MORNING REPORT September 12th 2011

Supervisor : dr. I Made W. Mahayasa, SpOG

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

Cases resume :

Normal Labor Phatologic Labor

3 G3P1A1H1 A/S/L/IU head presentation with 1st stage latent phase of labor + fetal 1. distress

Name Age Address

Time

: Mrs. DT : 34 years old : Kediri

CTH

: September 11 th 2011 At 23.00 wita

Subject
Patient referred from GH of Gerung with G3P1A1H1 A/S/L/IU with latent phase first stage of labor + fetal distress. Patient confessed abdominal pain since 22.00 (10/09/2011), bloodslim (-). History rupture of membrane (-), FM (+). History of DM (-), HT (-), asthma (-). LMP : 20/12/2010 EDD : 27/09/2011 History of ANC : > 4 x, midwife Last ANC : August 2011 History of USG : never History of family planning : inj 3 month Next family planning : IUD Obstetrical history : I. aterm, 3100 gram, spontant, 14 yo, RSUP NTB II. Abortus at 2 month III. This

Object

Assesment
G3P1A1H1 37-38 weeks/S/L/IU head presentation with 1st stage latent phase of labor

Planning
Observe mother & fetal well being DL & HbSAg checked Continnue rescucitatiion Consult to GP. Pro CTG and observation, CTG and observation acc

11/9/ 2011 23.00

General Condition : well GCS: E4V5M6 BP : 160/80 mmHg PR : 88 x/minute RR: 18 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: 30 cms L2 : fetal back on left side L3 : head L4 : 4/5 EFW : 3100 g UC: 2x10, 25 FHR : +, 10-10-11 VT : 3 cms, eff 50%, amnion (+), head palpable HI. Denominator unclear. Unpalpable small part / umbilical cord.

Time

S
Chronologist : 11/9/2011 08.30 S: Patient came directly to Kuripan PHC confessed abdominal pain since 22.00 (10/09/2011) O: TD : 120/90, HR : 84x, RR: 18, T:36,4 Obstetric status : L1 : breech, TFU : 31 cm, EFW: 3100 gr L2: back on left L3 : head L4 : 4/5 His : 2x10 25 DJJ : 11-11-12 VT : 1 cm, eff 25%, amn (+), head palpable iin H1, denominator unclear, unpalpable small part/umbilical cord A: G3P1A1H1 A/S/L/IU head presentation + observasi inpartu P: -Observation 12.30 His : 2x10 25 FHR : 12-12-12 VT : 1 cm, eff 25%, amn (+), head palpable in H1, denominator uunclear, not palpable small part/umbilicalcord Lab : WBC : 9,69 RBC :4,30 PLT : 109.000 HCT : 36% HGB : 11,4 HbSAg : -

Time

S
16.30 His : 2x10-25 FHR : 11-10-11 VT : 3 cm, eff 25%, amn (+), head palpable in H1, denominator uunclear, not palpable small part/umbilicalcord 20.30 His : 2x10-25 FHR : 10-10-9 VT : 3 cm, eff 25%, amn (+), head palpable in H1, denominator uunclear, not palpable small part/umbilicalcord A: G3P1A1H1 A/S/L/IU head presentation + latent phase first stage of labor + fetal distress P: -O2 5 lpm -RL flash 1 fast drop 21.00 His : 2x10-25 FHR : 10-9-9 A: G3P1A1H1 A/S/L/IU head presentation + latent phase first stage of labor + fetal distress P: -Inj ampisiilin 2gr/IV -RL flash II 21.30 Referred to GH of Gerung

Time

O
His : 2x10 30 CTG result : bradikardi

A
G3P1A1H1 37-38 weeks/S/L/IU head presentation with 1st stage latent phase of labor + fetal distress

P
Coass consult to GP pro SC, GP consult to supervisor : SC acc

12/09/ 2011 00.00

01.30

SC began Baby was born, female., A-S : 7-9. BW/BL : 3200g Anomali (-) Posterm sign (-) Amnion greenish (+) Placenta was born manual. Bleeding 200cc IUD inserted

02.00

SC Finished

Subject 03.00 (-)

Object GC : well cons : E4V5M6 BP : 150/80 mmHg PR : 100 x/minute RR : 20 x/minute T : 37 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 300 cc

Assesment 1 hour Post SC

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

04.00

(-)

GC : well cons : E4V5M6 BP : 140/80 mmHg PR : 100 x/minute RR : 20 x/minute T : 37,1C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 350 cc Baby in NICU: HR: 126x/minute RR: 45 x/minute T: 35,6

2 hour post SC

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

Subject 07.00 (12-92011) (-)

Object GC : well cons : E4V5M6 BP : 140/80 mmHg PR : 96 x/minute RR : 20 x/minute T : 36,6C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Baby in NICU: HR: 126x/minute RR: 45 x/minute T: 35,6

Assesment 1st dayPost SC

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