MR PEB Kl1 f Aktif Macet 26.4.12

8/10/2019 MR PEB Kl1 f Aktif Macet 26.4.12

1/6

MORNING REPORT

April 26th2012

Supervisor : dr. Edi Prasetyo W, SpOG

Medical Students:

Nana, Ira, Nisia, Fahmi, Heri, Hasaniah, Rani, Zihni, Fadhil

Cases resume :

Normal Labor -

Phatologic Labor G3P2A0L2 37-38 weeks/S/L/IU breech presentation with active phasefirst stage of labor

G5P4A0L3 A/S/L/IU with active phase 1ststage of labor

G3P2A0L1 38-39 weeks/S/L/IU with impending eclamsia


2/6

Name : Mrs. H CTH : April 25h2011

Age : 30 years old At 13.00 wita

Address : Narmada

Time Subject Object Assesment Planning

25/04/

2012

13.00

Patient referred from Sumbawa GH

with G3P2A0L2 A/S/L/IU active

phase first stage of labor with

severe preeklampsia. History

rupture of membrane (+) since

06.30 (25/04/2012). Patient

confessed abdominal pain since

06.00 (25/04/2012), bloody slim

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

LMP : Forgot

EDD : -

History of ANC : >4x, at PHC

Last ANC : 13/04/12

History of USG : never

Obstetrical history :

I. Aterm, male, 3300 g,

spontant, midwife, PHC, 12 yo

II. Aterm, female, 3000 g,

spontant, midwife, PHC, 7 yo

III. This

General Condition : well

Consciousness : CM

BP : 160/100 mmHg PR : 88 x/minute

RR: 26 x/minute T : 37,4C

Status Generalis:

Eye :anemis(-), icteric (-)

Thorax :

Cor : S1S2 single reguler (murmur -),(gallop -)

Pulmo : vesikuler (+/+), wheezing (-/-),

Ronkhi (-/-).

Abdomen : scar (-), striae (+),linea

nigra(+)

Extremity : edema (-), warm acral (+)

Obstetrical status :

L1 : breech UFH: 32 cms

L2 : fetal back on right side

L3 : head

L4 : 4/5

EFW : 3255 gram

UC: (+), 2 x 1030

FHR : (+), 11-11-12 (136bpm)

VT : 9 cms, eff 90%, amnion (-) clear ,

head palpable HI, denominatorunclear, Unpalpable small part /

umbilical cord.

G3P2A0L2 A/S/L/IU

active phase first stage

of labor with severe

preeklampsia

Observe mother &

fetal well being

DL, UL, HbSAg

checked

Observe progress of

labor


3/6

Time S O A P

14.00

Chronologist :

Mother confessed abdominal painmore often

Lab :

DL:HGB : 10,2

RBC : 3,07

HCT : 34,5

WBC : 16,0

PLT : 478

HbSAg : -Urineprotein : +2

General Condition : wellConsciousness : CM



UC : (+) 2 x 10~30

FHR : (+) 11-12-12 ( 140x )

VT :

Arrested active phasefirst stage of labor +

PEB

Obs. Mother and fetalwell being

DM co to GP, GP co to

SPV, SPV adv:

- Improve UC

- Give Nifedipine oral 1

tab/8hours (15.10)

- Inj. Ampicillin 1g/IV

(15.35)


4/6

Subject Object Assesment Planning

16.05

19.30

Abdominal pain (++)

-


Consciousness : CM



Obstetrical status :L1 : breech UFH: 36 cms

L2 : fetal back on right side

L3 : head

L4 : 4/5

EFW : 3875 gram

UC: (+), 4 x 1040

FHR : (+), 12-13-12 (148bpm)


head palpable HI, denominator suturasagitalis transversal, moulage Gr. I,

unpalpable small part / umbilical cord.


Consciousness : CM



Obstetrical status :

UC: (+), 4 x 1040

FHR : (+), 13-13-12 (152bpm)


head palpable HI, denominator sutura

sagitalis transversal, moulage Gr. III,

caput (+), unpalpable small part /

umbilical cord.

Arrested active phase

1ststage of Labor with

severe preeklampsia

Arrested active phase

1ststage of Labor with

severe preeklampsia

- Obs Mother and fetal

well being

- Obs progress of Labor

- Co to SPV pro CS, SPV

adv: acc CS, CIE

patient and family,rehidration, call SPV

again at 19.30

Co to SPV, SPV adv:

Pro CS cito now


5/6


20.00

20.50

CS began

Lower segment of uteri thin

Baby was born female, AS 7-9, 3500g, Anus

(+), Anomali congenital (-)

Placenta was born manually, complete,

bleeding 250ccIntraoperative finding: Ovarian Cist dextra

12x7cmoophorectomy dextra

CS finished

20.50-

22.50

Operation

wound pain

GC: well

BP: 110/60 mmHg

PR: 84x/mnt

RR: 20x/mntT: 36.5C

UFH: 1 finger below umbillicus

UC: (+) good

AB: (-)

UO: 70cc/hour

2 hours post CS Obs. Mother well being

CIE patient to take a rest

Drip oxytocin 10IU+ketorolac 1amp in RL

500cc 20tpm


6/6


26/05/

12

07.00

Operation

wound pain

GC: well

BP: 110/70 mmHg

PR: 80x/mnt

RR: 20x/mnt

T: 36.8C

UFH: 1 finger below umbillicusUC: (+) good

AB: (-)

UO: 70cc/hour

Baby in NICU

PR: 144x/mnt

RR: 40x/mnt

T: 5,6C

1 day post CS Obs. Mother well being

CIE patient to take a rest

Mefenamat Acid 500mg/8 hours

Amoxicillin 500mg/8hours

SF 1 tab/12 hours

MR PEB Kl1 f Aktif Macet 26.4.12

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