10-11-15 kjdr
DESCRIPTION
IUGRTRANSCRIPT
Morning ReportNovember 10th , 2015Supervisor : dr. Gede Made
Punarbawa, Sp.OG(K)Medical Students :
Dede, Dila, Nita, Dhani, Farid, Sobri
CASES RESUME NORMAL LABOR
(-)
PATHOLOGY LABOR
1.G2P1A0L1 40-41 weeks S/L/IU head presentation with oligohydramnion
2.G3P0A2H0 43 weeks S/L/IU head presentation with BOH
3. G3P0A2H0 25-26 weeks /S/IUFD/IU + BOH
• Name : Mrs. M• RM : 56 95 30• Age : 22 years old• Address : Lingsar• Admitted : 8th November 2015 at 08.53
WITA
Case Report
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
08/11/2015
08.53
Patient referred from Akasia Klinik to VK IGD NTB GH with G3P0A2L0 18-20 weeks S/IUFD/IU. Patient 4 months pregnancy confessed dindn’t fell the fetal movement since 1 weeks ago, abdominal pain that spread to flank (-), water leaked from her womb (-), bloody slim (-). history of DM (-), HT (-), asthma (+), alergi (-)
LMP : 15 – 05 - 2015EDD : 22– 02 – 2016GW : 25-26 weeks
History of ANC : 6x at PHC and posyanduLast ANC : 06/11/2015Result : BP 110/70, BW 63 kg, GW 17-18 weeks, UFH 1 finger below umbilicus, ballotement (+), FHB (+) History of USG : 1x at Sp.OGLast : 05/11/2015Result : Fetal S/IUFD/IU 16-17 weeks FM (-), FHB (-)
History of family planning : -Next family planning : -
Obstetrical History :1.Abortus 3 months curretage2.Abortus 2 months curretage3.This
General Status :GC : wellBP : 120/80 mmHgPR : 82 bpmRR : 20 bpm Temp : 36,5oCEye : palor (-/-), icteric (-/-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).
Obstetrical Status :Leopold : can’t performUFH : as the umbilicusUC : -FHB : - Ballotement (+)
VT : Ø 1 cm, eff 10 %, amnion (+), impapable small part of fetus and umbilical cord
Lab :Hb 12,2WBC 10,45PLT 297BT 1’45’’CT 5’12’’HbsAg (-)
G3P0A2L0 25-26 weeks S/IUFD/IU
with BOH
DM Planning :Diagnostiik• Lab (Dl, BT, CT,
HbsAg)
Therapy• Observation
mother well being.
• Obs. Inpartu sign• Suggest mother
to at and drink• Pro termination
with misoprostol induction
09.00DM co to GP, GP
to SPV advice : Insertion misoprostol by the vagina ½ tablet per 6 hours
At 06.00 before patient had take gastrul
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Pelvic score (total) : 3Dilatation 1cm (1), cervix length 2cm(1), station H0(0), consistency rigid (0), position middle (1)
12.00 Insertion of misoprostol ½ tab
14.00 GC : wellBP : 110/70 mmHgPR : 80 bpmRR : 22 bpm Temp : 36,8oCUC : -VT : not perform
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
- Obs mother well being suggest mother to eat and drink
- Obs for vaginal delivery
18.00 GC : wellBP : 120/70 mmHgPR : 84 bpmRR : 20 bpm Temp : 36,5oCUC : -VT : not perform
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
• Obs mother well being
• Insertion of misoprostol ½ tab
00.00 • Insertion of misoprostol ½ tab
9/11/201506.00
GC : wellBP : 110/70 mmHgPR : 88 bpmRR : 19 bpm Temp : 36,4oCUC : -VT : not perform
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
• Obs mother well being
• Dm co to GP, GP co to SPV, advice increase misoprostol dose be 1 tab/6hours
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
12.00 GC : wellBP : 110/80 mmHgPR : 92 bpmRR : 21 bpm Temp : 36,3oCUC : -VT : dilatation 1cm, eff 10%, amnion (+), palpable part of fetal or tissue
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
- Obs mother well being suggest mother to rest well, eat and drink- Insertion of misoprostol 1tab/6hours
18.00 Patient confessed abdominal pain still seldom
GC : wellBP : 110/70 mmHgPR : 96 bpmRR : 22 bpm Temp : 36,5oCUC : 2x10’-15”VT : dilatation 1cm, eff 10%, amnion (+), palpable part of fetal or tissue
G3P0A2L0 25-26 weeks S/IUFD/IU with BOH
-Obs mother well being suggest mother to rest well, eat and drink- Insertion of misoprostol 1tab/6hours
19.00 Patient confessed water leaked from her womb
GC : wellBP : 110/70 mmHgPR : 84 bpmRR : 20 bpm Temp : 36,7oCUC : 4x10’-45”VT : dilatation 4cm, eff 50%, amnion (-), hodge II, palpable part of fetal
G3P0A2L0 25-26 weeks S/IUFD/IU with inpartu active phase of labor + BOH
-Obs mother well being suggest mother to eat and drink-Obs progress of labor
19.12 Mother wants to bear down Inspection : bulging perineum, opening vulva, anus pressure
Second stage of labor
Conduct labor
Baby was born at 19.15 death, male, BW 300gr, BL 21cm, Maseration grade III
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
19.20 GC : wellBP : 100/60 mmHgPR : 76 bpmRR : 22 bpm Temp : 36,7oCUC wellUFH 2 fingers above symphisisBleeding about 50ccPerineum intact
3rd phase of labor with IUFD + suspect rest placenta
- Injection oxytocin 1amp IM- placenta was born spontan not complete, doing exploration- UC well- UFH 2 fingers above symphisis- Bleeding about 50cc- Perineum intact- suggest mother to eat and drink
-DM co to GP, GP co to SPV advice : pro USG tomorrow morning
21.00 GC : wellBP : 120/80 mmHgPR : 80 bpmRR : 19 bpm Temp : 36,8oCUC wellUFH 2 fingers above symphisisActive bleeding (-)
2 hours post partum with IUFD + suspect rest placenta
- Obs UC, bleeding, mother well being- Suggest mother to rest well, eat and drink
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10/11/201506.00
GC : wellBP : 110/70 mmHgPR : 84 bpmRR : 18 bpm Temp : 36,6oCUC wellUFH 2 fingers above symphisisActive bleeding (-)
1 day post partum with IUFD + suspect rest placenta
- Obs mother well being, UC, bleeding- Suggest mother to eat and drink- Pro USG this morning