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Morning Report

DOKTER MUDA FK. UNRAM


BAGIAN SMF OBGYN
RSU MATARAM
4 November 2008

Supervisor : dr. Punarbawa, Sp.OG


Dokter Muda Jaga:
1.Nasrullah
2.Sulistiawati
3.Zikrul Haikal

Resume Kasus :
No. Jenis Kasus Jumlah
1. IUFD 1
2. PPROM 1
3. Footling preentation 1. 1
4. Prolong labor with complication 1
5. APB e.c placenta previa totalis 1
6. Normal Delivery 1
Name : Mrs. Salmiah CTH : 13 – 10 - 2009
Age : 22 years Pukul : 18.15
Address : Banjar Ampenan
Waktu Subject Object Assesment Planning
18.15 Patient refered by Tanjung Karang General status : - G2P1A0H1 preterm/
Community Health Center with •General condition: well, single/life/intra uterine  Laboratory
G2P1A0H1 •Conciousness: CM tranversal liy examination :
preterm/single/life/intra uterine •Blood presure: 110/70 presentation+ active DL,HbSag
with transverse liy presentation. •RR: 20 x/mnt fase of stage 1 + informed Supervisor :
•Pulse :88 x/mnt suspect IUFD. - advice : SC.
•T: 36,5 C
cronologis : Eyes : an(-) ikt (-)
Patient felt intermitten abdominal Cor -Pulmo : in normal range
pain and bloody shows since 03.00
(12-10-2009), then she went to Obstetric status :
Tanjung Karang Community Health L1 : -
Center at 16.30 (13-10-2009). She L2 : left head
feel rupture of amnion membrane L3 : -
at 18.00 (13.10.09), and the fetal L4 :
movement wasnt active since 1 day Uterine Fundal Length : 22 cm
ago. History of The examination EFBW : -
in Tanjung Karang Community  His : (+), 3x/10~40”
Fetal Heart Rate : -
Health Center found :
18.15
General status : well VT : Φ 6 cm, eff 75 %, amniotic fluid
BP : 110/80 mmHg (-), right Hand precentation, descend HI.
Pulse = 84 x/mnt
RR: 24 x/mnt Lab. result:
Temp = 36,5’C HBsAg (-)
Fetal heart rate = (+) 140 x/mnt Hb : 11,3 gr %
Uterine fundal length = 24 cm WB = 14.900/mm3
17.00 PLT = 232.000
VT : ф 10 cm,eff 100 %, HCT = 33,2 %
amnion fluid (+), head was
Waktu Subject Object Assesment Planning

Last menstrual period : march??


Estimate of Delivery Date :
december
History of family planning : -
Family planning : IUD
ANC : routine in public health
center
Obstetric History :
1. female, traditional attenden, 9
years.
2. Now

Therapy in PHC:
iNfus RL 20 dpm

17.45
Patient reffered to Mataram GH
Reason : baby premature
Waktu Subject Object Assesment Planning
18.45 Abdominal pain ++ BP = 110/80 G2P1A0H1 preterm/ Observation maternal well
RR= 20 x/mnt single/life/intra uterine being
Tax = 36,8 tranversal liy presentation+ Prepare SC :
Pulse = 80 x/mnt active fase of stage 1 + Insert Dc
UC : 2-4x 10 40’ suspect IUFD. Injection Ampicilin 2 gr IV
FHR -

19.15 BP = 130/80 G2P1A0H1 preterm/ Observation maternal well


RR= 24 x/mnt single/life/intra uterine being
Tax = 36,8 tranversal liy presentation+
Pulse = 88 x/mnt active fase of stage 1 +
UC : 2-3 x 10 40” suspect IUFD.
FHR -

19.40 SC begun stage II of labor Baby was born death


,maseration +, female, length
39 cm, weight 1500 gram.
Amniotic fluid nothing,
placenta low lying position
Placenta was born complete
Stage III of Labor

21.40 BP = 100/80 stage IV of labor Observation VS, Uterus


RR= 18 x/mnt Contraction, bleeding and
Tax = 36,8 subjective complain
Pulse = 84 x/mnt
Uterus contraction : well,
Fundal uterine length = 2
finger below umbilical
Bleeding = -
Waktu Subject Object Assesment Planning
14/10/09 BP = 110/80 1 st day post SC Observation maternal well
06.00 RR= 20 x/mnt being
Tax = 36,5
Pulse = 80 x/mnt
Uterus contraction : well,
Fundal uterine length = 2
finger below umbilical
Bleeding = -