MORNING REPORT

02nd February 2012

Supervisor: Mahayasa SpOG
Medical Students:
Wuri,Arma, Dewi,Ica, Anggun,Zul
CASE RESUME NORMAL LABOUR PATHOLOGIES LABOUR G1P0A0L0 39-40 weaks S/L/IU head presentation with neglected 2nd stage of labor

Ny. M U 26 yo Narmada Admitted to GH of 2nd feb 2012, 11.30

TIME 11.30

SUBJECTIVE Patient referred from Narmada PHC with G1P0A0L0 39-40 wk with prolonged 2nd stage. Patient confessed abdominal pain and bloody slim since yesterday (1/2/2012 ). History of membran rupture (+) at 07.30 am this morning. LMP: 30/04/2011 EDD: 7/02/2012 ANC: >4x, PHC Last ANC: 16/01/ 2012 History family planning: Next family planning: -

OBJECTIVE General status: GC: weak BP: 100/70 PR: 88 RR: 24 T: 36,8 General status : Eye: an -/-, ict -/Cor/pulmo: in normal range Extremity; in normal range Obstetrical status: L1: breech L2: back on the right side L3: head L4: 3/5 UFH: 31 cm EFW: 3100 gr UC: 4x/10-45 FHB: 11-12-11 (136x/minute) VT: complete, eff 100%, amn (-), meconeal, head H III, caput (+), unpapable small part of fetal/umbilical cord PE: Pubic arc >90

ASSESTMENT G1P0A0L0 A/S/L/IU head presentation with neglected 2nd stage of labor

PLANNING Observation mother and fetal well being Check lab: DL, HBsAg Injection amoxicillin 1 gr Resuscitation intrauterine+O2 5L Coass co to GP: pro termination per abdominal GP co to SPV: acc SC

Obstetrical history: 1. This

Chronologist: 23.30 (1 feb 2012) Patient came to polindes confessed of abdominal pain and bloody slim

General condiition : BP: 120/80 PR: 80 RR: 20 T: 36,5

UFH: 29 cm FHB: (136x/minute)

Lab: Hb: 10,7 Hct: 36,3 WBC: 18 Plt: 103

TIME

SUBJECTIVE 02.30 VT: 4 cm,eff 25%, amn (+), head HI FHB: (136x/minute) BP: 120/70 PR: 80 RR: 20 T: 36,5

OBJECTIVE

ASSESTMENT

PLANNING

06.30 VT: 8 cm, eff 75%, amn (-), head H III FHB: (136x/minute)
07.30 Patient confessed water came out from her womb and want to bear down. VT: complete, head H III 08.00 Conduct labor 09.00 Patient reffered to Narmada PHC with G1P0A0L0 A/S/L with prolonged 2nd stage. P: IVFD RL flash II

TIME

SUBJECTIVE 09.30 (Narmada PHC) Arrived in Narmada PHC General condiition : BP: 120/80 PR: 88 RR: 20 T: 36,5 UFH: 34 cm , back on the left side, head presentation, pelvic inlet : 3/5 EFW: 3565gr FHB: (136x/minute) UC: 4x/10-45 A: G1P0A0L0 A/S/L with prolonged 2nd stage. P: Ampicillin injection 1 gr IVFD RL + D5 10.00 Ampicillin injection 1 gr 10.30 Vacum extraction was tried failed

OBJECTIVE

ASSESTMENT

PLANNING

10.45 -Reffered to NTB GH -IV line D5

12.35 SC began Baby was born, male, 2900 gr, AS: 6-8, aamnion : red cloudy, anus (+), anomaly conginetal (-) Bleeding 500 cc Placenta born manual, complete

14.35

Operation wound pain GC: well BP: 130/70 mmHg RR: 18 T: 36,5 PR: 100 Active vaginal bleeding: UC: good UFH: 2 finger below umbilicus

2 hours post SC

Continue observation and medication Suggest mother to mobilisation

08.00

GC: well BP: 130/70 mmHg RR: 18 T: 36,5 PR: 100 Active vaginal bleeding: UC: good UFH: 2 finger below umbilicus

1st day post SC

Continue observation and medication Suggest mother to mobilisation

Baby in NICU : FHR: 120 bpm RR: 40x/mnt T: 35