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Morning Report

9 February 2009

Supervisor : dr. H. Doddy A.K, SpOG(K)


Medical Student: 1. Ghea 2.Hadian 3.Heru 4.Miftah
Cases resume : 1. 2. 3. 4. 5. PROM+fetal distress+mild preeclamsia Serotinus Severe preeclamsia

1 1 1 1 5

1. Abortus infectiosus + sepsis


Normal labor

Name / Age Address


Time

: Mrs. Mahnim / 36 years old : Rembiga


Subject Object

CTH

: 3 February 2009 : 10.40


Planning

Time
Assesment

12.45

Patient came to out patients departement of Mataram General Hospital. with pregnancy more than 9 month.
chronologis : At 6-2-09 came to out patient departement with pregnancy 9 month. Patient had USG. The doctor than advice her to control at 9-2-09 if until that date patient did not got sign of labor. At 9-2-09 patient came to out patient departement of Mataram General hospital with pregnancy more than 9 month. Abdominal discomfort (), vaginal discharge (-). Patient also said that she had married since 14 years ago. Patient had LMP: 29-4-08 EDD: 6-2-09 Obstetric history: 1.This USG (6-2-09): Fetal S/L/IU head presentation, male BPD: 36 weeks AC: 33 weeks FL: 38 weeks

General status : General condition: well, Conciousness: CM BP: 110/70 mmHg RR: 22 x/mnt PR: 80 x/mnt T: 36,7 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range
Obstetric status : L1 : breech UFH: 33 cm L2 : left back L3 : head L4 : head descencus 4/5 EFW : 3410 g UC : (-) Fetal Heart Rate : 11-12-12 x/mnt VT : CD 2 cm, eff 25 %, AM (+), head palpable, denominator unclear, descensus HI, umbilical cord or small part of fetal unpalpable Bishop score: 6 Dilatation cervix: 1 Length of cervix: 2 Station: 1 Consistensi: 1 Position of cervix: 1

G1P0A0H0 41-42 weeks/S/L + old primigravida + infertilitas 14 years

Observation mother and fetal well being. Laboratory examination : DL, HBsAg CTG Advice from poliklinik: If until 9-2-09 termination with oxytocin drip
Report to supervisor Delivery room, advive ACC drip oxytocin

Time 12.45

Subject

Object Pelvic evaluation: Spina ischiadica: unpalpable Coxigis: mobile Simpisis: > 90O Lab: Hb: 9 g% WBC: 9.000/mm3 PLT: 275.000/mm3 HCT: 25,4 % HBsAg: (-)

Assesment

Planning

Time
11.00

Subject
Abdominal discomfort (-).

Object
General status: well FHB: 12-12-12 UC : (-)

Assesment

Planning
Start drip oxytocin 8 drop/mnt Observation mother fetal well being

11.30

Abdominal discomfort (+), rare

General status: well FHB: 16-17-17 UC : 1x/10 ~ 20

Drip oxytocin 12 drop/mnt Observation mother fetal well being

12.00

Abdominal discomfort (+),

General status: well FHB: 15-15-16 UC : 2x/10 ~ 30

Drip oxytocin 16 drop/mnt Observation mother fetal well being

12.30

Abdominal discomfort (+)

General status: well FHB: 13-14-14 UC : 2x/10 ~ 30

Drip oxytocin 20 drop/mnt Observation mother fetal well being

Time
13.00

Subject
Abdominal discomfort (+)

Object
General status: well FHB: 12-12-12 UC : 2x/10 ~ 35

Assesment

Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being

13.30

Abdominal discomfort (+)

General status: well FHB: 12-12-11 UC : 2x/10 ~ 35

Drip oxytocin 20 drop/mnt Observation mother fetal well being

14.00

Abdominal discomfort (+)

General status: well FHB: 11-11-12 UC : 2x/10 ~ 35

Drip oxytocin 20 drop/mnt Observation mother fetal well being

14.30

Abdominal discomfort (+)

