Supervisor : dr. Agus Thoriq, Sp.OGMedical Students :Akbar, Nugraha, AsriMORNING REPORTFEBRUARY 23TH, 2014

CASE RESUMEPathology laborG1P0A0L0 40-41 wk S/L/IU with PROM>12h + Oligohidramnion + CPD

CASE 1

TIMESUBJECTOBJECTASSESMENT PLANNING 22/02/2014

12.00 amPatient referred from Meninting PHC with G1P0A0L0 40 41 weeks S/L/IU general condition of mother and fetus well with PROM. Patient confessed water came out from her vagina since 11.00 pm (16/02/2014). Abdominal pain (-), bloody slim (-), fetal movement (+).No history of DM, HT, asthma. No history of allergic reaction to medicine or food.LMP : 09/05/2013EDD: 16/02/2014General StatusGC : wellGCS: E4V5M6BP : 120/70 mmHgPR : 88 bpmRR : 24 bpmT : 36,5oC

Eye : anemis (-/-), icteric (-/-)Cor : S1S2 single reguler, M (-), G (-)Pulmo : vesikuler (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (+), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+)G1P0A0L0 40-41 wk S/L/IU PROM>12 h + OligohidramnionObs. Mother and fetal well beingCTGDM co to GP, GP co to SPV advice: resusitation intra uterine (O2 + Inf. RL:Dex 5 % 2:1)Oxytocin dripCTG repeat if inpartu

TIMESUBJECTOBJECTASSESMENT PLANNING 22/02/2014

12.00 amHistory of ANC : 13xLast ANC: 18/02/2014, result: BP: 120/80 mmHg, 39 40 wk, FHB (+), PROM > 12 h, oligohidramnionSuggest: SC cito

History of Family Planning: - Next Family Planning: injection

History of obstetry:This

Chronologist : S: Patient came tomeninting PHC with history rupture of membran since 11.00 pm(16/02/2014),FM(+).Obstetrical StatusL1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 29 cm EFW : 2790 grUC : -FHB : 12-12-11 (140 bpm)VT : - cm, fornix palpable head impression, Pelvic score: 3Cervix dilatation: 0Cervix length: 0Cervix consistency: 1Cervix position: 1Head position: 1

TIMESUBJECTOBJECTASSESMENT PLANNING 22/02/2014

12.00 amA : G1P0A0L0 40-41 wk /S/L/IU with PROM>12 h +oligohidramnionP : Refereed to NTB GH

TIMESUBJECTOBJECTASSESMENT PLANNING 02.00 pm-General statusGC : wellGCS: E4V5M6BP : 100/70 mmHgPR: 88 ppmRR: 24 rpmT: 36,5CUC : -FHB : 12.11.12 (140 bpm)VT: not doingG1P0A0L0 40-41 wk S/L/IU PROM>12 h + OligohidramnionPro CTG02.30 pm--G1P0A0L0 40-41 wk S/L/IU PROM>12 h + OligohidramnionDM co to GP result CTG, advice observation.

CTG RESULT (02.20 PM)

TIMESUBJECTOBJECTASSESMENT PLANNING 06.00 pm-General statusGC : wellGCS: E4V5M6BP : 130/90 mmHgPR: 80 ppmRR: 18 rpmT: 36,8CUC : -FHB : 150 bpmVT: not doingG1P0A0L0 40-41 wk S/L/IU PROM>12 h + Oligohidramnion + Fetal DistressObs. Mother and fetal well beingCTG suspicius, DM co to GP, GP co to SPV, advice prepare SC

TIMESUBJECTOBJECTASSESMENT PLANNING 09.20 pm--G1P0A0L0 40-41 wk S/L/IU PROM>12 h + Oligohidramnion + Fetal DistressSC began09.28 pm--G1P0A0L0 40-41 wk S/L/IU PROM>12 h + Oligohidramnion + Fetal Distress + CPDBaby was born, male, A-S : 7-9, Birth Weight : 2.600 gram, Birth Lenght 47 cm. Anus (+), anomaly kongenital (-), head circumference : 31 cm09.33 pm--G1P0A0L0 40-41 wk S/L/IU PROM>12 h + Oligohidramnion + Fetal Distress + CPDPlacenta was born,manual, complete, 500 gr, bleeding 500 cc

TIMESUBJECTOBJECTASSESMENT PLANNING 11.30 pm-General condition : WellGCS : E4V5M6BP : 110/70 mmHgPR : 80 x / mRR : 20x/mTemp : 36,0 CUFH : 2 finger bellow umbilicalUC : + well Active bleeding (-)P1A0L1 2 hours post partum Obs. General Condition, Vital signObs. Mother and baby well being

23/02/2014

07.00 amGeneral condition : well BP : 120/80 mmHgPR : 80 x / mRR : 20x/mTemp : 36,8 CUFH : 2 finger below umbilicalUC : + wellActive bleeding (-)

Babies roomingPR: 160 bpmRR: 50 x/mTemp :36,6 C1st day post partumObs. Mother and baby well beingCIE: explanation about result of examination, drink n eat, breast feeding, and mobilization

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