MORNING REPORT September 26th 2011

Supervisor : dr. Juliawan, SpOG

Medical Student: Lili, Elin, Ika, Maria, Noval

Cases resume :

Normal Labor Phatologic Labor

4 G1P0A0H0 A/S/L/IU breech presentation with latent phase first stage of labor + 1. history rupture of membrane + prolapse umbilical cord

Name Age Address

Time

: Mrs. F : 35 years old : Ampenan

CTH

: September 29th 2011 At 09.50 wita

Subject
Patient referred from Maternity Clinic with G4P3A1H2 38 week/S/L/IU breech presentation with latent phase first stage of labor + history rupture of membrane + prolapse umbilical cord. Patient confessed abdominal pain, since 16.00 (26/09/2011), bloodyslim (-). History rupture of membrane (+) since 2 week ago, FM (+). History of DM (-), HT (-), asthma (+). LMP : 5 EDD : History of ANC : > 4 x, midwife Last ANC : August 2011 History of USG : never History of family planning : Next family planning : IUD Obstetrical history : I. This

Object
General Condition : well Consciousness : CM BP : 120/80 mmHg PR : 84 x/minute RR: 20 x/minute T : 36,8C 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 : head, UFH: 27 cms, AC : 90 cm L2 : fetal back on right side L3 : breech L4 : breech on pelvic inlet EFW : 2430 g His: (+), 2 x 10 30 FHR : (+), 10-10-10 (120 x/minute) VT : 3 cms, eff 25%, amnion (-) greeny, breech palpable HI, palpable umbilical cord. ZA score : 7

Assesment
G1P0A0H0 A/S/L/IU breech presentation with latent phase first stage of labor + history rupture of membrane + prolapse umbilical cord

Planning
Observe mother & fetal well being DL, HbSAg checked Coass consult to GP Injeksi Ampicilin 1 gr/IV & pro SC GP ACC inj Ampicilin 1 gr/iv GP consult to supervisor pro SC. Advice from supervisor : ACC SC

29/9/ 2011 09.50

Time

S
Chronologist : Lab : DL:HGB : 11,7 RBC : 3,98 HCT : 33,7 MCV : 84,7 WBC : 17,30 PLT : 226 HbSAg : -

Time

A
SC began

27/09/ 2011 01.45

02.00

Baby was born, Female., A-S : 5-7. BW : 2700 g Anus (+), congenital anomali (+) ; CTEV dextra Amnion meconeal Placenta was born manually, bleeding 200 cc Intraoperation : uterus arcuata

02.15

SC Finished

Subject

Object

Assesment

Planning

04.15

(-)

GC : well cons : E4V5M6 BP : 100/70 mmHg PR : 92 x/minute RR : 20 x/minute T : 36,6 C UFH : 2 finger above umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 100 cc/hours

2 hour Post SC

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

27/9/ 2011 07.00

Wound pain

GC : well cons : E4V5M6 BP : 130/70 mmHg PR : 80 x/minute RR : 20 x/minute T : 36,5 C UFH : 2 finger above umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 65 cc/hours 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