MORNING REPORT

April, 13th 2016

Supervisor: dr. Juliawan, Sp.OG

DM: Ros, Elmy, Ana, Ranova, Vian
Cases resume :
Normal Labor -
Pathologic Labor 1. G1P0A0H0 S/L/IU Head presentation with prolonged
active phase of labor + PEB
 Case 1
Name : Mrs. P
Age : 23 yo
Address : Tanjung
Admitted : 2nd April 2016
 TIME
TIME SUBJECTIVE
SUBJECTIVE OBJECTIVE
OBJECTIVE ASSESTMENT
ASSESSMENT PLANNING
PLANNING
06/04/
2/04/2016Patient
Patient refferedreferred
from RSUDfrom General
Generalstatus:
status 1. G2P0A1L0
G1P0A0L0 35-36
40- DM
DMplaning:
planning:
2016
14.15 witaSigeronganpp
KLU with G1P0A0L0 PHC41-42 with GC:
GC well
: well weeks S/L/IU with
41 weeks Diagnostic
Diagnostic : :
11.00 G2P0A1L0 35-36
weeks S/L/IU head weeks S/L/IU GCS: E4V5M6 CM
consciousness: PROM > 12
S/L/IU hours
head Inspekulo
DL, HbsAg
head presentation,
presentation. mother
Abdomen painand
(+), BP:
BP 120/80
: 140/70mmHg
mmHg presentation Lakmus
CTG test
fetalwater
in good condition
leaked out fromwith
herPROM
womb HR:
PR 90: 116bpmbpm with prolonged CBC,
UL HbSAg
> 12 hours.09:00
(+) since Patient confessed
and midwife talk RR:
RR:20 28x/min
bpm active phase of Therapy:
water leaked
that fromofher
dilatation womb
cervix 8cm.since T:T:36,3 0
C
38,3C labor + PEB Therapy
Obs mother: & fetal well
04/04/2016
History ofatbloody
04.30 slim
a.m.(-),
There is being
Pro (temperature
termination with
no active bleeding from her womb. Eye
Local : anemis
status (-/-), icteric (-/-) every
SC 6 hours)
Abdominal
History ofpain
DM (-), HT bloody
in slime Thorax
Eye : an : (+/+), ict (-/-) Ampicilin
Monitoring1 gr/6
: VShrs
(-), FM (+).
pregnancy (-), asthma (-) and Cor
Pulmo :S1S2
: single
ves (+/+), reguler
rh (-/-), wh , Dexamethason
mother, UC, FHB, inj 2 x
allergy (-). murmur(
(-/-) -), gallop 6observation
mg IM progress
No history
Hidtoryof DM, HT,
family: andHT(-),
DM(-), asthma (-)
Cor : S1S2 single regular, m Pro USG
of labor
History of family:
Asthma (-). DM (-), HT (-), Pulmo
(-), g (-): vesikuler (+/+), wheezing CIE : CIE mother and
asthma (-) (-/-),
AbdRonkhi
: striae (-/-).
gravidarum (+), DM co GP;
family GP co SPV ,
about
LMP : 30/07/2015 Abdomen :
scar (-), linea nigra scar (+)(-), striae SPV advice:
diagnostic planning
LMP: EDD31/07/2015
: 06/04/2016 gravidarum(+),
Ext : edema oflinea nigra (+)
lower Dexamethason
and therapeutic inj 2
EDD: GW 07/05/2016
: 40-41 weeks Extremity
extremity(+/+), : edema (-/-), (+/
warm acral warm amp/12
planninghrs
GW: 35-36 weeks acral
+). (+/+) Ampicilin
PCT 500mg inj 1p.r.n
gram/6
History of ANC : 7x at PHC hours
MgSO4 (40%) drip
History
Lastofresult:
ANC:(31/03/2017)
7x at Posyandu Obstetrical status:
Obstetric status Pro
withUSG (tomorrow
NaCl 500cc
LastBPresult
110/70 mmHg, (05/04/2016):
UFH 32 cm, BP: L1:
L1 breech
: breech morning)
110/70
headmmHg, BW: 49FHB
presentation, kg, GW
(+) 36 L2:
L2 back
: backononright
the side
right side DM co to GP, GP co to
weeks, UFH 24 cm, head L3: head
L3 : head presentation SPV, advice :
presentation,
History of FHB
USG (+) : 1x, at Sp.OG L4:
L4 5/5
: 4/5 pro C-section
Last : 4/02/2017 UFH:
UFH:22 33cm
cm
History
S/L/IUof head
USG:presentation,
1x at OBGYN GW EFW:
EFW 1,70550
: 1562 g gram
(05/04/2016)
30 Minggu, EFW 1562 gram, UC:
UC -FHB:
:- 12-12-12 (144 bpm)
Result:
placenta Fetal
at CorpusS/L/IU, head
anterior/II VT: -
FHB : 14-13-14
presentation, BPD/AC/FL: 30-32 VT : 9 cm, eff 75%, amnion
weeks, EFW:
History 1630planning:
of family g, AFI :(-)0,4, (+), head presentation, not
clear, placenta at fundus grade III, palpable small part &
EDD: 22/06/2016 umbilical cord

History of family planning: -

Next family planning: -
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetric History: Laboratory (01/04/2016):

I. This HB: 8,6 g/dl
RBC: 3,73 (10^6/uL)
HCT: 27,2%
WBC: 22,89 (10^3/uL)
PLT: 281 (10^3/uL)
HbsAg: non reactive
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.15 Abdominal Pain UC : 3x10~20 Drip MgSO4

FHB : 14-13-14

14.45 Abdominal Pain UC : x10~20 First serial of DM planning:

FHB : 13-12-12 oxytocyn drip Rest for 24 hours
finished IVFD RL 20 dpm
continue drip oxytocin
after 24 hour patient
rest
Observe mother &
fetal well being.

DM co to GP, GP co
to SPV (morning
shift), SPV advice:
CSection at 10.00 pm

15.30 C-section started

Baby was born (23.33
pm), male, A-S 7-9, BW
3850 grams, BL 52 cm.
Anus (+), congenital
anomaly

Placenta was born

complete
Bleeding : 400 cc