MORNING REPORTSeptember 14th, 2012

Supervisor : dr. Agus Rusdhy Hariawan Hamid, Sp.OGMedical Students :

Jun, Erma, Dini H, Dini F, Jatna

CASES RESUME

NORMAL LABOR 1

PATHOLOGY LABOR 1. G4P1A2L1 A/S/L/IU head presentation with laten phase 1st stage of labor + history CS 11 years ago + History rupture of membrane

2. G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

3. G3P2A0H2 A/S/L/IU with PROM >12 hours

Name: Mrs.NAge: 27 yoAddress: Kapu, Jenggara, Tanjung, KLUAdmitted: September, 14th 2012 at 11.00 wita

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

14/09/2012(11.00)

Patient referred from Tanjung GH with G3P2A0L1 36-37 weaks/S/L/IU with PROM > 12 hours. Patient confessed rupture of membrane since 20.00 (13/09/2012). Abdominal pain (-). Bloody slim (-), FM (+). No history of DM, HT, asthma.

LMP: forgotEDD : -

History of ANC: > 4 X posyanduLast ANC : 06-09-2012Result : normalHistory of USG: never

History of family planning : pillNext family planning : injection 3 month

Obstetrical history:I. ♀, Premature, 2500

gram, RSU Tanjung, 12 yoII. ♀, Aterm, 2500 gram,

midwife, death 3 month III. This

General status:GC: wellBP: 110/70 mmHgPR: 80 bpmRR: 20 T: 36,5OCEye : anemis (-), icteric (-)Thorax :Cor : S1S2 single regular (murmur -), (gallop -)Pulmo : vesicular (+/+), wheezing (-/-),Ronchi (-/-).Abdomen : scar (-), striae (+), linea nigra (+)Extremity : edema (-/-), warm acral (+/+)

Obstetrical status:L1: breechL2: back on the left sideL3: headL4: 4/5UFH: 29 cm EFW: 2790 gUC : -FHB: 11-11-11 (132 x/min)VT: Ø 2 cm, eff 10 %, amnion (-), head palpable ↓HI, impalpable small part / umbilical cord.

G3P2A0L1 A/S/L/IU head presentation

with PROM > 12 hours

•Obs mother & fetal well being• skin test ampi (-) Inj. Ampicillin 1 gr /6 hour IV•DM announce to SPV

pro induction with oxytocin drip if CTG reactive, advice:

acc induction with drip oxytocin if CTG reactive

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

Chronology:09.30 (14/09/2012)S :Patient referred from midwife came to Tanjung GH confessed rupture of membrane since 19.30 (13/09/2012). Bloody Slim (-). Abdominal pain (-). History of DM (-), asthma (--), HT (-)LMP: forgot EDD: -O :GC: wellBP: 100/70 mmHgPR: 80 bpmRR: 20 bpm T: 36,4ocL1: breech TFU : 27 cmL2: back on the left side TBJ : 2480 gL3: headL4: 4/523.30 (13-09-2012)UC: -FHB: 12-12-11 (140 x/min)VT: Ø 1 cm, eff 25 %, amnion (-), head palpable ↓HI, denom unclear, impalpable small part / umbilical cord.08.30 (14-09-2012)UC: -FHB: 11-12-12 (140 bpm)VT: Ø 1 cm, eff 25 %, amnion (-), head palpable ↓HI, denom unclear, impalpable small part / umbilical cord.A:G3P2A0L1 36-37 weaks/S/L/IU with PROM > 12 hours.P: • infuse RL 20 dpm• inj. Ampicillin 1 gr (IV) 23.20 wita• Obs mother & fetal well being• Refer to NTB GH

PS: 5Cervic dilatation 2 cm : 1Cervix length 1 cm : 2Cervix consistency moderate : 1Cervix position posterior : 0Station H I : 1

Lab:HB: 13,1 g/dl RBC : 4,46 M/dl WBC : 6,7 K/dlPLT : 165 K/dlHbSAg: (-)

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

13.00 - GC: wellBP: 120/80 mmHgPR: 88 bpmRR: 20 T: 36,5

CTG: reactiveUC: -FHR: 11-12-13 (144 bpm )

