Morning ReportAugust, 31st 2014

Supervisor:dr. Edi Prasetyo Wibowo, Sp.OG

DM Jaga:Santi, Faisol, Aluh

Morning ReportAugust 31st 2014

Case Resume

NORMAL LABOR

0

PATHOLOGIES LABOR

1. G3P1A1L0 39-40 weeks/S/L/IU head presentation with arrested active phase + history of ROM

Case 1

Name : Mrs. SAge : 27 years oldAddress : KLUAdmitted : 31-08-2014 No. RM : 54-56-59

G3P1A1L0 39-40 weeks/S/L/IU head presentation with arrested active

phase + history of ROM

Time Subject Object Assessment Planning

31-08-201405.10

Patient come to NTB GH, referred from KLU GH with G3P1A1L0 39-40 weeks/S/L/IU head presentation with prolonged active phase

Patient confessed water come out from her womb since 29-08-2014 (23.00) clear, bloody slim (+), abominal pain (+) since 30-08-2014 (21.30) and FM (+)

No history of DM, HT, asthma.

LMP : 28-11-2013EDD : 5-9-2014

History ANC : 9x at PHCLast ANC : 18-08-2014result: BP : 110/70

History of USG (-)

General statusGC : wellGCS: CM (E4V5M6)BP : 100/60 mmHgHR: 72 x/mRR: 18 x/mT: 36 °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: 33 cmEFW : 3410 gram

UC : 2x/10’ ~ 25”FHB : 12-12-11 (140x/min)

G3P1A1L0 39-40 weeks/S/L/IU

head presentation with arrested

active phase + history of ROM

•Obs. Mother and fetal well being• Inj. Ceftriaxon 1 gr/IV•DM co to GP advice : rehydration, CTG (acceleration if reactive)

Time Subject Object Assessment

Planning

History of family planning : -Next family planning : injection

History of obstetric :I. ♂/normal/Mataram GH/3300

gr/IUFD/4yII.Ab 3 weeksIII.This

Cronologist (KLU GH: 30/08/2014)

13.45S: patient come from Pemenang

PHC with PROM > 12 hours, and water came out from her womb since 20.00. 3rd pregnancy 9 months, USG (-), and FM (+).

O: GC well; BP 110/70; HR 84; RR 18; T 36,7

BH 147 cm; BW 69 kg, AC 25; oedem extremity (-)

UFH 30 cm; EFW 2945 gr; back on right; UC (-); FHB 12-11-12 (140x/m)

VT: Ø 1 cm, eff. 25%, amnion(-, head palpable, denom unclear, ↓H1, unpalpable small part/umbilical cord

P: co to spv adv induction oxy start at 4 dpm, observation/30 minutes

VT: Ø 6 cm, eff. 70%, amnion(-) clear, head palpable, caput (+), molase (3), denom unclear, ↓H2, unpalpable small part/umbilical cord

Lab (18-08-2014):HGB = 13 g/dlRBC = 4.95 K/ulWBC = 26.90 M/ulHCT : 35,2 %PLT = 275 M/ulBT = 2’00”CT = 5’45”HBsAg = (-)

Time Subject Object Assessment

Planning

15.00UC (-) FHB 144Drip oxy 4 dpm

15.30UC (-) FHB 144Drip oxy 8 dpm

16.00UC (-) FHB 140Drip oxy 12 dpm

16.30UC 1x/10’ ~ 15” FHB 148Drip oxy 16 dpm

17.00UC 2x/10’ ~ 15” FHB 148Drip oxy 20 dpm

17.30UC 2x/10’ ~ 15” FHB 144VT: Ø 3 cm, eff. 25%, amnion(-), head palpable,

denom unclear, ↓H1, unpalpable small part/umbilical cord

Drip oxy 24 dpm

18.00UC 2x/10’ ~ 15” FHB 13-14-12 (156x/m)Drip oxy stop, oxygen 4 lpm, obs FHB

Time Subject Object Assessment

Planning

18.30UC 2x/10’ ~ 15” FHB 13-13-14 (160x/m)

