Morning Report

21 February 2009

Supervisor : dr. Agus Thoriq, SpOG

Medical Student: 1. Ghea 2.Hadian
Cases resume : 1. 2. 3. 4. Preterm + Breech presentation + PROM Neglected in active phase of 1st stage of labor Mola hidatidosa Normal labor

3 1 1

1.

Name / Age Address

Time 7/9/20 11 16.30

: Mrs. Sinati / 27 years old : Gubuk Baru, Lombok Utara

Subject Object General status : General condition: well Conciousness: CM BP: 120/80 mmHg RR: 20 x/mnt PR: 88x/mnt T: 36,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range

Admitted

: 07. 09.2011 : 22.00

Planning Observation mother Laboratorium examination DL, HBsAg

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Assesment

Patient refered from GH Tanjung (midwife: Winarni) with G1P0A0H0 A/T/M 39 weeks head presentation With KPD and IUFD, abdominal pain since 22.00 (04-9-09). History rupture of membrane (-), abdominal pain (+) , bloody slim (+), FM (-), AM (-). History of HT (-), DM (-), Asthma (-) LMP : forgot EDD : History of ANC : History of family planning : Next family planning : IUD History of obstetric 1. This Chronologis: 10.30 Patient came to GH Tanjung with Keluar air banyak dari jalan lahir sejak + 2 hari yang lalu 19.00 Wita ( 5-72011) abdominal pain since 22.00 (049-09). Examination in PHC: General status: well BP: 120/70 mmHg PR: 92 x/mnt RR: 20 x/mnt UFH: 35 cm , head palpable VT: 7 cm, eff 75 %, AM (-), HII , DJJ (-)

G1P0A0H0 A/T/IUFD inpartu kala 1 fase aktif

Obstetric status : L1 : breech UFH: 32cm L2 : left back L3 : head L4 : 4/5 EFW : 3255g UC : 3x10,,,30 Fetal Heart Rate : (-) VT: 7 cm, eff 75 %, AM (-), head palpable . HI Lab result: Hb: 12 g% WBC: 18.77mm3 PLT: 113000/mm3 HCT: 34,9 % HBsAg: (-)

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Subject 12.20 Ganti infus RL fles II 28 tpm 13.30 VT : 8cm, eff 75%, AM (-), head presentation, HII Unpalpable small part or umbilical cord A G1P0A0H0 A/T/M 39 weeks head presentation With KPD and IUFD P KIE keluarga untuk di rujuk Reffered to GH

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19.30

UC : 2x10,,,30 FHB : -

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Name / Age Address

Time 20.30

: Mrs. Jumakyah / 21 years old : Mataram

Subject Object General status : General condition: well, Conciousness: CM BP: 140/90 mmHg RR: 20 x/mnt PR: 80 x/mnt T: 37,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Extremity: udema (-) Obstetric status : L1 : breech UFH: 35 cm L2 : right back L3 : head L4 : head descencus 4/5 EFW : 3720 g UC : 3x/10 ~ 40 Fetal Heart Rate : 15-16-16 VT : CD 7 cm, eff 75 % portio udema, AM (-), head palpable descensus HII, caput (+), umbilical cord or small part of fetal unpalpable Pelvic evaluation: Spina ischiadica: unpalpable Coxigis: mobile Simpisis: > 90O lab result: Hb: 11,2 g%

Admitted

: 21 February 2009 : 20.30

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg, UL Resucitation intrauterin (RL 2 fls + D5% 1 fls) rapid drop CTG Report to supervisor proposed SC, supervisor agreed

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Patient refered by midwife (Nuri M) with G1P0A0H0 41weeks/S/L/IU active phase of 1st stage of labor + susp big baby chronologis : 09.30 (21-2-09) Patient came to widwife (Nuri) with confess abdominal discomfort since 22.00 (20-2-09), bloody show(+), fetal movement (+), vaginal discharge (-) Examination: BP: 120/P PR: 84 x/mnt RR: 24 x/mnt t: 36,5 C Palpation: UFH: 35 cm, breech palpable in fundus, right back, head presentation, descensus 3/5 EFW: 372 0 g UC: 3x/10 ~ 35 Auscultation: FHB 144 x/mnt 10.00 (21-2-09) VT : CD 2 cm, eff 30 % , AM (+), head palpable, SS trasverse presentation, small part of fetal or umbilical cord unpapable Ass: G1P0A0H0 41 weeks/S/L/IU head laten phase of 1st stage of labor 14.00 (21-2-09)

G1P0A0H0 A/S/L/IU head presentation neglected in active phase of 1st stage of labor + Mild Preeklamsia

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14.00 (21-2-09) BP: 110/70 mmHg PR: 84 x/mnt RR: 24 x/mnt t: 36,6 C UC: 3x/10 ~ 35 FHB: 144 x/mnt VT: CD 4 cm, eff 30 %, AM (+), head descensus HI, small part of fetal or umbilical cord unpapable 16.00 (21-2-09) Vaginal discharge (+), clear BP: 110/70 mmHg PR: 84 x/mnt t: 36,6 C UC: 3x/10 ~ 40 FHB: 144 x/mnt VT: CD 6 cm, eff 60 %, AM (-), head descensus HII, small part of fetal or umbilical cord unpapable 18.45 (21-2-09) Patient bearing down every felt abdominal discomfort BP: 110/70 mmHg PR: 84 x/mnt t: 37,0 C UC: 4x/10 ~ 45 FHB: 144 x/mnt VT: CD 6 cm, eff 60 %, AM (-), head descensus HII, small part of fetal or umbilical cord unpapable Ass: G1P0A0H0 41 weeks/S/L/IU head active phase of 1st stage of labor + susp big baby

Pelvic evaluation: Spina ischiadica: unpalpable Coxigis: mobile Simpisis: > 90O lab result: Hb: 11,2 g% WBC: 23.000/mm3 PLT: 272.000/mm3 HCT: 34,1 % Protein : +1

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Ass: G1P0A0H0 41 weeks/S/L/IU head active phase of 1st stage of labor + susp big baby
Tx: amoxicilin 1000 mg, paracetamol 500 mg Patient than refered to Mataram General Hospital ANC: LMP: 10-5-09 EDD: 17-2-09 Obstetric history: 1.This Planning for Family planning:

Time
21.30

Subject
Abdominal discomfort (+), febris (+)

Object
General status: well FHB: 13-13-14 UC : 3x/10 ~ 45

Assesment

Planning
Skin test cefotaxim(-) Injection cefotaxim 2 g Applied DC

22.00

Sended patient to operation Room

22.55

Baby was born, female, W: 3300 g, L: 50 cm, AS: 7-9, Caput (+), AM: Clear Placenta was born completely.

23.30

General status: well BP: 110/60 mmHg PR: 88 x/mnt UC: well UFH: 3 cm under umbilicus Active bleeding (-)

4th stage of labor

Observation mother and baby well being Baby in NICU

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