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Flash I Drip oxy began 8 dpm

13.30 - UC: -FHR: 12-12-12 (144 bpm)

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Drip oxy 12 dpm

14.00 - UC: -FHR: 12-11-11 (136 bpm)

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Drip oxy 16 dpm

14.30 - UC: -FHR: 11-11-12 (136 bpm)

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Drip oxy 20 dpm

15.00 Abdominal pain came and relieved

UC: 2x/10’ ~ 20”FHR: 12-12-12 (144 bpm)

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Drip oxy 24 dpm

15.30 Abdominal pain came and relieved

UC: 2x/10’ ~ 30”FHR: 12-11-12 (140 bpm)

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Drip oxy 28 dpm

TIME SUBJECTIVE OBJECTIVE PLANNING

16.00 Abdominal pain came and relieved

UC: 3x/10’ ~ 30”FHR: 12-12-12 (144)VT: Ø 3 cm, eff 25%, amnion (-), head palpable ↓HI, impalpable small part of fetal/ umbilical cord

G3P2A0L1 A/S/L/IU head presentation latent phase 1st stage of labor with history rupture of membrane

Drip oxy 32 dpmCTG, result: reactive

16.30 Abdominal pain came and relieved

UC : 3x/10” ~ 35”FHR : 12-12-13 (148 bpm)

Drip oxy 36 dpm

17.00 Abdominal pain came and relieved

UC: 3x/10” ~ 35”FHR: 12-13-13 (152 bpm)

Drip oxy 40 dpm

17.30 Abdominal pain came and relieved

UC: 4x/10” ~ 35”FHR: 12-12-12 (144 bpm)

Drip oxy 40 dpm

18.00 Abdominal pain came and relieved

UC: 4x/10” ~ 35”FHR: 12-13-12 (148 bpm)

Drip oxy 40 dpm

18.30 Abdominal pain came and relieved

UC: 4x/10” ~ 35”FHR: 12-11-13 (144 bpm)

Drip oxy 40 dpm

19.00 Abdominal pain came and relieved

UC: 4x/10” ~ 35”FHR: 12-12-12 (144 bpm)

Flash II Drip oxy 40 dpm

19.30 Abdominal pain came and relieved

UC: 4x/10” ~ 35”FHR: 11-12-11 (136 bpm)

Drip oxy 40 dpm

TIME SUBJECTIVE OBJECTIVE PLANNING

20.00 Abdominal pain came and relieved

UC: 4x/10” ~ 35”FHR: 13-12-13 (152 bpm)

VT: Ø 8 cm, effacement 75 %, amnion (-), head palpable ↓HII denominator LOA, impalpable small part of fetal / umbilical cord

G3P2A0L1 A/S/L/IU head presentation active phase 1st stage of labor with history rupture of membrane

Drip oxy 40 dpm

20.30 Abdominal pain came and relieved

UC: 4x/10” ~ 45”FHR: 12-12-12 (144 bpm)

Drip oxy 40 dpm

21.00 Abdominal pain ++Mother want to bearing down doran

UC: 4x/10” ~ 45”FHR: 12-12-12 (144 bpm)

Teknus perjol vulka

2nd stage of labor Drip oxy 40 dpm

Conduct mother to bearing down

21.35 Baby was born, male, AS 7-9, 2750 gram, 48 cm, Anus (+), congenital anomaly (-)Placenta was born spontaneous, complete, perineum intak bleeding ±150cc

23.35 Delivery wound pain GC: well Cons: CMBP: 120/70 HR: 84 bpmRR: 24 tpm T: 36,5 CUC: +UFH: 1 finger below umbilicus

2 day post partum •Observed mother and baby well being• Suggest mother to mobilisation.

15/09/2012(07.00)

Delivery wound pain GC: well Cons: CMBP: 120/80 HR : 80 bpm RR : 20 tpm T : 36,4 CUFH : 1 finger below umbilicusUC : +

Baby rooming inPR: 120RR: 44T: 36,7

1 day post partum •Observed mother and baby well being• Suggest mother to mobilisation, eat, and drink, medication.