MR 4 Agustus 2014

Morning ReportAugust, 4th 2014

Supervisor:dr. Agus Thoriq, Sp.OGdr. I Made Putra Juliawan, Sp.OG

DM Jaga:Zia, Yid, Santi, Ayu, Ria

Morning ReportAugust 2nd 2014

Case Resume

NORMAL LABOR

0

PATHOLOGIES LABOR

1. G1P0A0L0 39-40 wks/S/L/IU with breech presentation + protracted active phase

Case 1

Name : Mrs. LSAge : 26 years oldAddress : Moyo Hulu, SBWAdmitted : 02-08-2014 No. RM : --

G1P0A0L0 39-40 wks/S/L/IU with breech presentation + protracted

active phase

Time Subject Object Assessment Planning

02-08-201409.40

Patient come to NTB GH, referred from Sumbawa GH with G1P0A0L0 39-40 wks/S/L/IU with breech presentation.

Patient confessed abdominal pain since 01-08-2014 (18.00) water come out from her womb since 31-07-2014 (15.00), bloody slim (+), and FM (+).

No history of DM, HT, asthma.

LMP : 28 – 10 – 2013 EDD : 04 – 08 – 2014

History ANC : 7x at PHCLast ANC : 14-05-2014result: BP : BP: 120/80 mmHg, UFH 25 cm, head presentation, FHB (+)

History of USG: -

General statusGC : wellGCS: CM (E4V5M6)BP : 120/80 mmHgHR: 84 x/mRR: 20 x/mT: 36,6 °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 : headL2 : back on the right sideL3 : breechL4 : 4/5UFH: 31 cmEFW : 3100 gram

UC : 2x/10’ ~ 30”FHB : 13-12-12 (148x/min)

G1P0A0L0 39-40 wks/S/L/IU with

breech presentation + active phase

•Obs. Mother and fetal well being•Observation progress of labor•Partograf

Time Subject Object Assessment Planning

History of family planning : -Next family planning : IUD

History of obstetric :I. This

Chronologist:Sumbawa GH (31/07/2014 – 19.30)

VT: Ø 6 cm, eff. 25%, amnion (-) meconeal, breech palpable, denom sacrum, ↓H1, unpalpable small part/umbilical cord

Lab:HGB = 10.7 g/dlRBC = 3.86 K/ulWBC = 8.81 M/ulHCT : 32.7 %PLT = 196 M/ulHBsAg = (-)

Time Subject Object Assessment

Planning

10.30 Abdominal wound pain

•UC: 2x/10’ ~ 30”•FHB: 12-12-12

11.00 •UC: 2x/10’ ~ 30”•FHB: 12-13-12

11.30 •UC: 2x/10’ ~ 30”•FHB: 12-12-12

12.00 •UC: 3x/10’ ~ 30”•FHB: 12-13-12

12.30 •UC: 3x/10’ ~ 30”•FHB: 12-13-12

13.00 •UC: 3x/10’ ~ 30”•FHB: 12-12-13

13.40 •GC: well•BP: 120/80 mmHg •HR: 82 bpm •T 36,70C •RR 20 x/m•UC: 3x/10’ ~ 40”•FHB: 12-12-12•VT: Ø 9 cm, eff. 25%, amnion (-) meconeal, breech palpable, denom sacrum, ↓H1, unpalpable small part/umbilical cord

Protracted active phase

•Co to SPV, adv: CS at 15.00

•Preop


Planning

15.30 CS beganBaby was born , female with body weight 3000 gr, AS 7-9, BL 49 cm.Placenta was born ,, complete.Bleeding ± 300 cc.

