MORNING REPORT

16th October 2011

Supervisor: dr.Made Putra Juliawan SpOG
Medical Students: Hones, Atun, Septian, Fida, Devi, Husnul

CASE RESUME NORMAL LABOUR PATHOLOGIES LABOUR 4

Mrs. N Age: 25 yo Address: Bayan TIME 20.00 SUBJECTIVE Patient referred from Bayan PHC, with A/S/L, prolonged 1st stage active phase with ibu cacat. History of bloody slim (+) since 02.00 WITA. History rupture of membrane at 05.00 WITA. Abdominal pain since 14.00 WITA. FM (+), frequent. LMP: forgot EDD: History of family planning: Next famiy planning:IUD Hisotry of ANC: 1x, midwife Last ANC: 13th Oct 2011 Obstetric status: 1. This Chronologist: 10.00 Patient came to Bayan PHC with abdominal pain since 02.00 WITA. GC: well BP: 100/70 mmHg PR: 80Xminute RR: 22x/minute T: 36,5C OBJECTIVE General status : General condition: moderate BP: 120/80 mmHg RR: 40x/mnt Pulse :120x/mnt T: 38,3 C Eyes : an (-/-) ikt (-/-) Extremity: in normal range Cor & pulmo in normal range. Obstetric status : L1 : breech UFH : 31cm L2 : back on the left L3 : head L4 : 3/5 UC : 3x10-35 FHR : 14-14-14 EFW : 3100 gr VT: 8 cm, eff 80%, amnion (-) dry, head palpable, H1, caput (+) HII, unpalpable small part or umbilical cord. Lab: Hb; 10,6 RBC: 4,70 Hct: 33,2 WBC: 26.330 Plt: 269000

Admitted to GH of NTB 10th october 2011, 20.00 WITA ASSESTMENT G1P0AO S/L/IU, head presentation with neglected 1st stage active phase+ fetal distress+ CPD e.c panggul picak PLANNING monitoring mother and fetal well being Check CBC, HBsAg, urine Rehidration with RL and D5% (2:1) Coass consult to SPV: pro SC Advice: acc SC Prepare for SC: DC Injection cefotaxim 2gr/IV CIE patient and family

TIME

SUBJECTIVE VT: 4 cm, eff 40%, amn (-), H II, unpalpable small part of fetal / umbilical cord 14.00 GC: well BP: 100/70 mmHg PR: 80/minute RR: 24x/minute T: 36,5C VT: 7 cm, eff 70%, amn (-), H II, unpalpable small part of fetal / umbilical cord 16.00 GC: well BP: 100/70 mmHg PR: 80/minute RR: 24x/minute T: 36,5C VT: 8 cm, eff 70%, amn (-), H II, unpalpable small part of fetal / umbilical cord FHB: 140x/minute A: with A/S/L, prolonged 1st stage active phase with ibu cacat P: RL 20 dpm, ampicillin 1 gr/IV

OBJECTIVE

ASSESTMENT

PLANNING

time 22.10

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING SC began Baby was born female, weight 2750 g, AS 3-5, BL: ?? cm anus (+), amnion was meconeal Placenta was born manually, complete, 750 gr Bleeding : 300cc Insertion of IUD successful

01.00 17th oct 2011

Operation wound pain (+)

BP : mmHg PR : x/minute RR : x/minute T:C TFU ; in umbilicus UC : is good Vaginal bleeding : Urine output: 50cc/kgBB/hour BP : mmHg PR : minute RR : minute T : 36,5C TFU ; in umbilicus UC : is good Vaginal bleeding : Urine output: 50cc/kgBB/hour

2 hours Post SC

Continue Observation general condition, vital sign, bleeding

07.00

Operation wound pain (+)

Continue Observation general condition, vital sign, bleeding