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Morning Report25 January 2009

Supervisor : dr. Agus Thoriq , SpOGMedical Student:

1. Hadian2.Miftah

1.

Cases resume :

1. LMR (history SC) + PROM + hipertension 1

2. Prolong in 2nd

stage of labor 1

3. Retensio placenta 1

4.

Normal labor 3

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Name / Age : Mrs. Ruslul / 20 years old CTH : 25 January 2009

Address : Pringgarata Time : 10.30

Time Subject Object Assesment Planning

10.30 Patient refered by PKM Pringgarata

(midwife: Nining Ardiani) with retensio

placenta

Chronologis:

08.00 (25-1-09)

Patient came to PKM Pringgarata

confess abdominal abdominal

discomfort and felt to bearing down.

Examination:

General status: wellBP: 100/70 mmHg PR: 80x/mnt

T: 36C

UFH: 28 cm FHB: (-)

VT: DC 10 cm, eff 100 %, AM (-), head

palpable, descensus HIII.

Patient then conducted to labor

08.30 (25-1-09)

Baby was born, female, 2000 g, AS: 0

(death).Management 3th stage of labor

09.00 (25-1-09)

Placenta was not born.

Patient then refered to Mataram general

hospital.

Tx: IVFD 2 fls RL rapid drop.

General status :

General condition: well

Conciousness: CM

BP: 100/70 mmHg

RR: 20 x/mnt

PR: 96 x/mnt

T: 36,6C

Eyes : an(-), ikt (-)

Cor -Pulmo : in normal range

UFH : 2 finger above umbilicus

UC: wellInspection : active bleeding (-),

umbilical cord appear in vulva

VT: DC 1 cm palpable umbilical

cord.

Laboratorium:

Hb: 11,4 g%

WBC: 20.000/mm3

PLT : 306.000/mm3HCT : 31,4 %

Retensio placenta Observation vital sign

and bleeding

Lab examination

Report to supervisor:

advice :

Antibiotic

Drip Oxytocin 1

ampul 24 drop/mnt

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Time Subject Object Assesment Planning

11.30 Vaginal bleeding (-) General status: well

BP: 100/70 mmHg

UFH: 2 finger above umbilical

UC: well

Retensio placenta Ampicilin test (-)

Injection 1 g ampicilin

Applied oxytocin drip

24 drop/mnt

14.00 Vaginal bleeding (-)

Abdominal discomfort (+)

General status: well

BP: 100/70 mmHg

UFH: 2 finger above umbilical

UC: well

Retensio placenta Applied oxytocin drip

24 drop/mnt

16.00 Vaginal bleeding (-)

Abdominal discomfort (-)

General status: well

BP: 100/70 mmHg

UFH: 2 finger above umbilical

UC: well

Retensio placenta Supervisor call, advice:

Prepare manual placenta

in operation room

17.00 Vaginal bleeding (-) General status: well

BP: 100/70 mmHg

UFH: 2 finger above umbilical

UC: well

Retensio placenta Applied dauer catheter

Injection 2 g ampicilin

Send patient to operation

room

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Time Subject Object Assesment Planning

18.12 Operation begun

Operator done manual placenta,

result: not complete

Then operator done curetase, result:

placenta remain

Suspect rest plaenta Supervisor advice:

Lab examination

Pro USG at thusday

Ampicilin 1 g/days

Mefenanic acid 3 x daily

19.00 feeling weak

Vaginal bleeding (-)

General status:well

BP: 110/80 mmHg PR: 90 x/mnt

Active bleeding (-)

Suspect rest placenta Lab examination

Pro USG at thusday

21.00 Vaginal bleeding (-) General status: well

BP: 110/70 mmHg

Active bleeding (-)

Lab:

Hb: 10,5 g%

WBC: 22.100/mm3

PLT: 253.000/mm3

HCT: 28,3%

Suspect rest placenta Pro USG at thusday

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Name / Age : Mrs. Halwiati / 36 years old CTH : 22 January 2009

Address : Lingsar Time : 20.00

Time Subject Object Assesment Planning

15.00 Patient came to emergency care unit

with pregnancy 9 month and confess

vaginal discharge.

Chronologis:

Patient confess vaginal discharge since

12.00 (25-1-09). Abdominal discomfort

(-).

LMP: forgot

History of pregnancy

1. male, SC (transvers presentation),

3000 g, 8 years

2. this

History of family planing:

Injection 3 month since 8 years ago.

Last injection 1 years ago.

Planing for family planing:

IUD

General status :

General condition: well

Conciousness: CM

BP: 120/80 mmHg

RR: 20 x/mnt

PR: 80 x/mnt

T: 37,8C

Eyes : an(-), ikt (-)

Cor -Pulmo : in normal range

Obstetric status:L1 : breech

L2 : left back

L3 : head

L4 : descensus descencus4/5

UFH 34 cm

EFW : 3565 g

UC : (-)

Fetal Heart Rate : 15-16-15

VT : DC 1 cm, eff 10 % AM (-),green, head palpable, descensus HI,

umbilical cord or small part of fetal

unpalpable,

G2P1A0H1 A/S/L

LMR (SC) + PROM

+ febris

Observation mother

and fetal well being

IVFD RL

Resusitation

intrauterin

Report to supervisor,

advice: SC

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Time Subject Object Assesment Planning

15.30 Febris (+), abdominal discomfort (-

)

General status: well

BP: 120/80 mmHg

FHB: 12-13-13

G2P1A0H1 A/S/L LMR

(SC) + PROM + febris

Ampicilin test (-)

Injection 2 g ampicilin

Applied dauer catheter

16.30 Febris (+), abdominal discomfort (-

)

General status: well

BP: 120/80 mmHg

FHB: 12-13-13

G2P1A0H1 A/S/L LMR

(SC) + PROM + febris

Send patient to operation

room

17.50 Baby was born, male,

3650 g, AS: 7-9, AF:

green

19.00 General status: well

BP: 120/80 mmHg

UC: well

Bleeding (-)

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Time Subject Object Assesment Planning