MORNING REPORT September 29th 2011

Supervisor : dr. Juliawan, SpOG

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

Cases resume :

Normal Labor Phatologic Labor

2 3

Name Age Address

Time

: Mrs. F : 35 years old : Ampenan

CTH

: September 29th 2011 At 09.50 wita

Subject
Patient referred from Maternity Clinic with G4P3A1L2 38 week/S/L/IU head presentation with totalis placenta previa, oligohydramnion, susp. Intrauterine retardation. Bleeding (-), bloodyslim (-). History rupture of membrane (+) since 2 week ago, FM (+). History of DM (-), HT (-), asthma (-). LMP : 05 01 2011 EDD : 12 10 2011 History of ANC : 9 x, SpOG Last ANC : 28 09 2011 History of USG : 1 x (28-09-2011) History of family planning : pil Next family planning : IUD Obstetrical history : I. Aterm, spontant, doctor, 3200 gr, male, 9 years old II. 8 week, abortus III. Aterm, SC, doctor, 3800 gr, male, 2 years old IV. This

Object
General Condition : well Consciousness : CM BP : 130/90 mmHg PR : 84 x/minute RR: 22 x/minute T : 36,9C 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: 25 cms L2 : fetal back on left side L3 : head L4 : 5/5 EFW : 2015 gr His: (-) FHR : (+), 11-11-12 (136 x/minute) VT : not done

Assesment
G4P3A1L2 38 week/S/L/IU head presentation with totalis placenta previa, oligohydramnion, susp. Intrauterine retardation.

Planning
Observe mother & fetal well being DL, HbSAg , BT, CT checked Coass consult to GP pro SC GP consult to supervisor pro SC. Advice from supervisor : ACC SC

29/9/ 2011 09.50

Time

S
Lab : DL:HGB : 13,9 RBC : 4,58 HCT : 45,2 MCV : 98,6 MCH : 30,3 WBC : 11,8 PLT : 260 HbSAg : BT : 2 30 CT : 6 00

14.00

His : (-) DJJ : (+), 12-12-11

G4P3A1H2 38 week/S/L/IU head presentation with totalis placenta previa, oligohydramnion, susp. Intrauterine retardation.

15.00

His : (-) DJJ : 12-12-13

16.00

His : (-) DJJ : 12-12-12

17.00

His : (-) DJJ : 12-11-12

Time

A
SC began

29/09 /2011 18.20

18.30

Baby was born, Male., A-S : 6-8. BW : 1800 gram BL : 45 cm Ballard score : SMK Anus (+), congenital anomali (-), Amnion clear Placenta was born manually, bleeding 400 cc Placenta weight: 400 gram

18.50

SC Finished

Subject

Object

Assesment

Planning

20.50

(-)

GC : well cons : E4V5M6 BP : 110/80 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: 70 cc/hours

2 hour Post SC

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

30/9/ 2011 07.00

Wound pain

GC : well cons : E4V5M6 BP : 110/80 mmHg PR : 92 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: 45 cc/hours Baby in NICU : PR : 160 x/minute RR : 28 x/minute T : 36C

1 day post SC

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

Name Age Address

Time

: Mrs. N A : 24 years old : Pringgarata

CTH

: September 29th 2011 At 20.45 wita

Subject
Patient referred from Pringgarata PHC with G1P0A0H0 36-37 week/S/L/IU head presentation with PEB. Headache since 2 week ago, extremity udem. Blured vision (-), vomiting (-), nausea (-). Abdominal pain (-), bloodyslim (-). History rupture of membrane (-), FM (+). History of DM (-), HT (-), asthma (-). LMP : 16 01 2011 EDD : 23 10 2011 History of ANC : 8 x, midwife Last ANC : August 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 : 175/100 mmHg PR : 90 x/minute RR: 22 x/minute T : 36,7C 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 (+)

Assesment
G1P0A0H0 37-38 week/S/L/IU head presentation with PEB

Planning
Observe mother & fetal well being DL, HbSAg , UL, SGOT, SGPT, BUN SC checked Coass consult to GP pro: - Bolus MgSO4 40% 4 gr/IV - Drip MgSO4 40% 6 gr in 500 cc RL 28 dpm - Nifedipin 3 x 10 mg - Insert DC Advice: ACC GP consult to supervisor pro SC. Advice from supervisor : ACC SC

29/9/ 2011 20.45

Obstetrical status : L1 : breech, UFH: 28 cms L2 : fetal back on left side L3 : head L4 : 4/5 EFW : 2790 gr His: (-) FHR : (+), 12-12-12 (140 x/minute) VT : -

Time

Subject
Chronologist : 29/9/2011 19.30 S: Patient confessed headache since 2 week ago. Patient came to NTB GH for ANC in 28-9-2011 and rejected to opname O: General Condition : well Consciousness : CM BP : 180/120 mmHg, PR : 88x RR: 20, T : 36,5C Obstetric status : L1 : breech, TFU : 30 cm L2: fetal back on left side L3 : head L4 : 4/5 DJJ: 150 x/minute A: G1P0A0H0 36-37 week/S/L/IU head presentation with PEB P: - Drip MgSO4 6 gram 28 dpm (20.00) - Nifedipin 10 mg (20.00)

Object
Pelvic score: 2 Cervix dilatation 0 (0) Cervix length 2 cms (1) Consistency rigid (0) Location mid (1) Station -3 (0) Lab: DL: HGB : 11,2 RBC : 4,04 HCT : 36,3 MCV : 89,9 MCH : 27,7 MCHC : 30,9 WBC : 14,54 PLT : 196 Kreatinin : 0,8 Ureum : 25 SGOT : 39 HBsAg : (-) UL: BJ : 1010 pH : 6,0 Nitrit : Protein : +3 Glukosa : Keton : Urobilinogen : Bilirubin : Darah : +2

Assesment

Planning

Time

O
TD : 170/100 mmHg N : 88 x/minute RR : 20 x/minute T : 36,7C His : (-) DJJ : (+), 12-12-11 UO : 30 cc/hours

21.45

22.45

TD : 170/110 mmHg N : 80 x/minute RR : 20 x/minute T : 36,7C His : (-) DJJ : (+), 12-13-13 UO : 35 cc/hours Prepare to SC

23.45

TD : 180/100 mmHg N : 88 x/minute RR : 20 x/minute T : 36,7C His : (-) DJJ : (+), 12-12-12 UO : 30 cc/hours

Time

A
SC began

30/9/2 011 00.00

00.30

Baby was born, Female., A-S : 6-8. BW : 2200 gram BL : 48 cm Ballard score : SMK Anus (+), congenital anomali (-), Amnion clear Placenta was born manually, bleeding 250 cc

01.00

SC Finished

Subject

Object

Assesment

Planning

03.00

(-)

GC : well cons : E4V5M6 BP : 170/80 mmHg PR : 80 x/minute RR : 20 x/minute T : 37,2 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 50 cc/hours

2 hour Post SC

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

31/9/ 2011 07.00

Wound pain

GC : well cons : E4V5M6 BP: 170/100 mmHg PR : 112 x/minute RR : 20 x/minute T : 37 C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 43 cc/hours Baby in NICU : PR : 140 x/minute RR : 24 x/minute T : 36,5C

1 day post SC

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