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Morning Report

5 DESEMBER 2009
Supervisor : dr. Edi Prasetyo Wibowo, SpOG
Medical Student:
Syarif
Winda
Helmiati
Halia

Cases resume :
1

G2P1A0H1 A/S/L/IU with neglected 2nd stage of


labor.

G1P0A0L0 A/S/L/IU head presentation


with
.
PRoM >12 hours

Normal labor

Name/adress

: Mrs. S/ Narmada

Age

28years old

Time
14.30

Subject

Patient came to Mataram GH referred by


Keru Polindes with G2P1A0L1 A/S/L/IU with
prolong 2nd stage of labor
LMP: Forgot
Chronologist :
Patient came to Keru polindes at 24.00
(05/12/09) confess abdominal pain (+),
bloody show (-), watery vaginal discharge (-).
Hipertention (-), DM (-), asma (-).
Examination in Polindes:
24.00
BP: 120/80 mmHg
PR; 80 bpm
T: 365 C
RR: 20 tpm
UFH : 32 cm
FHR: 124 bpm
VT : CD 2 cm, eff 20%, AM (+), head
palpable, descend HI.
02.00
Watery vaginal discharge, clear
04.00
BP: 120/80 mmHg
PR: 80 bpm
T: 36,5 C
FHR: 124 bpm
VT : CD 4 cm, eff 40%, AM (-), descend HI.
08.00
BP: 120/80 mmHg
PR: 80 bpm
T: 36,5 C
FHR: 124 bpm
VT : CD 8 cm, eff 80%, AM (-),descend HI.

Admitted
to
Hospital

5 desember 2009

14.30 wita
Object
Examinaton at Mataram GH:
General condition: good
GCS : CM
BP :130/90 mmHg
PR : 80 bpm
RR : 24 tmp
Temp : 37 C
An +/+, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :32cm
EFW : 3255 gr
FHR : 152 bpm
UC :3x10-40
VT :CD complete, AM (-), green, head
palpable, caput (+), denom fontanella
minor anterior, descend HIII, small part
and umbilical cord wasnt palpable.
Lab. Examination :
Hb : 11,8 gr%
Leko : 22.800 mm3
Trombo : 247.000 mm3
Hct : 32,8 gr%
HBsAg : -

Assesment

Planning

G2P1A0L1 A/S/L/IU
with neglected 2nd
stage of labor.

Obs. Mother and fetal wellbeing


Inject cefotaxim 1g IV
Report to supervisor:
Propose :resusitation
Advice : left side,resusitation,
call back
16.30
Report to supervisor:
Propose: EV
Advice: EV
KIE patient n family, preparing to
EV

Time

Subject

Object

Assesment

Planning

10.00
Patient want to bear
FHR : 124 bpm
VT: CD complete, eff 100%, AM (-), descend
H
10.30
Conduct to bear until 11.30,but nothing
progress
13.00
Reffered to mataram GH
Therapy:
D5
Motivated to eat n drink
Motivated to left side
ANC 8 x,at polindes, last 17 nov 2009
Obstetric history
1. aterm, male,9 th, midwife, normal, 3600 g
2.This pregnant
Contraception history: IUD 7 years, inject 3
month 2 x
Contraception planing: inject 3 month

17.00

19.00

EV begun

Baby was born male, 3500 gram,


AS 6-8, amniotic fluid green, . In
3rd pull
Placenta was born 1 minutes letter,
complete.
CU good, 2 finger under umbilicus,
bleeding 150cc, perineum
epis, heckting jelujur
-General condition: good
-BP : 120/80 mmHg
-PR : 80 x/mnt
-RR : 20 x/mnt
-T : 37 C
-UFH :2 finger under umbilicus
-UC : good
-Lokea (+)
-Wound of epis : good

2 hours post partum

Obs. Mother and baby well being


Motivated to breast feeding
Motivated to drink n eat
To nifas

Time
06.00

Subject

Object
-General condition: good
-BP : 120/80 mmHg
-PR : 84 x/mnt
-RR : 22 x/mnt
-T : 37 C
-UFH :2 finger under umbilicus
-UC : good
-Lokea (+)
-Wound of epis : good

