Morning Report

October 14th, 2012 Supervisor : dr. Edi Prasetyo W, Sp.OG

Medical Students :
Diah, Rani, Dini F, Subi, Indah
CASES RESUME NORMAL LABOR PATHOLOGY LABOR 1 1. G1P0A0L0 37-38 weeks /S/L/IU head presentation with severe preeclampsia and impending eclampsia + obs. dyspnea 2. G1P0A0L0 35-36 weeks/S/L/IU head presentation with PROM <12 hours

Name: Mrs.AA Age: 19 yo Address: Pringgarata, Lombok Tengah Admitted: October, 13th 2012 at 21.30 wita

TIME 13/10/ 2012 (21.30)

SUBJECTIVE Patient referred from Pringgarata PHC with G1P0A0L0 35-36 weaks/S/L/IU with PROM > 12 hours. Patient confessed rupture of membrane since 17.00 (13/10/2012). Abdominal pain (-). Bloody slim (-), FM (+). No history of DM, HT, asthma. LMP: 09/02/2012 EDD : 16/11/2012 History of ANC: > 4 X posyandu Last ANC : 08/10/2012 Result : normal History of USG: never

OBJECTIVE General status: GC: well BP: 110/70 mmHg PR: 84 bpm RR: 21 T: 36,8OC Eye : anemis (-/-), icteric (-/-) Thorax : Cor : S1S2 single regular, murmur (-), gallop (-) Pulmo : vesicular (+/+), wheezing (-/-), Ronchi (-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (-/-), warm acral (+/+)

ASSESTMENT G1P0A0L0 35-36 weeks/S/L/IU head presentation with PROM <12 hours

PLANNING Obs mother & fetal well being skin test Ampicilin (-) Inj. Ampicillin 1 gr /6 hour IV DM announce to SPV : pro induction with oxytocin drip if CTG reactive, and if PROM>12 hours SPV advice: acc

History of family planning : Next family planning : IUD

Obstetrical history: I. This

Obstetrical status: L1: breech L2: back on the left side L3: head L4: 4/5 UFH: 28 cm EFW: 2635 g UC : FHB: 11-11-11 (132 x/min) VT: 1 cm, eff 25 %, amnion (-), head palpable HI, impalpable small part / umbilical cord.

TIME

SUBJECTIVE Chronology: 20.00 (13/10/2012) S: Patient come to Pringgarata PHC, at 20.00 confessed rupture of membrane since 17.00 (13/10/2012). Abdominal pain (-). Bloody slim (-), FM (+). No history of DM, HT, asthma. LMP: 09/02/2012 EDD : 16/11/2012 O: GC: well BP: 100/60 mmHg PR: 80 bpm RR: 20 bpm T: 36,5oc L1: breech L2: back on the left side L3: head L4: 4/5

OBJECTIVE PS: 5 Cervic dilatation 2 cm : 1 Cervix length 1 cm : 2 Cervix consistency moderate : 1 Cervix position posterior : 0 Station H I : 1

ASSESTMENT

PLANNING

Lab: HB: 11,0 g/dl RBC : 4,15 M/dl WBC : 8,36 K/dl PLT : 258 K/dl HbSAg: (-)

TFU : 25 cm TBJ : 2170 g

UC: 2x10-20 FHB: 12-12-11 (140 x/min) VT: 1 cm, eff 10 %, amnion (-), head palpable HI, denom unclear, impalpable small part / umbilical cord. A: G1P0A0L0 preterm/S/L/IU with PROM P: infuse RL 20 dpm inj. Ampicillin 1 gr (IV) 20.30 wita Obs mother & fetal well being Refer to NTB GH

TIME 14/10/ 2012 05.00 -

SUBJECTIVE

OBJECTIVE GC: well BP: 120/80 mmHg PR: 88 bpm RR: 20 T: 36,5 CTG: reactive UC: 1X10-10 FHR: 12-10-12 (136 bpm ) VT: 1 cm, eff 10 %, amnion (-), head palpable HI, denom unclear, impalpable small part / umbilical cord.