General status: well FHB: 11-12-11 UC : 2x/10 ~ 35

Drip oxytocin 20 drop/mnt Observation mother fetal well being

Time
15.00

Subject
Abdominal discomfort (+)

Object
General status: well FHB: 11-12-12 UC : 3x/10 ~ 40

Assesment

Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being

15.30

Patient confess vaginal discharge. Abdominal discomfort (+)

General status: well FHB: 11-12-12 UC : 3x/10 ~ 40

Drip oxytocin 20 drop/mnt Observation mother fetal well being

16.00

Abdominal discomfort (+)

General status: well FHB: 12-12-12 UC : 3x/10 ~ 45

Drip oxytocin 20 drop/mnt Observation mother fetal well being

16.30

Abdominal discomfort (+)

General status: well FHB: 11-12-12 UC : 4x/10 ~ 45

Drip oxytocin 20 drop/mnt Observation mother fetal well being

Time
17.00

Subject
Abdominal discomfort (+)

Object
General status: well FHB: 11-12-12 UC : 3x/10 ~ 40

Assesment

Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being

17.30

Patient confess vaginal discharge. Abdominal discomfort (+)

General status: well FHB: 11-12-12 UC : 3x/10 ~ 40

Drip oxytocin 20 drop/mnt Observation mother fetal well being

18.00

Abdominal discomfort (+)

General status: well FHB: 12-12-12 UC : 3x/10 ~ 45

Drip oxytocin 20 drop/mnt Observation mother fetal well being

18.30

Abdominal discomfort (+)

General status: well FHB: 11-12-12 UC : 4x/10 ~ 45

Drip oxytocin 20 drop/mnt Observation mother fetal well being

Time
19.00

Subject
Abdominal discomfort (+)

Object
General status: well FHB: 11-12-12 UC : 3x/10 ~ 40

Assesment

Planning
Drip oxytocin 20 drop/mnt Observation mother fetal well being

19.30

Patient confess vaginal discharge. Abdominal discomfort (+)

General status: well FHB: 11-12-12 UC : 3x/10 ~ 40

Drip oxytocin 20 drop/mnt Observation mother fetal well being

20.00

Abdominal discomfort (+)

General status: well FHB: 12-12-12 UC : 3x/10 ~ 45

Drip oxytocin 20 drop/mnt Observation mother fetal well being

16.30

Abdominal discomfort (+)

General status: well FHB: 11-12-12 UC : 4x/10 ~ 45

Drip oxytocin 20 drop/mnt Observation mother fetal well being

Time
21.00

Subject
Abdominal discomfort more often

Object
General status: well FHB: 12-13-13 UC: 4x/10 ~ 45 VT: CD complete, eff 100%, AM (-) clear, head palpable, denom: left occiput anterior, descensus HIII, umbilical cord or small part of fetal unpalpable Doran teknus perjol vulka

Assesment
G3P1A1H1 43 weeks/S/L/IU in 2nd stage of labor

Planning
Drip oxytocin 28 drop/mnt Observation mother and fetal well being

21.20 21.30

Mother want to bearing down

Conducted mother to labor Baby was born, male, AS: 7-9, W: 3300 g, L: 50 cm. Placenta was born spontaneusly, complete. Serotinus sign (-): Umbilical cord fress Dry skin (-) Wrinkle skin (-) Meconium (-)

22.00

General status: well BP: 110/70 mmHg PR: 84 x/mnt UC: well UFH: 2 finger under umbilical Active bleeding (-)

4th stage of labor

Observation mother and baby well being Observation UC and bleeding

23.30

General status: well BP: 110/70 mmHg PR: 84 x/mnt UC: well UFH: 2 finger under umbilical

Puerperium

Early initiation Sended mother to melati room

Time

Subject

Object

Assesment

Planning

Time
21.30

Subject
Abdominal discomfort (+), rare

Object
General status: well FHB: 148 x/mnt UC : 2x/10 ~ 25

Assesment
G1P0A0H0 41-42 weeks/S/L Induction labor seri 1 failure

Planning
induction labor seri 2 after 24 hour later Patient remove to melati room