19.00UC 2x/10’ ~ 15” FHB 12-12-12 (144x/m)

19.30UC 2x/10’ ~ 15” FHB 12-12-12 (144x/m)Obs. Progres of labor

21.30VT: Ø 6 cm, eff. 50%, superior portio oedem, amnion

(-), head palpable, ↓H2, unpalpable small part/umbilical cord

Inj. Ampicillin 1 gr/IV

01.30VT: Ø 6 cm, eff. 50%, superior portio oedem, amnion

(-), head palpable, ↓H2, unpalpable small part/umbilical cord

02.00Co to GP, GP to to SPV adv: referred to NTB GH,

rehydration

Time Subject Object Assessment

Planning

07.15 - •Do CTG•Co CTG result to GP, adv: acceleration

08.30 - UC: 2x/10’ ~ 25”FHB: 12-11-11

Drip oxy start at 8 dpm

09.00 - GC : wellGCS: CM (E4V5M6)BP : 110/60 mmHgHR: 72 x/mRR: 18 x/mT: 36,7 °CUC: 2x/10’ ~ 25”FHB: 12-11-11

Drip oxy start at 8 dpmGP adv: evaluation at 11.00

09.30 - UC: 3x/10’ ~ 25”FHB: 12-12-11

Drip oxy 12 dpm

10.00 - UC: 3x/10’ ~ 30”FHB: 12-12-12

Drip oxy 16 dpm

10.30 - UC: 3x/10’ ~ 35”FHB: 12-12-13

Drip oxy 20 dpm

11.00 - UC: 3x/10’ ~ 35”FHB: 12-12-12VT: Ø 8 cm, eff. 77%, amnion(-) clear, head palpable, caput (+), molase (1), denom unclear, ↓H2, unpalpable small part/umbilical cord

Prolonged active phase

Drip oxy 24 dpmCo to GP, adv: CTG

Co CTG result, adv: resusitation

Time Subject Object Assessment

Planning

11.30 - UC: 3x/10’ ~ 40”FHB: 12-12-11

Drip oxy 28 dpm

12.00 - UC: 4x/10’ ~ 40”FHB: 12-11-11

Drip oxy 28 dpm

12.25 Mother wants to bearing down

GC : wellGCS: CM (E4V5M6)BP : 110/70 mmHgHR: 72 x/mRR: 18 x/mT: 36,5 °CUC: 4x/10’ ~ 40”FHB: 12-12-11Inspection: opening vulva (+), bulging of perineum (+), pressure of anus (+)

Drip oxy 28 dpmConduct the labor

12.30 Baby was born, male, 3500 gram, 52 cm, A-S 6-8, anus (+), anomaly congenital (-).Placenta was born spontaneous, complete.Bleeding ± 200 ccPerineum intact

Time Subject Object Assessment Planning

14.30 Abdominal pain •GC: well •GCS: E4V5M6•BP: 110/70 mmHg •PR: 80x/m• RR: 20x/m •T: 36,6 0C•UC: (+) well•UFH: 2 fingers below umbilicus•Active bleeding: (-)•UO: +•Lokea rubra (+)

2 hours post partum

•Observation mother and baby well being•Suggest mother to eat and drink•Suggest mother to mobilization•Suggest mother to early breast feeding

1-09-2014 7.00 am

Abdominal pain •GC: well cons:E4V5M6•BP: 110/70 mmHg •PR: 80x/m• RR: 20x/m •T: 36,8 0C•UC: (+) well•UFH: 2 fingers below umbilicus•Active bleeding: (-)•UO: +•Lokea rubra (+)

Baby rooming in:Pulse : 144 bpmRR : 68x/mT : 36,7 C

1 day post partum •Observed mother and baby well being•Suggest mother to mobilization•Suggest mother to eat and drink

.. Thank You ..