ASSESTMENT G1P0A0L0S 35-36 weeks/L/IU head presentation with PROM > 12 hours

PLANNING Flash I Drip oxy began 8 dpm

05.30

Abdominal pain (+)

UC: 1X10-10 FHR: 12-12-12 (144 bpm)

Drip oxy 12 dpm

06.00

Abdominal pain (+)

UC: 1X10-10 FHR: 12-11-11 (136 bpm)

Drip oxy 16 dpm

06.30

Abdominal pain (+)

UC: 1X10-10 FHR: 11-11-12 (136 bpm)

Drip oxy 20 dpm

07.00

Abdominal pain (+)

UC: 2x/10 ~ 20 FHR: 12-12-12 (144 bpm)

Drip oxy 24 dpm

07.30

Abdominal pain (+)

UC: 2x/10 ~ 30 FHR: 12-11-12 (140 bpm)

Drip oxy 28 dpm

TIME 08.00

SUBJECTIVE Abdominal pain (+)

OBJECTIVE UC: 2x/10 ~ 30 FHR: 12-12-12 (144) UC : 2x/10 ~ 35 FHR : 12-12-13 (148 bpm)

PLANNING Drip oxy 32 dpm

08.30

Abdominal pain (+)

Drip oxy 36 dpm

09.00

Abdominal pain (+)

UC: 2x/10 ~ 35 FHR: 12-13-13 (152 bpm)

Drip oxy 40 dpm

09.30

Abdominal pain (+)

UC: 2x/10 ~ 35 FHR: 12-12-12 (144 bpm)

Drip oxy 40 dpm

10.00

Abdominal pain (+)

UC: 2x/10 ~ 30 FHR: 12-13-12 (148 bpm)

Drip oxy 40 dpm

10.30

Abdominal pain (+)

UC: 2x/10 ~ 30 FHR: 12-11-13 (144 bpm)

Drip oxy 40 dpm

11.00

Abdominal pain (+)

UC: 2x/10 ~ 35 FHR: 12-12-12 (144 bpm)

Flash II Drip oxy 40 dpm

11.30

Abdominal pain (+)

UC: 2x/10 ~ 35 FHR: 11-12-11 (136 bpm)

Drip oxy 40 dpm

TIME 12.00

SUBJECTIVE Abdominal pain (+)

OBJECTIVE UC: 2x/10 ~ 35 FHR: 13-12-13 (152 bpm)

PLANNING Drip oxy 40 dpm

12.30

Abdominal pain (+)

UC: 2x/10 ~ 35 FHR: 12-12-12 (144 bpm) UC: 2x/10 ~ 35 FHR: 9-9-9 (108bpm) fetal distress

Drip oxy 40 dpm

13.00

Abdominal pain (+)

Stop drip DM co SPVPro resusitation intra uterin and CS. Advice: acc resusitation and Cs at 20.00 - CIE patient and family - Insert DC - inj, ampicillin 2g/ IV Resusitation began RL:D5: 2:1 O2 3 L/m

13.30

TIME 14.00

SUBJECTIVE Abdominal pain (+)

OBJECTIVE UC: 2x/10 ~ 25 FHR: 11-11-11(132 bpm) UC: 2x/10 ~ 25 FHR: 10-11-10 (124 bpm) UC: 2x/10 ~ 35 FHR: 10-11-10 (124 bpm)

PLANNING

14.30

Abdominal pain (+)

15.00

Abdominal pain (+)

16.00

Abdominal pain (+)

UC: 2x/10 ~ 35 FHR: 10-11-11(128 bpm) UC: 2x/10 ~ 35 FHR: 11-11-11(132 bpm) UC: 2x/10 ~ 35 FHR: 12-12-11 (140bpm) C-section began : Baby was born, male, BW 2700 gram, AS 6-8 Anus (+), congenital anomaly (-), Placenta was born manually, complete, bleeding + 200 cc.

16.30

Abdominal pain (+)

17.00

Abdominal pain (+)

22.30

TIME

SUBJECTIVE

OBJECTIVE

PLANNING

15/10 /2012 00.30

Patient confessed her leg cant moved and operation wound pain

GC : well BP : 110/70 mmHg PR : 88 bpm RR : 22 bpm T : 36,7C UO : 100 cc/hours UC : (+) well UFH : 1 fingers below the umbilicus Active bleeding : (-)

2 hours post CS

Observe mother well being. Suggest mother to take a rest, medication, eat & drink.

15/10 /2012
07.00

Operation wound pain

GC : well BP : 120/80 mmHg PR : 88 bpm RR : 22 bpm T : 36,5C UO : 80 cc/hours UC : (+) well UFH : 1 fingers below the umbilicus Lochea rubra : (+)
Baby in NICU : GC : well PR : 112 bpm RR : 32 bpm T : 36,7oC

1st day post CS

Observe mother & baby well being. Suggest mother to take a rest, medication, eat & drink.