Assesment

Planning

1 day post partum

Obs. Mother and baby well


being
Motivated to breast feeding
Motivated to drink n eat

Name/adress

Age
Time
Address
21.30

: Mrs. N / Sweta

Admitted
to Hospital

22 years old

4 Des 2009

21.30 wita

Subject
Narmada

Object

Assesment

Planning

Patient came to Mataram GH at 21.30


(04/11/09) confess watery vaginal discharge
since 23.30 (30/11/2009), AM (-), bloody
show (-), abdominal pain (-) fetal movement
(+), history of hipertension (-), and history of
DM (-).
LMP : Forgot
ANC : 6x at PHC , last about 2 weeks ago
Obstetric status:
1.This
History of contraception:Planning contraception: inject 3 month

Examinaton at VK :
General condition: good
GCS : CM
BP :110/70 mmHg
PR : 84 x/
RR : 20x/
Temp : 36,7C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :30 cm
EFW : 2945 gram
FHR : 12-12-12
UC : VT : CD 1 cm, eff 10%, AM (-), clear,
head
palpable,
descend
H1+,
denominator unclear, unpalpable small
part of fetal and umbilical cord
Lab. Examination :
Hb : 10,7 gr%
Leko : 12.600 mm3
Trombo : 266.000 mm3
Hct : 31,5 gr%
HBsAg : Pelvic evaluation:
Promontorium not prominent
Spina ischiadica not prominent
Archus pubis >90
Os coccygeus mobile
PS:?????????????????????

G1P0A0L0 A/S/L/IU
head presentation
with PRoM >12
hours

Obs. Mother and fetal wellbeing


Cek lab
Ampicillin 1 gr iv
Report to suvervised
Propose: induction drip oxy
Advice : drip oxitosin
CTG

Time

Subject

Object
Lab. Examination :
Hb : 10,7 gr%
Leko : 12.600 mm3
Trombo : 266.000 mm3
Hct : 31,5 gr%
HBsAg : Pelvic evaluation:
Promontorium not palpable
Spina ischiadica not prominent
Archus pubis >90
Os coccygeus mobile
PS: 5
Cervic dilatation: 1 1
Panjang cervic: 2 1
Station: H1 1
Konsistensi: mild 1
Potition: mid 1

Assesment

Planning

Time
05.00

Subject
Abdominal pain>

0%

Object

Assesment

Planning

BP :120/80 mmHg
PR : 84x/
RR : 24x/
Temp : 36,5C
UC : 1x10/10
FHR:11-12-12
CTG base line: 140x/mnt

