MORNING REPORT

August 18th, 2012

Supervisor : dr. I Made P. Juliawan, Sp.OG

Medical Students : Jun, Dini H, Erma, Rani, Diah, Dini F, Jatna
CASES RESUME NORMAL LABOR 2

PATHOLOGY LABOR

Name : Mrs. M Age : 32 yo Adress : Bagek Nunggal, lombok tengah Admitted : August, 18th 2012 at 11.45

TIME 18/08/ 2012 11.45

SUBJECTIVE Patient referred from Praya GH with G5P3A1L2 A/S/L/IU with transverse lie and low lying placenta. Patient confessed blood come out from her womb since 20.00 (17/08/12). Water came out from her womb since 20.00 (17/08/12). Abdominal pain that spread to waist since 05.00 (18/08/12). Bloody slim (+), FM (+). No history of DM, HT, asthma. LMP : forgot EDD : History of ANC : > 4x at Posyandu Last ANC : 31/08/2012 History of USG : 1x Last USG : 18/08/2012 Result : low lying placenta + transverse lie, EFW : 2450 g. History of family planning : injection 3 months Next family planning : Tubectomy

OBJECTIVE General Status GC : well Consciusness : CM BP : 140/90 mmHg PR : 88 bpm RR : 24 bpm T : 36,5oC Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single reguler, M (-), G (-) Pulmo : vesikuler (+/+), wheezing (-/-), ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+) Obstetrical Status L1 : back L2 : O L3 : extremities L4 : UFH : 22 cm EFW : UC : 3x/10 ~ 40 FHB : 13-13-12 (152 bpm) Inspeculo : (+), membrane of plasenta (+), stolsel (-), livide (+), active bleeding (-). VT : not evaluated

ASSESSMENT G5P3A1H2 A/S/L/IU transverse lie with low-lying placenta + history rupture of membrane + gestasional hypertension

PLANNING Observe mother and fetal well being. DM co to SPV pro CS, advice : Acc CS at 16.00 Wita - CIE patient and family - Insert DC - Skin test (-), inj. Ampicillin 2 g/IV.

TIME

SUBJECTIVE Obstetrical History : I. / 9 month/ TBA/ spontan/ dead at 17 days II. / 9 month/ TBA/ spontan/ 19 yo III. Abortus at 3 months of pregnancy IV. / 9 month/ TBA/ spontan/ 9 yo V. This Chronologist at Praya GH : (18/08/2012) S : patient confessed water came out from her womb since 20.00 (17/08/2012) O : GC : well BP : 130/90 mmHg PR : 84 bpm RR : 18 bpm T : 36,5oC UFH : 26 cm FHB : 152 bpm VT : 4 cm, eff 35%, amnion (-), HI A : G5P3A1L2 A/S/L/IU transverse lie with low lying placenta P: Infuse RL Ampicilin 3x1 1 gram Pro CS

OBJECTIVE Lab Evaluation HB : 11,7 g/dl RBC : 4,21 M/dl HCT : 39,1 % WBC : 13,7 K/dl PLT : 268 K/dl HbSAg : (-) Proteinuria : (-)

ASSESSMENT

PLANNING

TIME 16.30

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING C-section began : Baby was born, female, BW 2000 gram, AS 6-8 Anus (+), congenital anomaly (-), Ballard score : 30, Gestation age : 35-36 weeks Placenta was born manually, complete, bleeding + 500 cc. Myoma uteri intramural Fimbriectomy bilateral done

TIME
19.30

SUBJECTIVE
Patient confessed her leg cant moved and operation wound pain

OBJECTIVE
GC : well BP : 100/60 mmHg PR : 80 bpm RR : 24 bpm T : 36,0oC UFH : 1 finger below umbilicus UC : (+) well UO : 30 cc/hours Operation wound good GC : well BP : 110/60 mmHg PR : 96 bpm RR : 24 bpm T : 37,9oC UFH : 2 finger below umbilicus UC : (+) well Lochea rubra : (+) Operation wound good Baby in NICU : PR : 148 bpm RR : 42 bpm T : 36,8OC GDS : 89 mg/dl

ASSESSMENT
2 hours post CS

PLANNING
Observe mother well being CIE mother to take a rest, eat, and drink.

19/08/ 2012 07.00

Operation wound pain

1 day post CS + febris

Observe mother well being CIE mother to mobilisation, eat and drink Paracetamol po 3x1 Breast feeding