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Morning Report
th
september 10 2015
Case Resume
NORMAL
LABOR
PATHOLOGIES
LABOR
1.
2.
Case 1
Name : Mrs. I
Age : 32 years old
Address : Narmada
Admitted : 09-09-2015
No. RM : 56-65-82
G5P2A2L2 39-40 weeks S/L/IU head
presentation with arrest active phase 1 stst
stage of labor
TIME
SUBJECTIVE
09/09/201
5
21.44 wita
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 120/80 mmHg
PR: 82 bpm
RR: 20 bpm
T: 37.5C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 35 cm
EFW : 3720 g
UC : 3x10~30
FHB : 13-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord
ASSESSMENT
PLANNING
G5P2A2L2
39-40
weeks S/L/IU head
presentation
with
arrest active phase
1st stage of labor
DM planning:
Diagnostic : CTG
Therapy :
Pro amniotomy
Observation progress
of labor
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
Advice : amniotomy
Acceleration if UC
inadequate
Amniotomy was done
at 22.30
VT : 5 cm, eff 50%,
amnion (-), clear,
head presentation,
H1, denominator
unclear, not palpable
small part & umbilical
cord
UC : 3x10~30
Oxytocin Drip starting
from 8 dpm (23.30)
TIME
SUBJECTIVE
Obstetric History:
I. Aterm/normal/polindes/390
0 g/female/7 yo
II. Aterm/normal/polindes/350
0 g/male/3 yo
III. Abortus
IV. Abortus
V. This
OBJECTIVE
Pelvic score = 6
Dilatation of cervix : 2
Length of cervix : 1
Station : 1
Consistency : 1
Position : 1
Laboratory (09/09/2015
21.57):
HB: 12.8 g/dl
RBC: 4.15
HCT: 37.5 %
WBC: 15.78
PLT: 235
HbsAg: non reactive
BT : 215
CT : 630
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
Chronology at Narmada PHC
(09/09/2015)
05.00
S:
Patient 9 months of pregnancy
come to PHC confessed
abdominal pain since 20.00
(08/09/2015) bloody slim (+)
amnion (-) FM (+)
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.4C
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 37 cm
UC : 3x10~25
FHB : 12-11-12
VT : 3 cm, eff 25%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
14.00
S:
Patient confessed abdominal
pain
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.6C
UC : 3x10~30
FHB : 12-11-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
18.00
S:
Patient confessed abdominal
pain
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.5C
UC : 3x10~35
FHB : 12-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
A:
G5P2A2L2 39-40 weeks S/L/IU
head presentation with mother
and fetal well being + arrest
active phase 1st stage of labor
P:
CIE mother about examination
result
RL : D5 infusion 2:1
Observation for mother and
fetal well being, progress of
labor
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
21.00
S:
Patient confessed abdominal
pain
O:
GC : well
consciousness: CM
UC : 3x10~35
FHB : 11-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
A:
G5P2A2L2 39-40 weeks S/L/IU
head presentation with mother
and fetal well being + arrest
active phase 1st stage of labor
P:
CIE mother about examination
result
Co to GP advice
Refer to NTB GH
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
23.30
UC : 3x10~30
FHB : 12-11-12
10/09/201
5
00.00
UC : 3x10~30
FHB : 12-12-13
00.30
UC : 4x10~40
FHB : 12-12-13
VT : 9 cm, eff 80%, amnion
(-), not clear, head
presentation, HII,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord
2
hours
amniotomy
post
TIME
00.55
SUBJECTIVE
Mother want to bearing down
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 92 bpm
RR: 20 bpm
T: 36,7C
ASSESSMENT
PLANNING
G5P2A2L2 39-40
weeks S/L/IU head
presentation with
2nd stage of labor
DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, FHB
CIE : suggest mother
to bearing down
UC : 4x10 ~40
FHB : 12-12-13
Conduct mother to
bearing down
VT : not perform
TIME
SUBJECTIVE
03.00
OBJECTIVE
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.4C
ASSESSMENT
PLANNING
2 hours post
partum + rest
placenta
DM planning:
Diagnostic : USG
Therapy :
Amoxicillin 3x500 mg
Mefenamic Acid 3 x
500 mg
Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink
DM planning:
Diagnostic : USG
Therapy : Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink
UC : well
UFH : 1 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU :
HR : 142x/minute
RR : 44x/minute
T : 35,8oC
07.00
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 1 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU :
