Morning Report August 24th 2014

Morning ReportAugust 25th 2014Santi, Faisol, AluhName: Ny. AAge: 20 years oldAddress: PrayaRM: 545211Admitted: August 25th 2014 at 04.30 am

G1P0A0L0 40-41 weeks /S/L/IU breech presentasion with PROM

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING25/8/1405.30Patient 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 breechpresentation AFL enoughPlacenta at posterior of fundusfemaleHistory 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 hPro SC

3Time 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

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 : (-)

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING08.45GC : wellBP : 110/70 PR : 82 bpmRR : 24 bpm T : 37, 1oCUC : (+) wellUFH : 2 fingers below umbilicusLochea rubra (+)

SPV advice SC cito

09.35SC beganInsersi IUD10.05Baby was born.female, 3250 gram, BL : 48 cm A-S 7-9,HC : 34 cm, anus (+)

11.30Baby in NICUGC : wellHR : 128 bpmRR : 48 x/mntT : 36,0 C

2 hours post SCObs. 26/8/2014

Post SC day 2TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING21.30 Placenta was born, spontan, complete, 500 gr. Bleeding 150 ccHecting episiotomiObservation 2 hours post partum21.40GC : wellBP : 110/70 PR : 82 bpmRR : 24 bpm T : 37, 1oCUC : (+) wellUFH : 2 fingers below umbilicusLochea rubra (+)

2 hours post partumObservation mather and fetal well beingSuggest eat and drinkEarly breast feedingObservation of bleeding11/07/1407.00-GC : wellBP : 110/70 PR : 82 bpmRR : 24 bpm T : 36,5oCUC : (+) wellUFH : 2 fingers below umbilicusLochea rubra (+)

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

1 day post partumObserved mother and baby well beingSuggest mother to mobilization, eat and drink, and medication.Breast feeding6THANK YOU