mr 10092015

Morning ReportSeptember, 10th 2015

Supervisor:Dr. Agus Thoriq, SpOG

DM Jaga:Rian

Morning Reportseptember 10th 2015

Case ResumeNORMAL LABOR

0

PATHOLOGIES LABOR

1. G1P0A0L0 39-40 weeks S/L/IU head presentation with Mild Preeclampsia + Condyloma Acuminata

Case 1Name : Mrs. IAge : 22 years oldAddress : Gunung SariAdmitted : 09-09-2015 No. RM : 56-65-50

G1P0A0L0 39-40 weeks S/L/IU head presentation with Mild Preeclampsia + Condyloma Acuminata

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

09/09/2015

12.12 wita

Patient reffered from Gunung Sari PHC with G1P0AL0 39-40 weeks S/L/IU head presentation mother and fetal well being with 1st stage latent phase + severe preeclampsia. Patient confessed about abdominal pain since 22.00 (08/09/2015) history of water leaked out from her womb (-) History of bloody slim (-), FM (+).

History of DM (-), HT in pregnancy (-), asthma (-) and allergy (-).

LMP : 07/12/2014EDD : 14/09/2015

History of ANC : 6x at PHCLast result: (20/08/2015) BP 110/70 mmHg, BW 57 kg, GW 36-37 w UFH 30 cm, head presentation, FHB (+)History of USG : 1x, at SpOGLast : 28/07/2015S/L/IU head presentation, male, GW 36-37 weeks, placenta at corpus posterior, amnion clear, EFW 2459 gEDD 01/09/2015

History of family planning: injection 3 monthNext family planning : IUD

General statusGC : wellconsciousness: CMBP : 140/10 mmHgPR: 72 bpmRR: 20 bpmT: 36.7°C

Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema of lower extremity(-/-), warm acral (+/+).

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 31 cmEFW : 3100 gUC : 1x10’~20”FHB : 12-12-12VT : Ø 2 cm, eff 25%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G1P0A0L0 39-40 weeks S/L/IU head presentation with mild preeclampsia + condyloma acuminata

DM planning:Diagnostic : CTGTherapy :Pro termination per CSMonitoring : VS mother,

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP co to SPV advice :

C-Section


Obstetric History:I. This

Pelvic ExaminationPromontorium unpalpableSpina ishiadica non prominemArcus pubis >90o

Os. Coccygeus mobile

Pelvic score = 5Dilatation of cervix : 1Length of cervix : 1Station : 1Consistency : 1Position : 1

Laboratory (09/09/2015 12.04):HB: 11.1 g/dl RBC: 4.31HCT: 33.8 %WBC: 10.98PLT: 427HbsAg: non reactiveBT : 3’00”CT : 6’10”Cr : 0.4Ur : 12SGOT : 16SGPT : 7


Chronology at Gunung Sari PHC (09/09/2015)10.00S :Patient 9 months of pregnancy come to PHC confessed abdominal pain nsince 22.00 (08/09/2015) water leaked out from the womb (-) fetal movement (+)

O :GC : wellconsciousness: CMBP : 140/90 mmHgPR: 84 bpmRR: 20 bpmT: 36.2°C

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 29 cmEFW : 2790 gUC : 1x10’~20”FHB : 12-11-11

VT : Ø 2 cm, eff 25%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord


Oedema -/-Protein urin +3

A :G1P0A0L0 39-40 weeks /S/L/IU head presentation mother and fetal well being with 1st stage latent phase + severe preeclampsia

P :CIE mother about examination resultCo to GP adviceNifedipine 10 mg poDrip MgSO4Refer to NTB GH


13.00 Patient transffered to OR General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36,7°C

UC : 1x10’ ~20”FHB : 12-12-13

G1P0A0L0 39-40 weeks S/L/IU head presentation with mild preeclampsia + condyloma acuminata

DM planning:Diagnostic : -Therapy : -Monitoring : VS mother,

UC, FHBCIE : suggest mother

to bearing down

C Section begin at 9/9/2015 13.30

At 13.37 Baby was born, female, BW 3000 g, BL 49 cm, A-S 7-9

Placenta was born completely at 13.40

Do the management of 4th stage of labor


16.00 GC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.4°C

UC : wellUFH : 1 fingers below umbilicalUO : 200cc/2 hoursActive bleeding (-)

Baby in NICU :HR : 152x/minuteRR : 54x/minuteT : 36,3oC

2 hours post CS DM planning:Diagnostic : -Therapy : Amoxicillin 3x500 mgMefenamic Acid 3 x

500 mgMonitoring : VS mother,

UC, UFH CIE : suggest mother

to eat and drink

10/09/201507.00

Patient confessed about abdominal wound pain

GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.4°C

UC : wellUFH : 2 fingers below umbilicalUO : not measuredActive bleeding (-)

Baby in NICU :HR : 148x/minuteRR : 50x/minuteT : 36,5oC

1 day post CS DM planning:Diagnostic : -Therapy : -Monitoring : VS mother,

UC, UFH, UOCIE : suggest mother

to eat and drink

.. Thank You ..

mr 10092015

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