HR : 144x/minute
RR : 46x/minute
T : 36,1oC
Case 2
Name : Mrs. S
Age : 34 years old
Address : Gunung Sari
Admitted : 09-09-2015
No. RM : 12-27-02
G1P0A0L0 39-40 weeks S/L/IU head
presentation with arrested 1stst stage of
labor active phase
TIME
SUBJECTIVE
09/09/201
5
16.21 wita
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 31 cm
EFW : 3100 g
UC : 2x10~25
FHB : 12-11-12
VT : 3 cm, eff 25%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord
ASSESSMENT
PLANNING
G1P0A0L0
39-40
weeks S/L/IU head
presentation latent
phase 1st stage of
labor
DM planning:
Diagnostic : CTG
Therapy :
Observation progress
of labor
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP advice :
Observation progress
of labor
TIME
SUBJECTIVE
Obstetric History:
I. This
OBJECTIVE
Pelvic Examination
Promontorium unpalpable
Spina ishiadica non prominem
Arcus pubis >90o
Os coccygeus mobile
Laboratory (09/09/2015
16.34):
HB: 10.4 g/dl
RBC: 3.92
HCT: 32.2 %
WBC: 10.31
PLT: 252
HbsAg: non reactive
BT : 200
CT : 510
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
Chronology at Gunung Sari
PHC (09/09/2015)
10.00
S:
Patient 9 months of pregnancy
come to PHC confessed
abdominal pain since 09.00
(09/09/2015) bloody slim (+)
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 30 cm
EFW : 2945 g
UC : 1x10~20
VT : 1 cm, eff 25%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part & umbilical
cord
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
A:
G1P0A0L0 39-40 weeks /S/L/IU
head presentation mother and
fetal well being with postterm
P:
CIE mother about examination
result
RL infusion 20 dpm
Refer to NTB GH
OBJECTIVE
ASSESSMENT
PLANNING
TIME
19.30
SUBJECTIVE
Patient confess about
abdominal pain
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 120/80 mmHg
PR: 86 bpm
RR: 22 bpm
T: 36.5C
ASSESSMENT
PLANNING
G1P0A0L0
39-40
weeks S/L/IU head
presentation active
phase 1st stage of
labor
DM planning:
Diagnostic :
Therapy :
Observation progress
of labor with
partograph
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
arrested 1st stage of
labor active phase
DM planning:
Diagnostic :
Therapy :
Observation progress
of labor with
partograph
Pro amniotomy
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
UC : 3x10~40
FHB : 11-11-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord
23.30
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
UC : 3x10~40
FHB : 12-11-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part &
umbilical cord
DM co to GP co to SPV
: not answered
TIME
01.30
SUBJECTIVE
Patient confess about
abdominal pain
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.7C
UC : 3x10~45
FHB : 13-12-13
VT : not perform
ASSESSMENT
PLANNING
G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
arrested 1st stage of
labor active phase
DM planning:
Diagnostic :
Therapy :
Observation progress
of labor with
partograph
Pro amniotomy
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
advice (02.00) :
amniotomy
Acceleration
Amniotomy was done
at 02.15
VT : 4 cm, eff 50%,
amnion (-), not clear,
head presentation,
H1, denominator
transverse sagitalis
suture, not palpable
small part & umbilical
cord
Oxytocin Drip starting
from 8 dpm (02.45)
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
02.45
UC : 3x10~30
FHB : 13-12-13
03.15
UC : 3x10~30
FHB : 13-12-12
03.45
UC : 3x10~30
FHB : 12-11-12
04.15
UC : 3x10~35
FHB : 12-11-12
VT : 4 cm, eff 50%, amnion
(-), not clear, head
presentation, H1,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord
04.45
UC : 3x10~35
FHB : 12-13-13
05.15
UC : 3x10~35
FHB : 12-12-12
05.45
UC : 4x10~40
FHB : 12-12-12
2
hours
amniotomy
post
TIME
06.15
SUBJECTIVE
Mother
confessed
abdominal pain
OBJECTIVE
about
General status
GC : well
consciousness: CM
BP : 110/60 mmHg
PR: 86 bpm
RR: 20 bpm
T: 36.8C
UC : 4x10~40
FHB : 13-12-12
VT : 4 cm, eff 50%, amnion
(+), head presentation, H1,
denominator transverse
sagitalis suture, not palpable
small part & umbilical cord
ASSESSMENT
PLANNING
G1P0A0L0
39-40
weeks S/L/IU head
presentation
with
arrested 1st stage of
labor active phase
suspect CPD
DM planning:
Diagnostic :
Therapy :
Pro CS
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
Advice : observation
progress of labor for 2
hours if there is no
progression CSection
.. Thank
You ..