Sie sind auf Seite 1von 6

MORNING REPORT

May 20th 2014


Supervisor: dr. I Made Putra Juliawan, SpOG
Medical Students:
Manda, Yid, Salman, Ziad

CASE RESUME

NORMAL LABOUR

PATHOLOGIES LABOUR
Identity
Ny. HS
25 yo
Pringgarate, Loteng
Admitted: 19th May 2014, 16.30 WITA
G3P2A0L1 37-38 weeks/S/L/IU, head
presentation with laten phase first stage of
labor + Mild Preeclampsia
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
16.30 Patient came to GH of NTB conffessed of 9 General status G3P2A0L1 37-38 Observe mother and fetal
month pregnancy. There is history of General condition: well weeks/S/L/IU, well being
abdominal pain since 18/05/14 21.00 BP: 140/100 mm Hg head presentation Observe progress of labor
WITA. No history of rupture of membrane, PR: 88x/minute with laten phase
bloody slim (-), FM (+). RR: 22x/minute first stage of labor
No history of DM, HT, or asthma T: 36,5 C + Mild
Eye: an (-/-), ict (-/-) Preeclampsia
LMP: 09/08/2013 Cor : S1S2 single, regular, murmur (-
EDD: 16/05/2014 ), gallops (-)
Pulmo: vesicular +/+, wheezing (-),
History of ANC: >4 x at PHC rhonchi (-).
Last ANC: 06/05/14 Abdomen: scar (-), striae (+), linea
Result : BP : 140/90mmHg, Weight : 67, 37 (+)
weeks, UFH : 29cm, head presentation Lower Extremity: oedem (-/-), warm
acral (+/+)
History of USG 1x ( 11/03/14)
S/L/IU 27-28 weeks, EFW : 1115gram, male Status Obstetric:
placenta in corpus anterior, enough UHF: 28 cm
amnion, EDD : 07/06/2014 L1: breech
L2: back on the left side
History of family plannning: ??? L3: head
Next family planning: - L4: 4/5
EFW: 2635 gr
Obstetrical status: UC: 1 x 10 30
1. Aterm, Male, 2500gr, midwife, die at 6 FHB: 11-12-11 (136)
months VT: 2 cm, eff 25%, amn (+), denom
2. Aterm, Male, 2500gr, midwife, 10 yo unclear, H1, unpalpable small part
3. This of fetal/umbilical cord
Lab:
Hb: 13,1 RBC: 4,86
Hct: 36,9 Plt: 371
WBC: 14,11
Protein : +1
HBsAg (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

20.30 General condition : well G3P2A0L1 37-38 Observe mother and


BP : 140/100 weeks/S/L/IU, head fetal well being
N : 84x/minute presentation with Observe progress of
PR : 20x/minute active phase first labor
T : 36,8 C stage of labor + Mild
Preeclampsia
VT: 4 cm, eff 50%, amn (+), H1,
unpalpable small part of fetal/umbilical cord

21.30 Dizzynes , vomite (2x) General condition: well G3P2A0L1 37-38 Observe mother and
BP: 170/120 mm Hg weeks/S/L/IU, head fetal well being
PR: 84x/minute presentation with Check UL
RR: 20x/minute active phase first DC
T : 36,7 C stage of labor + severe DM co to GP
Preeclampsia + advise : therapy as
UC: 3 x 10 40 impending eclampsia severe preeclampsia
FHB: 12-11-12 (140) Bolus MgSO4 4 gram
20 cc
Drip MgSO4 6 gram
UL : proteinuria +1 15cc
Observe vital sign,
UO
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

23.00 Mother General condition: well G3P2A0L1 37-38 Conduct of labor


confessed water BP: 150/90 mm Hg weeks/S/L/IU, head
come out from PR: 92x/minute presentation with
her vagina, RR: 20x/minute second stage of labor
Abdominal pain, T : 36,5 C + Severe Preeclampsia
mother want to Urine output: 100cc
bearing down
UC : 4x10-45
FHB : 148x/m

VT: complete, eff 100 %, amn (-) clear,


denom LOA, H III, unpalpable umbilical
cord
23.15 Third stage of labor Baby was born male, AS 7-9, 2250
gram, 45cm, Anus (+), Congenital
anomali (-)

Placenta was born spontaneus,


complete, bleeding 150cc
Rupture (-)
20/05/14 General condition: well P3A0L2, 2 hours post Observe mother and baby well being
01.15 BP: mm Hg partum Continue drip MgSO4, 6 gr at 500 cc
PRx/minute RL, 28 dpm
RR: x/minute
T: C
UO: 40 cc/KgBB/hours
UFH: 1 finger bellow umbilicus

Baby in NICU:
PR: 140x/minute
RR: 40x/minute
T: 36,7C
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

20/05/14 - General condition: well 1st day post partum


07.00 BP: 140/100 mm Hg
PR: 80x/minute
RR: 18x/minute
T: 36,5 C
UO: 40 cc/KgBB/hours
UFH: umbilicus

Baby in NICU:
PR: 140x/minute
RR: 40x/minute
T: 36,7C