MORNING REPORT October 2nd 2011

Supervisor : dr. Juliawan, SpOG

Medical Students: Lili, Ika, Maria, Noval, Fida

Cases resume :

Normal Labor

Phatologic Labor

Name Age Address

Time

: Mrs. M A : 36 years old : Dasan Agung Baru

CTH

: October 2nd 2011 At 18.10

Subject

Object

Assesment

Planning

02/10 /2011 18.10

Patient came to NTB GH confessed rupture of membrane since 17.30 (02/10/2011). Abdominal pain (-), bloody slim (-), FM (+). History of DM (-), HT (-), asthma (-). LMP: 29-01-2011 EDD: 05-11-2011 History of ANC: >4x,PHC Last ANC: forgot USG: never History of family planning : Next family planning : Obstetric History : 1.Abortus 2. This

General Condition : well Consciousness : CM BP : 120/70 mmHg PR : 96 x/minute RR: 20 x/minute T : 36,5C 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 at right side L2: breech at left side L3: small part of fetal L4: FHR:144x/minute UHF : 31 cm UC : VT : (-), forniks palpable

G2P0A0H0 36-37 weeks S/L/IU with transverse lie + history of rupture membrane

Obs. Mother and fetal well being Check DL, HbsAg Coass to GP: pro injection Ampisilin 2gr/iv & pro SC GP : acc injection Ampisilin 2 gr/iv GP consult to SPV advice: pro SC SPV acc SC

Time

S
Laboratory result: HGB : 11,5 WBC : 13,59 x 103 RBC : 4,23 x 106 HCT :37,1 PLT: 277.000 HbsAg: (-)

02/10 /2011 21.55 SC began

22.00

Baby was born, female, 1750 gr, AS 3-5, Ballard score : , transverse lie, amnion clear 250 cc , anus (+), congenital anomaly (-), Placenta was born manually, complete, bleeding 450 cc

23.00

SC finished

Time

O
General condition : well
BP: 110/60 mmHg PR: 92x/minute RR: 20x/minute T: 36,8 C UO : 33 cc/hours UFH: 2 finger under umbilicus UC: (+) good Vaginal active bleeding (-)

A
2 hours post SC

P
Observe mother condition KIE mother to take a rest

03/10 /2011 01.00

07.00

Wound pain operation

General condition : well BP: 110/60 mmHg PR: 92x/minute RR: 20x/minute T: 36,8 C UO : 33 cc/hours UFH: 2 finger under umbilicus UC: (+) good Vaginal active bleeding (-) Baby in NICU PR : RR : T: