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  • Supervisor: Dr. Edi Prasetyo Wibowo Spog: 2 NOVEMBER 2009

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    Arja' Waas
    27 Ansichten4 Seiten
    1. A 16-year-old woman, G1P0A0L0 at 24 weeks gestation, presented with breech presentation and active labor. 2. Examination found her to be in the first stage of active labor with a breech presentation, descended head, and effacement of 50%. 3. Her care included observation of her and her baby's wellbeing, laboratory tests, observation for labor signs, and maternal and fetal monitoring.

    Originalbeschreibung:

    MR 021109

    Originaltitel

    MR 021109

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    1. A 16-year-old woman, G1P0A0L0 at 24 weeks gestation, presented with breech presentation and active labor. 2. Examination found her to be in the first stage of active labor with a breech presentation, descended head, and effacement of 50%. 3. Her care included observation of her and her baby's wellbeing, laboratory tests, observation for labor signs, and maternal and fetal monitoring.

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    © All Rights Reserved
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    27 Ansichten4 Seiten

    Supervisor: Dr. Edi Prasetyo Wibowo Spog: 2 NOVEMBER 2009

    Hochgeladen von

    Arja' Waas
    1. A 16-year-old woman, G1P0A0L0 at 24 weeks gestation, presented with breech presentation and active labor. 2. Examination found her to be in the first stage of active labor with a breech presentation, descended head, and effacement of 50%. 3. Her care included observation of her and her baby's wellbeing, laboratory tests, observation for labor signs, and maternal and fetal monitoring.

    Copyright:

    © All Rights Reserved
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    von 4

    Morning Report

    2 NOVEMBER 2009

    Supervisor : dr. Edi Prasetyo Wibowo


    SpOG
    Medical Student:
    Halia
    Cases resume :
    1

    G1P0A0L0 24W /S/L/IU with breech


    presentation, inpartu kala 1 fase aktif

    Name

    : Mrs. X/BatuKliang

    Age

    : 16 years old

    Wakt
    u

    Subject

    23.3
    0
    (31/
    11/0
    9)

    Patient came to Mataram GH referred


    by Narmada PHC
    Cronologis :
    Patient came to Narmada PHC at
    13.30
    (31/11/09)
    confess
    abdominal pain (+) since 16.00,
    watery vaginal discharge (-)
    bloody show (+). Night before, she
    was came to dukun.
    LMP : 22/1/2009
    EDD: 29/10/2009
    ANC : 4x
    Examination in PKM:
    BP: 120/80 mmHg
    PR; 84 bpm
    RR: 22 tmp
    UFH : 15 cm
    Temp : 37,8 C
    AC:100cm
    EFW:3400 gram
    FHR: 158 bpm
    UC: 1x1020
    VT : CD 4 cm, eff 50%, AM (+),
    upside down palpable, descend
    H1, papable small organ or, small
    part of fetal
    Refered to Mataram GH at 13.30.

    admite
    d

    : Oct, 31 th 2009
    : 13.30pm

    Object

    General status :
    General condition: good
    Conciousness: CM
    BP: 120/70
    RR: 16x/mnt
    Pulse :104 x/mnt
    T: 38,8C
    Eyes : an(-) ikt (-)
    Cor -Pulmo : within normal limit
    Obstetric status :
    L1 : breech
    L2 : L3 : head
    L4 : desend 4/5
    UFH: ~ cm
    AC:98 cm
    EFW : 3234 g
    UC : 4x10-40
    Fetal Heart Rate : 136 bpm
    VT : full, eff 100 %, AM (+),
    descend HIV, palpable small organ

    Assesment

    Planning

    G2P1A0 40W/S/L/IU
    with abortus
    provokatus infeksious

    Obs. Mother and baby


    wellbeing
    Cek lab
    Obs. Inpartu sign
    KIE ibu & klg

    Wakt
    u

    Subject

    Object

    Assesment

    Planning

    Lab. result:
    HBsAg (-)
    HB = 13,8
    WB =20.200
    TRB = 371.000
    Hct = 28.0
    13.4
    5

    The baby was born


    female, 500 gr, AS 1-1
    The placenta was born
    spontan, complete
    Terlihat batangan kayu
    sebanyak 2 biji, @ uk 5
    cm
    CUT good
    -Inj Oxytocin 1 amp/ IM
    -Infuss grojok 2 fls, RL
    -Ampicillin test (-)
    -Inj Ampicillin 1 gr/ IV
    -Report to supervisor

    Terlihat selaput janin/janin


    sudah keluar

    14.0
    0

    BP: 120/70 mmHg


    PR; 100 bpm
    RR: tmp
    Temp : 38,8 C

    20.0
    0

    BP: 90/60 mmHg


    PR; 88 bpm
    RR: tmp
    Temp : C

    -advice: inj. Ceftriaxon 2


    gr/day, Metronidazol drip
    500 ml/ 12 hours, inj
    Xylomidon 2 cc/ IM (if
    BP sistole > 100),
    paracetamol tabel 1 (if
    BP sistole < 100)

    Wakt
    u

    08.0
    0

    Subject

    Object
    BP: 120/70 mmHg
    PR; 88 bpm
    RR: tmp
    Temp : 37,2C

    Assesment

    Planning
    Inj ceftriaxon 2 gr/day

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