Morning Report july 15th 2009

Supervise by : dr.Agus Thoriq, SpOG

Medical Student: Dwi Retna Sumiati Husni
Cases resume : 1 2

G1P1A0 A/S/L with head presentation + PROM <12 hours + severe PE

1
1

Name age Address

: Mrs. Zuhaerani : 35 years : Cakra-utara

Additted

: 15.07.09 : 13.00

Time 13.00

Subject Patien come to ER General Hospital of Mataram confess abdominal pain and bloody show since at 11.00 (15/7/09). history watery vaginal discharge since at 08.00 (15/7/09). Headache (-),blur vision (),epigastric pain (-)
LMP : forgot ANC : routine at PHC (>7x) History family planning : Family planning : IUD

Object General status : General condition: well Conciousness: CM BP: 150/110 mmHg RR: 20 x/mnt Pulse :80x/mnt T: 36.8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Ext : edema -/Obstetric status : L1 : breech L2 : Right back L3 : head L4 : descensus 4/5 UFH 29 cm EFW : 2790 g UC : 1x/10 20 Fetal Heart Rate : 12-12-12 VT : CD 1 cm, eff 25 % AM (-), clear, head palpable, descensus HI, umbilical cord or small part of fetal unpalpable

Assesment G1P0A0 A/S/L head presentation with PROM +severe PE

Planning - Observation mother and fetal well being - Laboratory tes, DL, UL, HbsAg - Inj ampicillin 1 gr IV
Report to superviser Proposed management severe PE Advice from supervisor : management severe PE and evaluation 2 hours if vital sign was good start drip oxytocin. - Education mother to eat and drink

time

Subject

Object Bishop score : 6 Dilatation cervix : 1 Length of servix : 2 Station : 1 Consistensi : 1 Position : 1 Pelvic evaluation : Spina ischiadica unpalpable, os coxigeus mobile, distansia tuberum >90 Lab examination : Hb :11,5 gr % Leukosit :7100 /mm3 Trombosit :308.000/mm3 Hematocrit :34,1 HBsAg : (-) Protein : +3

Assesment

Planning

time 13.30

Subject Abdominal pain (+) Subjective complain (-)

Object General status : well BP : 160/110 mmhg RR : 18x/mnt Pulse : 84x/mnt Temp : 37,2 c prod urine : 100 cc/hr FHR : 154x/mnt UC : 2-3x/10-25 General status : well BP : 160/110 mmHg RR : 20x/mnt Pulse : 80x/mnt Temp : 36,8 c FHR : 156x/mnt UC : 2-3x/10 -25 General status : well BP : 170/100 mmHg RR : 20x/mnt Pulse : 84x/mnt Temp : 36,5 c Prod urine : 100 cc/hr FHR : 150x/mnt UC : 3-4x/10-30

Assesment G1P0A0 A/S/L/Head presentation with PROM + severe PE

Planning Management severe PE : MgSO4 bolus 4 gr IV MgSO4 6 gr in RL 28dpm Nifedipine 3x10 mg DC Educate mother to eat and drink obs. Mother and fetal well being Educate mother to left lateral position Educate mother to eat and drink

14.00

Abdominal pain (+) Subjective complain (-)

G1P0A0 A/S/L/Head presentatiion with PROM + Severe PE

14.30

Abdominal pain (++) Subjective complain (-)

G1P0A0 A/S/L/Head presentatiion with PROM + severe PE

obs. Mother and fetal well being Educate mother to left lateral position Educate mother to eat and drink

time 15.00

Subject Abdominal pain (++) Subjective complain (-)

Object General status : well BP : 160/100 Pulse : 84x/mnt RR : 18x/mnt Temp : 36,7 c FHR : 146x/mnt UC : 3-4x/10 30 VT : CD 4 cm, eff 45%,AM (), clear, head palpable decensus H1, umbilical cord and small part of fetal unpalpable.

Assesment G1P0A0 A/S/L head presentation + PROM + Severe PE

Planning Observation mother and fetal well being Educate mother to left lateral position Educate mother to eat and drink

15.30

Abdominal pain (++)

Subjective complain (-)

General status : well BP : 160/100 mmHg RR : 18x/mnt Pulse : 80x/mnt Temp : 36,7 c Prod urine : 120 cc/hr FHR : 146 UC : 3-4x/10 ~ 30

G1P0A0 A/S/L/Head presentatiion + PROM + severe PE

obs. Mother and fetal well being Educate mother to left lateral position Educate mother to eat and drink

time 16.00

Subject Abdominal pain (++) Subjective compalain (-)

Object General status : well BP : 170/100 Pulse : 84x/mnt RR : 22x/mnt Temp : 36,7 c FHR : 138 UC : 3-4x/10 ~ 35

Assesment G1P0A0 A/S/L/Head presentatiion + PROM + severe PE

Planning obs. Mother and fetal well being Educate mother to left lateral position Educate mother to eat and drink

16.30

Abdominal pain (++) Subjective complain (-)

General status : well BP : 170/100 mmHg RR : 18x/mnt Pulse : 84x/mnt Temp : 36,6 c Prod urine :130 cc/hr FHR : 146 x/mnt UC : 3-4x/10 -40 General status : well BP : 170/100 mmHg RR : 18x/mnt Pulse : 84x/mnt Temp : 36,5 c

G1P0A0 A/S/L/Head presentatiion + PROM + severe PE

Educate mother to left lateral position Educate mother and fetal well being Educate mother to eat and drink

17.00

Patient want to bearing down

G1P0A0 A/S/L/Head presentatiion + PROM +severe PE

Aff DC Report to supervisor : proposed vacuum, Proposed agree

Time

Subject

Object

Assesment

Planning

VT : CD complete, eff 100%, AM (-),clear, head palpable decensus H111, umbilical cord and small part of fetal unpalpable.

17.20

Mother wont to bearing down

Doran teknus perjol vulka

G1P0A0 A/S/L/ 2nd Stage of labor + head presentation

Conduct mother to bearing down episisiotomi Obs.mother and fetal well being

17.30

2nd

stage of labor

Baby was born, female. Weight 2600 gr ,length 46 cm. AS 7-9

3nd stage of labor

Placenta was born complete Hemorarge 150 cc

Time 18.00

Subject

Object

Assesment

Planning Obs.vital sign of mother Obs. Uterus contraction Obs.bleeding

General status : well BP : 150/100 mmHg RR : 20x/mnt Pulse : 88x/mnt Temp : 37 c UFH : 2 fingers below the umbilical UC : good General status : well BP : 150/100 mmHg RR : 18x/mnt Pulse : 80x/mnt Temp : 36,5 c UFH : 2 fingers below the umbilical UC : good
General status : well BP : 150/100 mmHg RR : 20x/mnt Pulse : 76x/mnt Temp : 36,8 c UFH : 2 fingers below the umbilical UC : good

4nd stage of labor + Mild PE

19.00

4nd stage of labor + Mild PE

Obs. Vital sign Obs.uterus contraction Obs.bleeding Educate mother to give lactation

07.00

Mother and baby rooming in melati room

1 day of puerpuralis