18.00 Patient confessed asbdominal wound pain

BP: 120/70 mmHgHR: 88 pmRR: 20 tpmT: 37,5 0CTFU; 1 finger bellow umbilicusUC: + Active bleeding: (-)UO: 100cc/2 hours

2 hours post CS

Observation VS of mother and babyObservation of bleeding Drip oxytocin + Ketorolac 20 tpm

03-08-2014 7.00 am

Abdominal wound pain

•GC: well cons:E4V5M6•BP: 100/60 mmHg •PR: 80x/m• RR: 20x/m •T: 36,8 0C•UC: (+) well•UFH: 2 fingers below umbilicus•Active bleeding: (-)•UO: 500cc/8 hour•Lokea rubra (+)

1 day post CS

•Observed mother and baby well being•Suggest mother to mobilization•Suggest mother to eat and drink


Planning

04-08-2014 7.00 am

Abdominal wound pain

•GC: well •cons:E4V5M6•BP: 100/60 mmHg •PR: 80x/m• RR: 20x/m •T: 36,8 0C•UC: (+) well•UFH: 2 fingers below umbilicus•Active bleeding: (-)•UO: 500cc/8 hour•Lokea rubra (+)

2 day post CS

•Observed mother and baby well being•Suggest mother to mobilization•Suggest mother to eat and drink

Morning ReportJuly 30th 2014

Case Resume

NORMAL LABOR

1

PATHOLOGIES LABOR

1. G1P0A0H0 39-40 weeks/ S/L/IU head presentation + prolong 2nd stage of labor

Case 1

Name : Mrs. IAge : 23 years oldAddress : Montong, LobarAdmitted : 30-07-2014 No. RM : 54-34-47

G1P0A0H0 39-40 weeks/ S/L/IU head presentation + prolong 2nd

stage of labor

Time Subjective Objective Assasement Planing

30-07-201412.00

Patien reffered from Narmada PHC with G1P0A0H0 38-39 weeks/ S/L/IU head presentation + prolonged active phase. Mother and baby well.

Mother confess abdominal pain since 02.00 (28/07/2014), water leak out from her womb (-). Bloody slym (+), and FM (+).

History of DM (-), HT(-), asthma (-).

LMP: 25-10-2013EDD: 01-08-2014

History of ANC; 9x d PHCLast ANC: BP 110/70 mmHg, UFH 30 cm, BW 52 kg.

USG: -

Obstetrical history I. This

General StatusGC: weellGCS: E4V5M6BP: 130/80 mmHgHR: 70 bpmRR: 20 bpmT: 37 0C

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

Obstetric statusUFH: 36 cmEFW 3875 gramUC: 2x10-30”FHB : 11-12.12 L1 : breechL2 : back on the right sideL3 : head presentationL4 : 3/5

G1P0A0H0 39-40 weeks/ S/L/IU head presentation + arrested active phase

•Obs. Mother and baby well being•DM co to GP, GP co to SPV, adv: amniotomy (evaluation 30 minutes, if no progress, vacum)

•Do amniotomy

Time

Subjective Objective Assessment

Planing

ChronologistAt Narmada PHC 06.00 (30/07/14)

S: mother 9 month of 1st pregnancy come and confess abdominal pain since 04.00 (30/07/14) , bloody slim (+), water came out (-), FM (+), LMP 25-10-2013.

O: GC: well, GCS: CMBP: 110/80 mmHgHR: 76 bpmRR: 19 bpmT: 36,7 0CObstetrical status:UFH: 31 cmBack on the left side, head presentation 4/5UC: 3x10-40”FHB: 11-11-12 (136 bpm) VT: Ø 6 cm, eff 75%, amnion (+), head palpable, ↓HI, denom unclear, impalpable small part of fetus ar umbilical cord.

A: G1P0A0H0 38-39 weeks S/L/IU with active phase

P: obs. Mother and fetal well being and progress of labor, suggest to eat and drink, LLD position

VT : Ø 8 cm, eff 90%, Amnion (+), head palpable ↓HII, denominator ROA, impalpable small part of fetal & umbilical cord.

