, denominator unclear,
impalpable small part and
umbilical cord

ASSESSMENT

PLANNING

G3P2A0L2 3637 weeks S/L/IU


head
presentation
with PROM >24
hours

Observation
mother and fetal
well being
Ampicillin
injection
1
gr
Intravenous
Dexamethasone
12 mg/12 hours
USG
at
Pro
10/11/2012

TIME
9/11/
2012
10.20

SUBJECTIVE

OBJECTIVE
Lab Examination :
HB : 12,2 g/dl
RBC : 4,13 x 106/L
HCT : 41,0 %
WBC : 9,08 x 103/L
PLT : 339x 103/L
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSME
NT

PLANNING

G3P2A0L2
36-37 weeks
S/L/IU head
presentation
with PROM

Observation
mother and
fetal well being
Ampicillin
injection 2g/iv
every 6 hours

Chronologist at PHC
7/11/
2012
13.0
0

Patient come to tanjung


karang PHC at 22.30
7/11/2012 because water
come out from her womb
since 13.00. abdominal
pain (-), bloody slim (-), FM
(+)

General Status :
GC : Well
BP : 130/80
PR : 84 bpm
RR : 22 tpm
T : 36,5 C
Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : Head
L4 : 3/5
UFH : 27
EFW : 2460
UC : FHB : 11-10-11 (128 bpm)
VT : 1 cm, effacement
10%, amnion (-), Head
palpable,
H1,
denominator unclear,
impalpable smll part
and umbilical cord

TIME
10/1
1/20
12
09.0
0

SUBJECTIVE

OBJECTIVE

ASSESSME
NT

Patient USG in VK teratai

PLANNING
SPV adv :
do as aterm
PROM

Result :
Fetus : S/L/IU
Amnion : Enough
Placenta : at Fundus grade
III
Pregnancy age : 36 weeks
EFW : 2500 gr

13.00

CTG : reactive
GC : Well
BP : 130/80 mmHg
PR : 90 bpm
RR : 24 tpm
T : 36,5 C
UC : FHB : 11-10-11 (128 bpm)
VT : 1 cm, effacement 10%,
amnion (-), Head palpable,
H1, denominator unclear,
impalpable small part and
umbilical cord

G3P2A0L2 3637 weeks


S/L/IU head
presentation
with PROM
>24 hours

Consult
to
DM
General
Doctor,
adv : Termination
with oxytosin drip
Oxytosin
Drip
Start at 8 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

10/11/1
2
13.30

UC : FHB : 11-11-11 (132


bpm)

Drip oxytocin 12 dpm

14.00

UC : FHB : 11-11-10 (128


bpm)

Drip oxytocin 16 dpm

14.30

Abdominal pain came and


relieved

UC : 2x10~15
FHB : 11-10-10 (124
bpm)

Drip oxytocin 20 dpm

15.00

Abdominal pain came and


relieved

UC : 2 x 10 ~ 25
FHB : 11-10-11 (128
bpm)

Drip oxytocin 24 dpm

15.30

Abdominal pain came and


relieved

UC : 2x 10 ~ 25
FHB : 11-11-11 (132
bpm)

Drip oxytocin 28 dpm

16.00

Abdominal pain came and


relieved

UC : 2x 10 ~ 25
FHB : 10-11-11 (128
bpm)

Drip oxytocin 32 dpm

16.30

Abdominal pain came and


relieved

UC : 2x 10 ~ 25
FHB : 10-11-11 (128
bpm)

Drip oxytocin 36 dpm

17.00

Abdominal pain came and


relieved

UC : 2x 10 ~ 25
FHB : 11-11-11 (132
bpm)

Drip oxytocin 40 dpm

GC : well
BP : 120/80 mmHg
PR : 88bpm
RR : 20 bpm
T : 36,8OC
17.30

Abdominal pain came and


relieved

UC : 2x 10 ~ 25
FHB : 11-11-10 (128

Drip oxytocin 40 dpm

TIME

SUBJECTIVE

10/11/1
2
19.00

Abdominal pain came and


relieved

OBJECTIVE

ASSESSMENT

UC : 3x 10 ~35
FHB : 11-11-11 (132
bpm)

PLANNING
Drip oxytocin 1st flash
end, continue with
2nd flash
Drip oxytocin 40 dpm

19.30

Abdominal pain came and


relieved

UC : 3x 10 ~35
FHB : 10-11-11 (128
bpm)

Drip oxytocin 40 dpm

20.00

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 10-11-11 (128
bpm)

Drip oxytocin 40 dpm

20.30

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 11-11-10 (128
bpm)

Drip oxytocin 40 dpm

21.00

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 11-10-11 (128
bpm)

Drip oxytocin 40 dpm

GC : well
BP : 120/80 mmHg
PR : 92bpm
RR : 20 bpm
T : 36,9OC
21.30

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 11-10-11 (128
bpm)

22.00

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 11-11-11 (132
bpm)
VT
:

1
cm,
effacement
10%,
amnion
(-),
Head

Drip oxytocin 40 dpm

G3P2A0L2 36-37 weeks


S/L/IU head
presentation with PROM
>24 hours

Drip oxytocin 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

22.30

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 11-11-11
(136bpm)

23.00

Abdominal pain came and


relieved

UC : 3x 10 ~40
FHB : 11-11-10 (128
bpm)
VT : 1 cm,
effacement 10%,
amnion (-), Head
palpable, H1,
denominator unclear,
impalpable small part
and umbilical cord

11/11/1
2
06.00

07.00

GC : well
BP : 120/80 mmHg
PR : 88bpm
RR : 24 bpm
T : 36,7OC

ASSESSMENT

PLANNING
Drip oxytocin 40 dpm

G3P2A0L2 36-37 weeks


S/L/IU head
presentation with PROM
>24 hours and drip
failure

Dm Consult to SPV :
SPV advice CS at
07.00 11/11/12

Prepared CS
Insert DC
Ampicillin 2 gr/IV

CS began
Baby was born, male,
BW : 2500 gram, BL:
45 cm, A-S : 7-9, anus
(+), congenital
anomaly (-),
Placenta was born
manually, complete
Bleeding : 500 cc
CS finished

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

11/11/1
2
10.00

GC: well
BP: 110/80 mmHg
PR: 104 bpm
RR: 24tpm
T: 37,2oC
UC : (+) well
UFH : 1 fingers below
umbilicus

2 hours post CS

Observed mother well


being
Observed bleeding &
VS mother
Suggest mother to
mobilisation, eat and
drink.

12/11/1
2
07.00

GC : well
BP : 120/80 mmHg
PR : 88 bpm
RR : 20 bpm
T : 36,7OC
UC : (+) well
UFH : 2 fingers below
umbilicus

1 day post CS

Observation vital sign


and bleeding
Suggest mother to
eat, drink,
mobilisation

Baby in NICU :
GC : well
PR : 132 bpm
RR : 44 bpm
T : 36,2OC