Morning Report

CASES RESUMENORMAL LABORPATHOLOGY LABORG2P1A0L1 A/S/L/IU head presentation with neglected 2nd stage of labour

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING25/12/201215.30Patient referred from Gangga PHC with G2P1A0L1 A/S/L/IU head presentation with prolonged 2nd stage of labour. Patient confessed abdominal pain (+) since 03.00 24/12/2012. Bloody slim (+). History rupture of membrane (+) since 10.20 25/12/2012, Fetal Movement (+). Dizziness (-)No history of DM, HT, asthma.

LMP: April 2012 (firs week)EDD: -

History of ANC: 7x at posyanduLast ANC: 13/12/2012Result : Normal

History of USG: 1x in SpOG (6/11/2012)

History of family planning: Injection 3 monthNext family planning: Injection 3 month

Obstetrical history :Aterm, Spontan, Polindes, Midwife, 3900 gr, Female, Life, 8 YOThisGeneral status :GC: WellCons : ComposmentisBP: 100/70 mmHgPR: 88 bpmRR: 22 bpm T: 37,1, C

Local Status :Eye : Anemic (-/-), icteric (-/-)Thorax :Cor : S1S2 single reguler, murmur (-), Gallop (-)Pulmo : vesikuler (+/+), wheezing (-/-),Ronkhi (-/-).Abdomen : scar (-), striae gravid (+), linea nigra (+)Extremity : edema (-/-), warm acral (+/+)

Obstetrical status:L1: breech UFH: 29 cm L2: back on the right side EFW: 2635 gL3: headL4: 2/5UC: (3x10~45)FHB: 12-12-13 (148 x/min)

VT: Complete, Amnion (-), meconeal, H III, caput (+), denom LOA, impalpable small part of fetus or umbilical cordG2P1A0L1 A/S/L/IU head presentation with neglected 2nd stage of labourObs mother & fetal well beingCheck CBC HBsAG. Rehidration with RL:D5% 2:1Give ceftriaxon 1 gr/IVDM suggest to GP to VE, GP co to SPV, SPV advice: VE

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGLab:HB: 12,0 g/dl RBC: 4,23 x106/l HCT: 36,2 %WBC: 23,79 x103/lPLT: 290 x103/lHbSAg: (-)

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGChronologist at Genggelang Polindes:07.15(25/12/2012)S : Patient came Genggeleng Polindes confessed abdominal pain that spread to waist since 03.00 25/12/2012

O : VT : 6 cm, amnion (+), portio thick and stiff, head palpable HI +, UC : 3x10P : Suggest mother to eat and drink Suggest mother to walk, if no abdominal pain

10.20S : Mother confessed want to bearing downO : VT : 10 cm, portio not palpable, amnion (-), unclear, head palpable HIII,

UC : 5x10 ~ 40P : Suggest mother to bearing down

11.20O : FHB : 138x/minutes, head palpable H III, UC : 5x10~40P : CIE patient and family to referred in Gangga PHC Mother not cooperative with Health Care Provider

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING12.00 (25/12/2012)S : Mother still bearing downO : VT : 10 cm, head palpable HIII, caput (+)FHB : 140x/minutesP : Give motivation to patient to referred to Gangga PHC IVFD

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGChronologist at Gangga PHC:12.50 (25/12/2012)S : Patient referred from Genggeleng Polindes confessed abdominal pain that spread to waist since 03.00 25/12/2012

O : General Status : Mother and fetal wellConsciousness : ComposmentisBP : 110/80 mmHgPR : 88 bpmRR : 20 tpmT : 36,6 C

UFH : 35 cmEFW : 3720 grUC : 4x10~40FHB : 11-12-11 (136 bpm)L1 : BreechL2 : Back on the right sideL3 : HeadL4 : 2/5VT : 10 cm, eff 100%, amnion (-), head palpable HIII , caput (+), denom LOA, impalpable small part of fetus/ umbilical cord.

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGA : G2P1A0L1 A/S/L/IU head presentation, with neglected 2nd stage of labour P : IVFD RL 2 flash 28 dpm (13.30)Co to GP adv : suggest mother to eat and drink, suggest mother to bearing down, if in 30 minutes no progress, referred to NTB GH

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING17.10VE start, with 1 traction, baby was born male, A-S 6-8 BW:3000 gr, BL:49 cm

Placenta was born spontaneously, complete,Bleeding : 300 cc19.10GC: well Cons: CMBP: 110/70 HR : 88 bpm RR : 20 tpm T : 36,6 CUFH : 1 finger below umbilicusUC : +2 hours post VEObserved mother and baby well beingSuggest mother to mobilisation.

26/12/201207.00GC: well Cons: CM BP: 120/80 HR : 72 bpm RR : 16 tpm T : 36,9 CUFH : 2 finger below umbilicus UC : +

Baby in NICU:PR:148 RR: 52 T: 36,41 day post VEObserved mother and baby well beingSuggest mother to mobilisation, eat, and drink, medication.

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