Induction with oxytocin 5 IU in


D5% 500 cc start at 8 dpm
Observed UC and FHR 30
minutes again

05.30

Abdominal pain>

UC: 1x10/10
FHR:12-12-12

Observed UC and FHR 30


minutes again

06.00

Abdominal pain>

UC: 1x10/10
FHR:12-12-13

Observed UC and FHR 30


minutes again

06.30

Abdominal pain>

UC: 1x10/10
FHR:12-12-13

Observed UC and FHR 30


minutes again

07.00

Abdominal pain>>

UC: 2x10/20
FHR:12-12-13

Observed UC and FHR 30


minutes again

07.30

Abdominal pain>>

UC: 2x10/20
FHR:13-12-12

Observed UC and FHR 30


minutes again

08.00

Abdominal pain>>

UC: 2x10/30
FHR:12-12-12
Temp:36,8C

Observed UC and FHR 30


minutes again

08.30

Abdominal pain>>

UC: 2x10/30
FHR:12-12-12

Observed UC and FHR 30


minutes again

09.00

Abdominal pain>>

UC: 3x10/30
FHR:12-12-12

Observed UC and FHR 30


minutes again
Maintenance at 40 dpm

09.30

Abdominal pain>>

UC: 3x10/30
FHR:12-12-13

Observed UC and FHR 30


minutes again

10.00

Abdominal pain>>>

UC: x10/30
FHR:12-12-13

Observed UC and FHR 30


minutes again

Time

Subject

10.30

Abdominal pain>>>

11.00

Object

Assesment

Planning

UC: 3x10/30
FHR:12-12-11

Observed UC and FHR 30


minutes again

Abdominal pain>>>

UC: 3x10/30
FHR:13-12-12
Temp:36,7C

Observed UC and FHR 30


minutes again

11.30

Abdominal pain>>>

UC: 3x10/30
FHR:12-12-13

Observed UC and FHR 30


minutes again

12.00

Abdominal pain>>>>

UC: 3x10/45
FHR:12-12-12

Observed UC and FHR 30


minutes again
Vaginal examination 2 hours
again

12.30

Abdominal pain>>>>

UC: 3x10/45
FHR:13-12-13

Observed UC and FHR 30


minutes again

13.00

Abdominal pain>>>>

UC: 3x10/45
FHR:12-13-13

Observed UC and FHR 30


minutes again

13.30

Abdominal pain>>>>

UC: 4x10/45
FHR:12-13-13

Observed UC and FHR 30


minutes again

14.00

Abdominal pain>>>>

UC: 4x10/45
FHR:12-13-13
Temp:36,7C
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-), clear,
head palpable, descend HIII,
denominator fontanella minor
right anterior, unpalpable small
part of fetal and umbilical

Stage 2 of labor

Educate to eat and drink


Motivated to squating position

16.00

Abdominal pain>>>>

UC: 2-3x10/35
FHR:12-13-13
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-), clear,
head palpable, descend HIII,
caput
(+),
denominator
fontanella minor right anterior,
unpalpable small part of fetal
and umbilical

G2P1A0L1 A/S/L/IU Head


persentation with prolonged
stage 2 of labor

Obs. Mother and fetal wellbeing


Report to suvervised
Proposed vacum extraction
Advice : vacum extraction

0%

Time
16.30

Subject

Object

Assesment

Planning

EV begun

0%
18.30

Abdominal pain>>>>

UC: 4x10/45
FHR:13-12-13

Observed UC and FHR 30


minutes again

19.00

Abdominal pain>>>>

UC: 4x10/45
FHR:12-12-13

Observed UC and FHR 30


minutes again

19.30

Abdominal pain>>>>

UC: 4x10/45
FHR:12-13-13

Observed UC and FHR 30


minutes again

20.00

Abdominal pain>>>>

UC: 4x10/45
FHR:12-13-13

Observed UC and FHR 30


minutes again

20.30

Abdominal pain>>>>

UC: 4x10/45
FHR:12-13-13

Observed UC and FHR 30


minutes again

21.00

Abdominal pain>>>>, mother want to bear


down

UC: 4x10/45
FHR:12-14-13
L4: was in pelvic inlet 1/5
VT: CD complete, AM (-), clear,
head palpable, descend HIII,
denominator fontanella minor
right anterior, unpalpable small
part of fetal and umbilical cord

21.15

Abdominal pain>>>>, mother want to bear


down

FHR: 13-12-12
Doran teknus perjol vulka

G1P0A0L0 38-39 W/S/L/IU


head presentation 2nd stage of
labor

Educate to prepare for delivery


of baby

Conduct mother to bear down

Time

Subject

Object

18.00

Assesment
Stage 2 of labor
Stage 3 of labor

Planning
Baby female was born,
3000 g, A-S 7-9
Amniotic fluid clear
Placenta was born 10
minutes later

20.00

BP :110/70 mmHg
PR : 80x/
RR : 20x/
Temp : 36,8C
UC : good
UFH : 2 finger below
umbilicus
Active vaginal bleeding (-)

2 hours post partum

Motivated mother to
breastfeeding for the baby
Referred mother and baby
to melati room

07.00

BP :110/80 mmHg
PR : 84 x/
RR : 20x/
Temp : 36,5
UC: good
FUH:
2
finger
below
umbilicus
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm
Active vaginal bleeding (-)

1 day post partum

Motivated mother to
breastfeeding for the baby