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Morning ReportAugust, 25th 2014Supervisor:dr. Agus Thoriq, SpOG

DM VK Pagi:Santi, Faisol, AluhMorning ReportAugust 25th 2014Case ResumeNORMAL LABOR0PATHOLOGIES LABORG1P0A0L0 40-41 weeks/S/L/IU breech presentation + PROMG2P1A0L1 39-40 weeks/S/L/IU with PROM + susp. MacrosomiaCase 1Name: Ny. AAge: 20 years oldAddress: PrayaRM: 545211Admitted: August 25th 2014 at 04.30 am

G1P0A0L0 40-41 weeks /S/L/IU breech presentasion with PROMTIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING25/8/1405.30Patient referred from Praya PHC to NTB GH with G1P0A0L0 A/S/L/IU with breech presentation. Patient confessed water leaked out since 03.00 (25/8/2014). Abdominal pain since 23.00(24/08/2014), bloody slim (-), FM (+). No history of DM, HT, and asthma.

LMP : 16-11-2013EDD : 23-8-2014

History ANC : >4x at PHCLast ANC : BP : 110/70

History of USG : (+) at SpOGLast USG : 24/8/14S/L/IU breech presentation AFL enoughPlacenta at posterior of fundusfemale

History of family planning : (-)Next family planning : IUD

Obstetric History :This

General StatusGC : wellGCS : E4V5M6BP : 110/70 mmHgPR : 80 bpmRR : 20 bpmT : 37,2 C

Locally Status Eye : anemis (-/-), icteric (-/-)Pulmo : vesicular (+/+), rhonki (-/-), wheezing (-/-).Cor : S1S2 single regular M (-), G (-).Abdomen : striae gravidarum (+), linea nigra (+), scar (-).Extremities : edema (-/-), warm acral (+/+).

Obstetric StatusL1 : headL2 : back on the right sideL3 : breechL4 : 4/5UFH: 30 cmAC : 107 cmEFW : 3210 gramUC : 3x10~30FHB : 12 -11-12(140 bpm).VT : 3 cm, eff 25%, amnion (-),breech presentation, denominator sacrum , H1, impalpable small pat/ umbilical cordG1P0A0L0 40-41 /S/L/IU breech presentation + PROMObserve mother and fetal well being.Check LabInj Ampicillin 1 gr/ 6 h

4Time Subjective Objective Assessment Planning Chronologist :S/ Patient 9 month pregnancy confessed water leaked out since 03.00 (25/8/2014). Abdominal pain since 23.00(24/08/2014), bloody slim (-), FM (+). Result of usg was breech presentation.No history of DM, HT, and asthma.

O/ -

A/ G1P0A0L0 A/S/L/IU with breech presentation

P/ Referred to NTB GH

Pelvic Evaluation :Spina ischiadica not prominentOs coccigeous mobileArcus pubis > 900

Lab Evaluation :Hb : 11,9 gr/dlHCT : 35,7%RBC : 4,21 M/uLPLT : 277 K/uLWBC : 15,96K/uLHBsAg : (-)

TimeSubjectObjectAssessmentPlanning08.45

GC : wellBP : 110/70 PR : 82 bpmRR : 24 bpm T : 37, 1oCCo to SPV, adv: CS

Preop09.35CS began + IUDBaby was born (10.05 am), female, 3250 gram, 48 cm, A-S 7-9, anus (+), anomaly congenital (-).Placenta was born, complete.Bleeding 350 cc12.40Patient confessed abdominal wound painGC: wellGCS: E4V5M6BP: 110/70 mmHg PR: 80x/m RR: 20x/m T: 36,2 0CUC: (+)UFH: 2 fingers above umbUO: (+) 200 cc2 hours Post CSObservation mather and fetal well beingSuggest eat and drinkEarly breast feedingObservation of bleedingBaby in NICU:GC : wellHR : 128 bpmRR : 48 x/mntT : 36,0 C6TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING26/08/1407.00-GC : wellBP : 110/70 PR : 82 bpmRR : 24 bpm T : 36,5oCUC : (+) wellUFH : 2 fingers below umbilicusLochea rubra (+)

Baby in NICU:HR : 148RR : 40T : 36,2oC

1 day post partumObserved mother and baby well beingSuggest mother to mobilization, eat and drink, and medication.Breast feeding7Case 2Name: Mrs. YAge: 27 years oldAddress: Aiq Bukaq, LotengAdmitted: 25-08-2014 No. RM: 54-52-05G2P1A0L1 39-40 weeks/S/L/IU with history of ROM + susp. MacrosomiaTimeSubjectObjectAssessmentPlanning25-08-20141.50 amPatient come to NTB GH, referred from Praya GH with G2P1A0L1 39-40 weeks/S/L/IU head presentation with PROM < 12 hours.

Patient confessed water come out from her womb since 24-08-2014 (7.00 pm), bloody slim (-), abominal pain (-) and FM (+).

No history of DM, HT, asthma.

