MORNING REPORT September 14th 2011

Supervisor : dr. Agus Thoriq, SpOG

Medical Student: Ita, Tomi, Ika, Lilik, Elin

Cases resume :

Normal Labor Phatologic Labor

6 G1P0A0H0 36 weeks/S/L/IU head presentation with impending eclampsia 1.

Name Age Address

Time

: Mrs. FT : 42 years old : Lingsar

CTH

: September 14th 2011 At 15.30 wita

Subject

Object

Assesment

Planning

14/9/ 2011 15.30

Patient referred from Lingsar PHC with G2P1A0H1 A/S/L/IU head presentation with protracted active phase 1st stage of labor . Patient confessed abdominal pain since yesterday (16/09/2011), bloodslim (+). History rupture of membrane (-), FM (+). History of DM (-), HT (-), asthma (-). LMP : 10/12/2010 EDD : 17/9/2011 History of ANC : > 4 x, midwife Last ANC : August 2011 History of USG : never History of family planning : Next family planning : injection for 3 month Obstetrical history : I. This

General Condition : restlessness Consciousness : CM BP : 120/90 mmHg PR : 108 x/minute RR: 20 x/minute T : 37,4C Status Generalis: Eye : palor (-), icteric (-) Thorax : Cor : S1S2 single reguler (murmur -), (gallop -) Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-). Abdomen : scar (-), striae (+),linea nigra(+) Extremity : edema (-), warm acral (+) Obstetrical status : L1 : breech UFH: 25 cms L2 : fetal back on right side L3 : head L4 : 4/5 EFW : 2170 g His: (-) FHR : +, 15-14-13 VT : not done

G1P0A0H0 36 weeks/S/L/IU head presentation with impending eclampsia

Observe mother & fetal well being DL, HbSAg , UL checked Cefotaxime inj. 2 gr/IV Coass consult to supervisor, pro rescucitatiion & SC. Advice : acc rescucitation & SC

Time

S
Chronologist : 14/9/2011 14.00 S: Patient confessed 8 month of pregnancy came directly to Pringgarata PHC confessed headache, blured vision, vomiting, nausea . O: General Condition : well Consciousness : CM BP : 160/120 mmHg, PR : 88x RR: 20, T : 37C Obstetric status : L1 : breech, TFU : 27 cm, EFW: 2170 gr L2: fetal back on right side L3 : head L4 : 4/5 His : ?, DJJ:? VT : (-) A: G1P0A0H0 36 weeks/S/L/IU head presentation with PEB P: -Infus RL -14.30 bolus MgSO4 20% + drip MgSo4 20% (30 cc) 28 tpm -Nifedifin 10 mg Lab : DL:HGB : 14,3 RBC : 5,56 HCT : 44,2 MCV : 79,5 WBC : 21,93 PLT : 568 HbSAg : UL:BJ : 1020 pH : 5,0 Nitrit : Protein : +3 Darah : +3

Time

A
SC began

14/09/ 2011 17.20

17.30

Baby was born, male., A-S : 3-5. BW : 1500g Ballard Score: SMK Anus (+), congenital anomali (-) Amnion clear (+) 25 cc Placenta was born manually, bleeding 200cc Intraoperation : solusio placenta in 1/3 part of placenta

18.10 SC Finished

Subject

Object

Assesment

Planning

18.20

(-)

GC : well cons : E4V5M6 BP : 110/70 mmHg PR : 90x/minute RR : 24x/minute T : 36,5 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 60 cc

2 hour Post SC

Observe mother and baby well being KIE mother to take a rest

15/9/ 2011 07.00

GC : well cons : E4V5M6 BP : 160/110 mmHg PR : 100x/minute RR : 20x/minute T : 36,5 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 150 cc/day Baby in NICU : PR : 150 x/minute RR : 28 x/minute T : 36C

1 day post SC

> Observe mother and baby well being KIE mother to take a rest > Nifedifin 10 mg (3 x 1)