MORNING REPORT September 17th 2011

Supervisor : dr. A. Rusdhy A.H., SpOG

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

Cases resume :

Normal Labor Phatologic Labor

6 G1P0A0H0 40 weeks/S/L/IU head presentation with nd prolonged 1. 2 stage of labor

Name Age Address

Time

: Mrs. FT : 21 years old : Gunung Sari

CTH

: September 17th 2011 At 15.30 wita

Subject

Object

Assesment

Planning

17/9/ 2011 15.30

Patient referred from Gunung Sari PHC with G1P0A0H0 A/S/L/IU head presentation with prolonged active phase 1st stage of labor . Patient confessed abdominal pain, since yesterday (16/09/2011), bloodslim (+), watery vaginal discharge (+). History rupture of membrane (+) since 15.00, 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 : inj. for 3 month Obstetrical history : I. This

General Condition : well Consciousness : CM BP : 130/70 mmHg PR : 104 x/minute RR: 20 x/minute T : 37C 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: 30 cms L2 : fetal back on left side L3 : head L4 : 3/5 EFW : 2945 g His: +, 3 x 10 35 FHR : +, 12-11-12 VT : 9 cm, eff 75%, AM (-), head palpable descends HII, unpalpable fetal small organ and umbilical cord

G1P0A0H0 40 weeks/S/L/IU head presentation with active phase 1st stage of labor

Observe mother & fetal well being DL, HbSAg Coass consult to GP, pro observe. Advice : acc observe

Time

S
Chronologist : 16/9/2011 22.32 S: Patient came directly to Gunung Sari PHC confessed abdominal pain O: General Condition : well Consciousness : CM BP : 120/70 mmHg, PR : 88 x/minute RR: 20 x/minute, T : 36,3C Obstetric status : UFH : 30 cm, EFW: 2945 gr UC : 2x10 15 , DJJ : 12-11-12 VT : 1 cm, eff 25%, AM (+), head palpable descends HI, unpalpable fetal small organ and umbilical A: G1P0A0H0 40 weeks/S/L/IU head presentation with latent phase 1st stage of labor P: -Observe mother & fetal well being -Suggest mother to eat and drink -Suggest mother to sleep left side Lab : DL:HGB : 12,1 RBC : 4,27 HCT : 38,3 WBC : 16,39 PLT : 219 HbSAg : -

Time

S
17/9/2011 02.32 S: Patient confessed abdominal pain O: General Condition : well Consciousness : CM BP : 120/80 mmHg, PR : 80 x/minute RR: 20 x/minute , T : 36,6C Obstetric status : UFH : 30 cm His : 3 x 10 40 FHR: +, 140 x/minute VT : 3 cm, eff 50%, AM (+), head palpable descends HII, unpalpable fetal small organ and umbilical A: G1P0A0H0 40 weeks/S/L/IU head presentation with latent phase 1st stage of labor P: -Observe mother & fetal well being -Suggest mother to eat and drink -Suggest mother to sleep left side

Time

S
17/9/2011 06.30 S: Patient confessed abdominal pain O: General Condition : well Consciousness : CM BP : 120/80 mmHg, PR : 82 x/minute RR: 20 x/minute, T : 36,5C Obstetric status : UFH : 30 cm His : 4 x 10 45 FHR: +, 144 x/minute VT : 5 cm, eff 50%, AM (+), head palpable descends HII, unpalpable fetal small organ and umbilical A: G1P0A0H0 40 weeks/S/L/IU head presentation with active phase 1st stage of labor P: -Observe mother & fetal well being -Suggest mother to eat and drink -Suggest mother to sleep left side

Time

S
17/9/2011 10.30 S: Patient confessed abdominal pain O: General Condition : well Consciousness : CM BP : 120/80 mmHg, PR : 82 x RR: 20, T : 36,5C Obstetric status : VT : 6 cm, eff 75%, AM (+), head palpable descends HII, unpalpable fetal small organ and umbilical A: G1P0A0H0 40 weeks/S/L/IU head presentation with active phase 1st stage of labor P: -Observe mother & fetal well being -Suggest mother to eat and drink -Suggest mother to sleep left side

Time

S
17/9/2011 14.30 S: Patient confessed abdominal pain O: VT : 7 cm, eff 75%, AM (+), head palpable descends HII, unpalpable fetal small organ and umbilical A: G1P0A0H0 40 weeks/S/L/IU head presentation with prolonged active phase 1st stage of labor P: -Consul to doctor, advice: Inf. RL 28 tpm Refer to NTB GH

Time

Subject

Object

Assesment

Planning

17/9/ 2011 17.30

Patient confessed abdominal pain

General Condition : well Consciousness : CM BP : 120/70 mmHg PR : 100 x/minute RR: 20 x/minute T : 37C Obstetrical status : His: +, 3 x 10 35 FHR : +, 12-12-12 VT : 10 cm, AM (-), head palpable descends HIII, unpalpable fetal small organ and umbilical

G1P0A0H0 40 weeks/S/L/IU head presentation with 2nd stage of labor

Suggest mother to bearing down Suggest mother to eat and drink

17/9/2 011 19.30

Abdominal pain and bearing down

General Condition : well Consciousness : CM BP : 120/70 mmHg PR : 108 x/minute RR: 24 x/minute T : 37C Obstetrical status : His: +, 4 x 10 35 FHR : +, 12-13-12 VT : 10 cm, Amn (-) clear, head palpable descends HIII, unpalpable fetal small organ and umbilical

G1P0A0H0 40 weeks/S/L/IU head presentation with prolonged 2nd stage of labor

Observe mother & fetal well being Coass consul to GP pro EV. Advice: EV

Time

Subject

Object

Assesment

Planning
EV began

17/9/ 2011 20.00

20.30

Baby was born male, weight 3100g, length 48 cm, AS 6-8. anus (+), nuchal cord (-)

20.40

Placenta was born complete, bleeding 250 cc Heating dalam VIII, heating luar jelujur Observe

Subject

Object

Assesment

Planning

22.40

Patient confessed abdominal pain

GC : well cons : E4V5M6 BP : 120/80 mmHg PR : 88 x/minute RR : 20x/minute T : 37 C UFH : 2 finger below umbilicus Uterine consistency firm Active bleeding (-) Lochea : (+) 10 cc

2 hour Post partum EV

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

18/9/ 2011 07.00

GC : well cons : E4V5M6 BP : 120/70 mmHg PR : 88 x/minute RR : 20x/minute T : 36,5 C UFH : 2 finger below umbilicus Uterine consistency firm Active bleeding (-) Lochea : (+)

1 day post partum EV

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