MORNING REPORT July 29th, 2011

Supervisor : dr. Punarbawa, SpOG

Medical Students: Eka, Mamad, Anom, Yanti, Uyunk, Intan

G5P4A0H3 T/S/L/IU head presentation with neglected 2nd stage of labor and susp macrosomia

NAME/AGE : Mrs. N/ 33 Years old ADDRESS : Kuripan, Kediri, Lobar

Admitted: 29 July 2011 at 23.05 wita

S
29/07/11 23.05 Patient referred from RSUP Gerung with G5P4A0L3 T/ S/L/IU head presentation with prolonged second stage of labor + macrosomia + mild pre eklampsia. Patient confessed abdominal pain (+) and bloody slim (+) since 04.00 wita (29-7-2011). Rupture of membrane (+) since 11.00 (29-7-2011), FM (+). History HT (-), asthma (-), DM (-). LMP : forgot EDD : History of ANC : > 4 x in midwife Last ANC :History of family planning : Next family planning : Tubektomi Obstetric status : 1. Male, Aterm, Spontan, Midwife, 4200gr, 17 years old 2. Male, Aterm, VE, Midwife, 4000gr, 15 years old 3. Male, Aterm, VE, Midwife, 4000gr, 11 years old 4. Male, Aterm, Sungsang, Midwife, 4000gr, + (8 years old) 5. this

O
General status : GC: well, GCS: E4V5M6 BP:140/90 mmHg RR: 20 x/mnt Pulse : 116 x/mnt T: 35,5 C Eyes : an(-/-) ikt (-/-) Cor & pulmo in normal range Abd : scar (-), striae (+) Extremity edema (-/-) Obstetric status : L1 : breech UFH: 37 cm L2 : back on right EFW: 4030 g L3 : head L4 : 3/5 UC : (+) 2x/10~25 FHB : 13-14-13 (160 bpm) VT : completed, amn (-), green, head palpable, denom LOA, HII, caput (+) HII+, unpalpable small part of fetal and umbilical cord. Lab exam WBC : 23.44 x 103 HGB :11,8 g/dL PLT : 408.000 HCT : 35% HbsAg (-) Proteinuri (-)

A
G5P4A0L3 T/ S/L/IU head presentation with neglected second stage of labor + susp. Macrosomia + HDK 1. 2. 3. 4. 5.

P
obs. Mother and fetal well being Cek lab DL, HbsAg, and UL Resusitasi (RL:D5% = 2:1, O2: 5lpm) Harus ada USUL KITA !!!!!! Consult to dr.Jaga Advice : Consult to dr.Sp.OG SC

S
Chronologist : (RSUD Gerung) S: 29 july 2011 (18.0 wita) Patient came from KuripanPHC with abdominal pain (+) and bloody slim (+) since 04.00 wita (29-7-2011). FM (+). O/ GC : well, Conciousness : CM BP : 130/80 mmHg; PR : 84 bpm RR : 20 rpm; T : 36,8C UFH : 30 cm EFW : 4100gr UC : (+) 3x/10~35 FHB : 12-12-13  VT (18.00 wita) : 8, eff. 75%, amn (-), head palpable, HI, unpalpable small part of fetal and umbilical cord.  VT (20.00 wita) : completed, eff.100%, amn (-), head palpable, denom LOA, HI, unpalpable small part of fetal and umbilical cord.  VT (22.00 wita) : completed, eff.100%, amn (-), head palpable, denom LOA, HI, unpalpable small part of fetal and umbilical cord.  (lab: proteinuri +1) A/ G5P4A0L3 T/ S/L/IU head presentation with prolonged second stage of labor + macrosomia + mild pre eklampsia. T/ inj. Ampicillin 1gr (iv) (22.00 wita) Rehidrasi Sent to GH NTB (harus ada alasan kenapa dirujuk padahal disana ada Sp.OG) (sp.An: tidak bs mengerjakan SC krn sdg

S
29 july 2011 01.23 wita

A
SC Began

01.25 wita

Baby was born, female, 3750gr, 43cm, AS 6-8, anus (+), congenital anomaly (-). Amnion fluid: 50cc, mekoneal (+). Posterm sign (-). Caput (+) minimal. Placenta was born manual completely, bleeding: 300cc

04.00 wita

Mother: GC: Well BP: 120/80 mmHg RR: 20 x/mnt PR: 104 x/mnt T: 35,6 0C UC : (+) good UFH : 2 fingers at umbilicus. UO : 325cc Baby in NICU

2 hours post SC

Cont observasi Drip oxy and ketorolac Cefotaxime 1gr/12 hour

S
30 july 2011 07.00 wita Post partum pain (+), dizzines (-), nausea/vomiting (-)

O
GC : Well, Conscousness: CM VS: BP : 130/90 mmHg Pulse Rate : 96 bpm RR : 18 rpm Tax : 36 C TFU : at umbilicus Active bleeding (-) UO: 500cc Baby condition: GC : Well HB : 136 bpm RR : 44 rpm Tax : 36 C Caput (+) minimal.

A
1 day post partum

P
Observate of mother and baby well being PCT 3x500mg Amoxicillin 3x500mg