Morning Report October 07th 2009

Supervisor : dr. Edy P.W., SpOG

Medica Stude!t: "iti!, #a ida, $dha%, #o is

Cases resume :
G1P0A0 with prolonged 2nd stage G1P0A0 with susp.big baby Normal labor

1 1 4

&.

Name Age Address

#a$tu

: Mrs. Zohrah : 22 years : johar pelita - sesela %ub&e't Patient came to emergency care unit of NTB province hospital (12.20) with G1P0 0 !"!# laten phase 1st la$our % watery vaginal &ischarge % fe$ris cronologis ' Patient felt a$&ominal pain ( since 0() 10)200*) an& watery vaginal &ischarge at 0+.00 am (0+)10)200*), then she went to gunung sari P-. at 11.00 am (0+)10)200*). )loo&y show ()) , the fetal movement was active. -istory of fe$ris ()). -istory of malaria ), history of thipoi& ). The e/amination gunung sari P-. General status ' well BP ' 120!+0 mm-g Pulse 011 /!mnt 22' 20 /!mnt Temp 0 31,45. 67- 0 not mention it 7-B 0 1+1 /!mnt 11.00 89T :T ' ; 3 cm, eff 2( <, amnionic mem$rane ()), hea& palpa$le, &escen& -9, unpalpa$le small organ an& um$ilical cor&. Terapi in P-.' 9n=e>si ampi 1 gr in P-. Paracetamol 1 ta$ in P-. 12.00 patient referre& to mataram G-

CTH

: 0 ! 10 ! 200" :

(b&e't

&'.0 0

9n emergency room ' General status ' ?General con&ition' well, ?.onciousness' @A:(B4 ?BP' 130!10 mmm-g ?22' 20 /!mnt ?Pulse '*2 /!mnt ?T' 3+,45 . @yes ' an()) i>t ()) .or )Pulmo ' in normal range C$stetric status ' #1 ' $reech T76D 31 cm #2 ' left $ac> #3 ' hea& #A ' A!( @78 ' 3100 g 6. ' 3/!10 E3(F 7-B ' 1+3 /!mnt :T ' ; 3 cm, eff 2( <, amnionic mem$rane (),) &ry, hea& palpa$le, &escen& -9, unpalpa$le small organ an& um$ilical cor&. Pelvic evaluationD Promontorium not prominent "pina iscia&ica not prominent rcus pu$is G *0 Cs co/igeus mo$ile

Assesment G1P0 0 term!single! life % laten phase of 1st stage la$or % watery vaginal &ischarge % fe$ris % fetal tachicar&y

Planning C$servation mother an& fetal well $eing. #a$oratory e/amination ' H#, -Bs g 2esusitation intra uterine .TG post resusitation Base line 1(4

Time

%ub&e't

(b&e't

Assesment

Planning

-istory of family planning ' ()) 7amilly planning 0 in=ection 3 month N. 2outine at posyan&u G A / C$stetrical history ' 1.This $&ominal pain GGG

#a$. result' -B 0 10 gr< 8B 0 23.+00 P#T 0 2A*.000 -.T 0 32,( -Bs g ())

&7.0 0

P2D 11 /!mnt T' 34.* c 6. ' (%) 3/!1053(F 7-B ' 1AA/!mnt #A ' 3!(

G1P0 0 term!single! life % active phase of 1st stage la$or % watery vaginal &ischarge

:T ' ; * cm, eff *0 <, amnionic mem$rane (),) &ry, hea& palpa$le, &escen& -99,&enominator fontanella minor left anterior. unpalpa$le small organ an& um$ilical cor&

)C$servation mother an& fetal well $eing )@valuation 1 hours again )#eft laterl position )@&ucate& mother to &rin>ing an& eating.

$&ominal pain %%% Bother want to $earing &own

&(.0 0

6. ' (%) 3)A /!105A0F 7-B ' 1AA/!mnt #A ' 3!(

G1P0 0 term!single! life % 2n& stage of la$or

"Iuating position

:T ' ; complete, amnionic mem$rane (),) &ry, hea& palpa$le, &escen& -99,&enominator fontanella minor left anterior. unpalpa$le small organ an& um$ilical cor&.

Time

%ub&e't

(b&e't

Assesment G1P0 0 term!single! life % prolonge& 2n& stage of la$or

Planning 2eport to supervisor Propose vacum e/traction Propose& agree&

20.0 0

$&ominal pain %%%

6. ' (%) A /!105A0F 7-B ' 1(A/!mnt #A ' 2!(

:T ' ; complete, amnionic mem$rane (),) &ry, hea& palpa$le, &escen& -999,&enominator fontanella minor left anterior. unpalpa$le small organ an& um$ilical cor&.