LMP : 20-11-2013EDD : 27-8-2014

History ANC : 10x at PHCLast ANC : 18-08-2014result: BP : 110/70, BW 70 kg, 40 weeks, UFH 35 cm, head presentation, FHB (+)General statusGC : wellGCS: CM (E4V5M6)BP : 100/70 mmHgHR: 96 x/mRR: 24 x/mT: 36,3 C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, M(-), G(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema (-/-), warm (+/+)

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 38 cmEFW : 4185 gram

UC : (-)FHB : 11-12-11 (140x/min)

G2P1A0L1 39-40 weeks/S/L/IU with PROM < 12 hours + susp. Macrosomia Obs. inpartuInj. Ampicillin 1gr/6 hours (PHC 8.20 pm ~ 24-08-14)

TimeSubjectObjectAssessmentPlanningHistory of USG : 1xLast USG (24-08-2014): S/L/IU head presentation, female, placenta at fundus, 39-40 weeks , EFW 4480 gr, EDD : 21/08/2014

History of family planning : injection 3 monthsNext family planning : IUD

History of obstetric :/9m/2800 gr/Polindes/midwife/7 yo/liveThis

Cronologist (PKM Teratak: 24/08/2014) 8.25 pmS: patient come with family confessed water come out since 6.30 pmVT: 2 cm, eff. (-), amnion(-), head palpable, denom unclear, H1, unpalpable small part/umbilical cord

Lab (25-08-2014):HGB = 11.2 g/dlRBC = 4.73 K/ulWBC = 11.65 M/ulHCT : 35,7 %PLT = 52 M/ulHBsAg = (-)BT = 130CT = 800TimeSubjectObjectAssessmentPlanningO : GC : wellBP : 140/100HR : 82T: 36,5RR : 20

Abd: UFH 40, FHB (+)Obs: VT 4 cm, eff 40%, amnion (-), head presentation, H1, unpalp small part & umb

A: G2P1A0L1 39-40 weeks/S/L/IU head presentation with PROM < 12 hours

P:IVFD RL 20/dpmInj. Ampicillin 1 gr/IVReffered to NTB GHTimeSubjectObjectAssessmentPlanning6.30 am

Patient confessed abdominal painGC: wellBP: 110/70 mmHg HR: 80 bpm T 36,50C RR 20 x/mUC: 1x/10 ~ 15FHB: 11-12-12 (140x/m)VT: 3 cm, eff. 25%, amnion(-) clear, head palpable, denom unclear, H1, unpalpable small part/umbilical cordObservation of mother & fetal well being

Co to SPV (8.50 am), adv: CS

Preop10.50 amCS beganBaby was born (11.05 am), female, 4800 gram, 53 cm, A-S 7-9, anus (+), anomaly congenital (-).Placenta was born, complete.Bleeding 500 cc11.30 amPatient confessed headache GC: weakGCS: E4V5M6BP: 80/70 mmHg PR: 100x/m RR: 24x/m T: 36,2 0CUC: (+)UFH: 2 fingers above umbUO: (+) 200 ccPost CSLoading RL 1 fl (30 minute)12TimeSubjectObjectAssessmentPlanning11.45 amPatient confessed headache + nauseaGC: weakGCS: E4V5M6BP: 70/40 mmHg PR: 68x/m RR: 28x/m T: 36 0CConj. Anemic (+)UC: (-)Active bleeding (+) 500 ccUFH: 2 fingers above umbUO: (+) 200 ccP2A0L2 post CS + HPP ec Atonia UteriCo to SpAn, adv inj. Ephedrine 3 cc, obs. In 10 minuteDouble line, loading RL 2 flLeb examinationMassase uterus (cont. -), IBC 5 minute, active bleeding (-)

12.00 pmGC: weakBP: 90/60 mmHg HR: 80 bpm T 350C RR 25 x/mUC: (-)Oxy drip 2 flInj. MeterginMisoprostol 4 tab IR

12.15 pmGC: weakBP: 70/p mmHg HR: 80 bpm T 350C RR 27 x/mUC: (-)Inj. Tranexamate acid + vit. KCondom catheterCo to SPV, adv: IBC continue, planning hysterectomy12.20 pmBP: 70/p mmHg HR: 80 bpm T 350C RR 28 x/mUC: (-)Loading widahes 1 flTimeSubjectObjectAssessmentPlanning12.30 pmGC: weakBP: 110/70 mmHg PR: 102x/m RR: 28x/m T: 36 0CUFH: umbilicalUC: (+) wellActive bleeding (-)12.45 pmGC: weakBP: 140/70 mmHg PR: 112x/m RR: 28x/m T: 36 0CActive bleeding (-)

Lab (25-08-2014):HGB = 6 g/dlRBC = 2,50 K/ulWBC = 14.68 M/ulHCT : 19,3 %PLT = 186 M/ulTransfusi WB 3 colf1.00 pmGC: weakBP: 120/70 mmHg PR: 80x/m RR: 24x/m T: 36 0CSpv pro hysterectomy1.20 pmHysterectomt beganTimeSubjectObjectAssessmentPlanning2.00BP: 110/70 mmHg PR: 80x/mRR: 20x/m T: 37 0CActive bleeding: (-)UO: +Post op hysterecomyObservation at ICU26-08-2014 6.30 amAbdominal painGC: well cons:E4V5M6BP: 120/70 mmHg PR: 94x/m RR: 20x/m T: 36,7 0CActive bleeding: (-)UO: (+) 300 cc/4 hours

Baby in NICU:Pulse : 144 bpmRR : 68x/mT : 36,7 C1 day post SC + hysterectomyObserved mother and baby well beingSuggest mother to mobilizationSuggest mother to eat and drink15.. Thank You ..