Lab ExaminationHb: 10,3 g/dlRBC: 3,84 10 /ulHct: 31,1 %WBC: 19,25 10/ulPlt: 366 10/ul

Time Subjective Objective Assasement

Planing

10.00 S: -O: GC: well Conc: CMBP: 110/70HR: 80 bpmRR: 20 bpmT: 36,6 0CUC: 4x/10’ ~ 40”FHB: 11-12-12 (140x/m)VT: Ø 8 cm, eff 75%, amnion (+) , head palpable, ↓HI+ , denom ROA, impalpable small part of fetus ar umbilical cord. A: -P: Co to GPRehydration, inj. Ampicillin 1 gr/IV, evaluation progress of labor, if no progress, refer to NTB GH

11.00VT: Ø 8 cm, eff 75%, amnion (+) , head palpable, ↓HI+ , denom ROA, impalpable small part of fetus ar umbilical cord. A: -P: referred to NTB GH


Planing

13.15

Patient confessed abdominal pain

Amniotomy (amnion 30 cc)VT : Ø 8 cm, eff 90%, Amnion (-) clear, head palpable ↓HII, denominator ROA, impalpable small part of fetal & umbilical cord.

Evaluation 30 minutes after amniotomy

13.45

GC: wellBP: 120/70 mmHgHR: 88 pmUC: 3x/10’ ~ 30”FHB: 12-13-13VT : Ø 9 cm, eff 90%, Amnion (-), head palpable ↓HII, denominator ROA, impalpable small part of fetal & umbilical cord.

Co to SPV, adv:•Acceleration•Report progres of labor at 16.00

Drip oxytocin 5IU in D5% 500 cc (14.00) 8 dpm

14.30

UC: 3x/10’ ~ 30”FHB: 12-12-13

Drip oxytocin 12 dpm

15.00

Patient confessed abdominal pain more frequently

UC: 3x/10’ ~ 45”FHB: 12-13-13VT : Ø complete, Amnion (-), head palpable ↓HII, impalpable small part of fetal & umbilical cord.

2nd stage of labor


15.30

UC: 3x/10’ ~ 45”FHB: 12-12-13



Planing

16.00 Patient confessed abominal pain

UC: 3x/10’ ~ 45”FHB: 12-13-13VT : Ø complete, Amnion (-), head palpable, caput (+) ↓HII, impalpable small part of fetal & umbilical cord.

Neglected 2nd stage of labor

Drip oxytocin 16 dpmCo to SPV, adv: CS, stop drip (RL 20 dpm)

13.45 GC: wellBP: 120/70 mmHgHR: 88 pmUC: 3x/10’ ~ 30”FHB: 12-13-13VT : Ø 9 cm, eff 90%, Amnion (-), head palpable ↓HII, denominator ROA, impalpable small part of fetal & umbilical cord.

Co to SPV, adv:•Acceleration•Report progres of labor at 16.00

Drip oxytocin 5IU in D5% 500 cc (14.00) 8 dpm

14.30 UC: 3x/10’ ~ 30”FHB: 12-12-13


15.00 UC: 3x/10’ ~ 30”FHB: 12-13-13


15.30 UC: 3x/10’ ~ 45”FHB: 12-13-12



17.00 CS beganBaby was born (17.13), male with body weight 3700 gr, AS 7-9, BL 51 cm.Placenta was born, complete.Bleeding 450 cc.

20.00 Patient confess abdominal wound pain

BP: 120/70 mmHgHR: 88 pmRR: 20 tpmT: 37,5 0CTFU; 1 finger bellow umbilicusUC: +Active bleeding: -UO: 70cc/2 hours

2 hours post CS Observation VS of motherand babyObservation of bleeding Drip oxytosin+ Cetorolac 28 tpm


31-07-201407.00

BP: 120/70 mmHgHR: 86 pmRR: 24 tpmT: 36,2 0CTFU; 2 finger bellow umbilicusUC: +Active bleeding: -UO: 220 cc/ 3 hoursBaby in NICU

Baby in NICU: HR: 120 bpmRR: 42 bpmT: 37,2 T

1 day post CS Observation mother and babyEarly mobilisationEarly breast feeding

03-08-201407.00

- BP: 120/70 mmHgHR: 86 pmRR: 24 tpmT: 36,2 0C

Baby: HR: 120 bpmRR: 42 bpmT: 37,2 T

Patient go home

.. Thank You ..

MR 4 Agustus 2014

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Transcript of MR 4 Agustus 2014