2 n& stage of la$or

20.' 0

Ba$y was $orn with vacum e/traction male, 3300 gram, K" ' 4)1 mniotic flui& green thin Nuchal cor& J $a$y sent to N9.6 Placenta compleete was $orn

3 r& stage of la$or

ctive $lee&ing J
22.' 0

BP 0 120!+0 22' 20 /!mnt Pulse 1A /!mnt 67- 0 1 fingers $elow the um$ilical 6. 0 goo&

9: stage of la$or

C$servation :" an& su$=ective complain

Time

%ub&e't

(b&e't

Assesment

Planning C$servation :" an& su$=ective complain

07.0 0 a%

"u$=ective complain J ctive $lee&ing )

BP 0 110!+0 22' 22 /!mnt Pulse 1A /!mnt 67- 0 2 fingers $elow the um$ilical 6. 0 goo& 8oun& episiotomy' &ry $a$y' -2 ' 120 22' 34/!mnt T' 34.+ c

1st &ay of vacum e/traction

NAME/AGE : Mrs. NA/22 Years old ADDRESS : a!esa"!a"

Admitted: 07/oct/09 at 13.00

%
07/10/ 09 13.00 patient came to @2, she confesse& pregnant * months an& felt a$&ominal pain rarely since 0+.00 B (+!10!0*)an& $loo&y show #$%, watery vaginal &ischarge ()), fetal movement (%). -istory of HB an& -T ()) #BP ' 21)12)01 @HH ' 0()10)0* C$stetric status ' 1.This

(
Ge"eral stat&s : ?General con&ition' goo&, ?.onciousness' .B ?BP' 110!+0mm-g ?22' 22/!mnt ?Pulse '1A /!mnt ?T' 34,+5 . @yes ' an()) i>t ()) .or )Pulmo ' in normal range $&omen ' in normal range 'bstetric stat&s ' #1 ' $reech, 67- ' A0cm, @78 'AA*(g #2 ' left $ac> #3 ' hea& #A ' was in pelvic inlet A!( 6. ' (%)2/!1052(5L 7etal -eart 2ate ' 1AA/!mnt :T'; 3cm, eff 2( <, B (%), hea& palpa$le, &enom transverse sagitalis suture , &escen& -9, unpalpa$le small organ an& um$ilical cor&. 5

A
G1P0 0 A0)A1 wee>s!"!#!96 hea& presentation % latent phase of 1st stage of la$or % susp. $ig $a$y

P
1. 2. 3. o$s. Bother an& fetal well $eing #a$ e/amination' H#, -$s g C$s progress of la$or

-istory of family planing ' ) Plan of family planing ' 96H

(
Pelvic evaluation' Promontorium not prominent "pina ischia&ica not prominent rcus pu$is G *0 Cs co/igeus mo$ile (aborator) res&lt: -Bs g ()) -B 0 1,+ gr< 8B 0 +000 P#T 0 332.000 -.T 0 30,1

1+.00

$&ominal pain GG

6. ' 3/!1053(F 7-B' 1(A/!mnt #A ' A!( :T'; (cm, eff (0 <, B (%), hea& palpa$le, &enom transverse sagitalis suture, &escen& -9, unpalpa$le small organ an& um$ilical cor&.

G1P0 0 A0)A1 wee>s!"!#!96 hea& presentation % active phase of 1st stage of la$or % susp. $ig $a$y

1. @valuation A hours later 2. o$s. Bother an& fetal well $eing 3. #eft lateral position A. @&ucate& mother to &rin>ing an& eating

1*.30

8atery vaginal &ischarge %, flui& of amnion clear $&ominal pain %%

6. ' A/!105A(F 7-B' 1A2/!mnt :T'; +cm, eff +( <, B ()) clear, hea& palpa$le, &enom transverse sagitalis suture, &escen& -9, unpalpa$le small organ an& um$ilical cor&.

G1P0 0 A0)A1 wee>s!"!#!96 hea& presentation % active phase of 1st stage of la$or % watery vaginal &ischarge % susp. $ig $a$y

1. @valuation 3 hours later 2. o$s. Bother an& fetal well $eing

%
22.30

(
6. ' 3)A/!105A0F 7-B' 1A0/!mnt :T'; +cm, eff +( <, B ()) clear, hea& palpa$le, &enom transverse sagitalis suture, &escen& -9, unpalpa$le small organ an& um$ilical cor&.

A
G1P0 0 A0)A1 wee>s!"!#!96 hea& presentation % secon&ary arreste& active phase of 1st stage of la$or e.c susp .PH

P
1. o$s. Bother an& fetal well $eing 2. 9n=ection ampicilin 1 gr iv .onsult to supervisor, a&vice ' o$servation. "upervisor want to call $ac>

23.00

"upervisor5s a&vice ' prepare to "., in=ection ampicilin 1 gr, H.

23.30

G1P0 0 A0)A1 wee>s!"!#!96 hea& presentation % secon&ary arreste& active phase of 1st stage of la$or e.c susp .PH

". $egun

S 23.A(

'

A 1. Ba$y was $orn male, weight A100g, length (3 cm, " ()+. anus (%), nuchal cor& ), $a$y a&mite& to N9.6 2. Placenta was $orn complete,weight (00 g, length (0 cm 3. -emorrage ' 200cc A. 96H insertion

01!10! 0* 01.00

General status ' well BP ' 120!40 mm-g P2 ' 10 /!mnt 22 ' 20 /!mnt 6. ' goo& 67- ' 2 cm $elow um$ilical

2 hours post ".

C$s. Bother an& $a$y well $eing

0(.30

General status ' well BP ' 110!+0 mm-g P2 ' 1A /!mnt 22 ' 11 /!mnt 6. ' goo& 67- ' 2 cm $elow um$ilical Ba$y' -2 ' 120 /!mnt 22' 34/!mnt T' 34.( c

1st &ay post ".

C$servation mother an& $a$y