MORNING REPORT October 5th 2011

Supervisor : dr. Doddy, SpOG

Medical Student: Lilik, Ika, Maria, Noval, Fida

Cases resume :

Normal Labor Phatologic Labor

2 G1P0A0H0 43 week/S/L/IU with arrested active phase first stage of labor 1.

Name Age Address

Time

: Mrs. S : 25 years old : Lendang Bajur, gunung sari

CTH

: September 5th 2011 At 11.50 wita

Subject
Patient referred from Gunung Sari PHC with G1P0A0H0 43 week/S/L/IU + serotinus. head presentation with active phase first stage of labor. Patient confessed abdominal pain, since 21.300 (4/10/2011), bloodyslim (+) since last night. History rupture of membrane (-). FM (+). History of DM (-), HT (-), asthma (-). LMP : 8-12-2010 EDD : 15-9-2011 History of ANC : > 4 x, midwife Last ANC : August 2011 History of USG : never History of family planning : Next family planning : injection for 3 month Obstetrical history : I. This

Object
General Condition : well Consciousness : CM BP : 130/80 mmHg PR : 92 x/minute RR: 20 x/minute T : 37C 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: 33 cms L2 : fetal back on right side L3 : head L4 : 4/5 EFW : 3410 g UC: (+), 2 x 10 40 FHR : (+), 12-11-12(140 x/minute) VT : 5 cms, eff 50%, amnion (+), head palpable HI, unpalpable small part/umbilical cord.

Assesment
G1P0A0H0 43 week/S/L/IU head presentation with active phase first stage of labor + serotinus

Planning
Observe mother & fetal well being DL, HbSAg checked Coass consult to GP pro observe. Advice: ACC

5/10/ 2011 11.50

Time

S
Chronologist : Lab : DL:HGB : 11,8 RBC : 4,9 HCT : 40,4 WBC : 11,6 PLT : 217 HbSAg : -

Time

O
UC : (+), 2 x/10 30 FHR : (+), 144 x/minute VT : 7 cms, eff 75%, amnion (+), head palpable HI, unpalpable small part/umbilical cord.

A
G1P0A0H0 43 week/S/L/IU with protacted active phase first stage of labor -

P
Co to GP pro amniotomy. Advice: ACC amniotomy, observe 2 hours again, if UC not good drip oxytocin

5/10/2 011 15.50

17.50

UC : (+), 3-4 x/10 40 FHR : 144 x/minute VT : 7 cms, eff 75%, amnion (-) unclear, head palpable, HI , unpalpable small part/umbilical cord.

G1P0A0H0 43 week/S/L/IU with arrested active phase first stage of labor

- Coass co to GP pro SC - GP consult to supervisor, advice: observe and rehydration

20.45

Abdominal pain (+)

UC : (+), 3 x/10 30 FHR : (+), 144 x/minute VT : 7 cms, eff 75%, amnion (-) unclear, head palpable HI, unpalpable small part/umbilical cord.

- Coass consult to GP pro SC - GP consult to supervisor pro SC. Advice: ACC

Subject

Object

Assesment

Planning

5/10/2 011 22.10

SC began Baby was born, Female., A-S : 6-8, BL: 49 cm, BW : 2700 gr Anus (+), congenital anomaly (-), Amnion fluid 10 cc, clear. Placenta was born manually, complete, bleeding 200cc Placenta weight : 550 gr

22.50

SC Finished

Subject

Object

Assesment

Planning

5/10/ 2011 00.50

(-)

GC : well cons : E4V5M6 BP : 110/70 mmHg PR : 80x/minute RR : 20 x/minute T : 36,7 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 30 cc/hours

2 hour Post SC

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

6/10/ 2011 07.00

Wound pain

GC : well cons : E4V5M6 BP : 120/70 mmHg PR : 88 x/minute RR : 20 x/minute T : 36,5 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 40 cc/hours Baby in NICU : PR : 140 x/minute RR : 40 x/minute T : 36C

1 day post SC

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