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Morning Report

October 07th 2009

Supervisor : dr. Edy P.W., SpOG

Medical Student:

Titin, Halida, Idham, Holis

1.

Cases resume :

G1P0A0 with prolonged 2nd stage 1

G1P0A0 with susp.big baby 1Normal labor 4

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s

Name : Mrs. Zohrah CTH : 07102009

Age : 22 years :

Address : johar pelita - sesela

Waktu Subject Object Assesment Planning

13.00 Patient came to emergency care unit

of NTB province hospital (12.20)

with G1P0A0 A/S/L laten phase 1stlabour + watery vaginal discharge +

febris

cronologis :

Patient felt abdominal pain ( since 05-

10-2009) and watery vaginal

discharge at 07.00 am (07-10-2009),

then she went to gunung sari PHC at

11.00 am (07-10-2009). Bloody show

(-) , the fetal movement was active.

History of febris (-). History of

malaria -, history of thipoid -.

The examination gunung sari PHC

General status : well

BP : 120/70 mmHg

Pulse =88 x/mnt

RR: 20 x/mnt

Temp = 38,6C

UFH = not mention it

FHB = 171 x/mnt

11.00 WITA

VT : 3 cm, eff 25 %, amnionic

membrane (-), head palpable, descend

HI, unpalpable small organ and

umbilical cord.

Terapi in PHC:

Injeksi ampi 1 gr in PHCParacetamol 1 tab in PHC

12.00 patient referred to mataram GH

In emergency room :

General status :

General condition: well,Conciousness: E4V5M6

BP: 130/80 mmmHg

RR: 20 x/mnt

Pulse :80 x/mnt

T: 37,6C

Eyes : an(-) ikt (-)

Cor -Pulmo : in normal range

Obstetric status :

L1 : breech TFU; 31 cm

L2 : left back

L3 : head

L4 : 4/5

EFW : 3100 g

UC : 3x/10 ~35

FHB : 173 x/mnt

VT : 3 cm, eff 25 %, amnionic

membrane (-,) dry, head palpable,

descend HI, unpalpable small organ and

umbilical cord.

Pelvic evaluation;

Promontorium not prominent

Spina isciadica not prominent

Arcus pubis > 90

Os coxigeus mobile

G1P0A0 Aterm/single/

life + laten phase of 1st

stage labor + wateryvaginal discharge +

febris + fetal

tachicardy

Observation mother

and fetal well being.

Laboratoryexamination : DL,

HBsAg

Resusitation intra

uterine

CTG post resusitation

Base line 156

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Time Subject Object Assesment Planning

17.00

18.00

History of family planning : (-)

Familly planning = injection 3

month

ANC Routine at posyandu > 4 x

Obstetrical history :

1.This

Abdominal pain >>>

Abdominal pain +++

Mother want to bearing down

Lab. result:

HB = 10 gr%

WB = 23.700

PLT = 249.000

HCT = 32,5HBsAg (-)

UC : (+) 3x/1035

FHB : 144x/mnt

L4 : 3/5VT : 9 cm, eff 90 %, amnionicmembrane (-,) dry, head palpable,

descend HII,denominator fontanella

minor left anterior. unpalpable small

organ and umbilical cord

UC : (+) 3-4 x/1040

FHB : 144x/mntL4 : 3/5VT : complete, amnionic membrane

(-,) dry, head palpable, descend

HII,denominator fontanella minor

left anterior. unpalpable small organ

and umbilical cord.

G1P0A0 Aterm/single/

life + active phase of

1st stage labor +

watery vaginaldischarge

G1P0A0 Aterm/single/

life + 2nd stage of

labor

-Observation mother

and fetal well being

-Evaluation 1 hours

again

-Left laterl position

-Educated mother to

drinking and eating.

Squating position

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Time Subject Object Assesment Planning

20.00

20.30

22.30

Abdominal pain +++

Active bleeding

UC : (+) 4 x/1040

FHB : 154x/mnt

L4 : 2/5VT : complete, amnionic membrane

(-,) dry, head palpable, descendHIII,denominator fontanella minor

left anterior. unpalpable small organ

and umbilical cord.

BP = 120/70

RR: 20 x/mnt

Pulse 84 x/mnt

UFH = 1 fingers below the

umbilical

UC = good

G1P0A0 Aterm/single/

life + prolonged 2nd

stage of labor

2 nd stage of labor

3 rd stage of labor

IV stage of labor

Report to supervisor

Propose vacum

extraction

Proposed agreed

Baby was born with

vacum extraction male,

3300 gram, A`S : 6-8

Amniotic fluid green thinNuchal cord baby sent

to NICU

Placenta was born

compleete

Observation VS and

subjective complain

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Time Subject Object Assesment Planning

07.00

am

Subjective complain

Active bleeding -BP = 110/70

RR: 22 x/mnt

Pulse 84 x/mnt

UFH = 2 fingers below the

umbilicalUC = good

Wound episiotomy: dry

baby:

HR : 120

RR: 36x/mnt

T: 36.7 c

1st day of vacum

extraction

Observation VS and

subjective complain