Supervisor :

dr. I Made Putra Juliawan SpOG

Medical Students :

Yan, Rifka, Agung, Tari, Metha, Santhi, Rona

MORNING REPORT4th September 2012

CASE RESUME

NORMAL LABOR

PATHOLOGIC LABOR 1. G4P1A2H1 39 - 40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor.

Case Report

Name : Mrs. RAge : 34 years oldAddress : Batu Rimpang, Narmada, Lombok

BaratAdmitted : September 3th, 2012 at 11.00

WITA

Time Subject Object Assessment Planning

Chronologist in Narmada PHC: 03/09/2012, 10.00 WITAS: Patient came confessed abdominal pain. Patient referred from midwife sembung village.LMP : 30/11/2012EDD : 7/09/2012O: General status : GC : well, Consciousness : CMBP : 100/70 mmHgHR : 80 x/minuteRR : 20 x/minuteT : 36,8 ºCObstetric status: L1 : breech TFU: 34 cm L2 : back on the right sideL3 : headL4 : 4/5UC : (+) 3x/10’ - 25”FHR : (+) 11–11–11 (132x/minute)VT : Ø 5 cm, eff. 50%, Amnion (+) , head palpable ↓HI, denom : ROA, impalpable small part of fetal & umbilical cord.A: G4P1A2L1 40 weeks S/L/IU head presentation, condition mother and fetal well with active phase 1st stage of labor.P: - Obs. Mother and fetal well being. - Inf RL 2 flash - Inf D5 28 tpm 1 flash

Pelvic evaluation :•Spina ischiadica not prominent•Os coccigeous mobile•Pubic arch > 900

Lab result in 11.46 (03/09/2012)Hb = 10,8 g/dl LRBC = 3,68 10^6/µL WBC = 9.0 10^3/µLPlt = 365 10^3/µLHct = 35,5 % LHbSAg = (-)

Time Subject Object Assessment Planning

13.00

15.00

Patient confessed abdominal pain.

Patient confessed abdominal pain.

General statusGC : wellConsciousness : CM (E4V5M6)BP : 120/70 mmHgHR: 96 bpmRR: 20 bpmT : 36,2°CObstetric statusUC : 2x/10’ – 35”FHB : 12-12-12 (144 bpm)

General statusGC : wellBP : 120/80 mmHgPR: 88 bpmRR: 20 bpmT : 36,7°CObstetric statusUC : 3x/10’ ~ 35“FHB : 12.11.12 (140 bpm)VT : Ø 4cm, eff. 50%, Amnion (-) , head palpable ↓HI,denom : ROA, impalpable small part of fetal & umbilical cord.

G4P1A2H1 39 - 40 weeks S/L/IU head prsentation with arrested active phase 1st stage of labor

-Obs. Mother and fetal well being.-Obs. Progress of labor

- Obs. Mother and fetal well being.-Obs. Progress of labor- DM co to SPV. pro CS. Advice : Acc CS at 21.00. Continue obs. Mother and fetal well being & progress of labor.

Time Subject Object Assessment Planning

17.00

18.00

Patient confessed abdominal pain.

Patient confessed abdominal pain.

General statusGC : wellConsciousness : CM (E4V5M6)BP : 110/70 mmHgHR: 88 bpmRR: 20 bpmT : 36, 7°CObstetric statusUC : 3x/10’ – 30”FHB : 11-11-11 (132 bpm)

General statusGC : wellConsciousness : CM (E4V5M6)BP : 120/70 mmHgHR: 96 bpmRR: 24 bpmT : 36, 8 °CObstetric statusUC : 3x/10’ – 35”FHB : 11-12-11 (136 bpm)

-Obs. Mother and fetal well being.-Obs. Progress of labor

-Obs. Mother and fetal well being.- Obs. Progress of labor

Time Subject Object Assessment Planning

17.00

22.20

Patient confessed abdominal pain.

General statusGC : wellBP : 120/80 mmHgPR: 88 bpmRR: 20 bpmT : 36,7°CObstetric statusUC : 3x/10’ ~ 35“FHB : 11.11.12 (136 bpm)VT : Ø 5 cm, eff. 50%, Amnion (-) , head palpable ↓HI,denom : ROA, impalpable small part of fetal & umbilical cord.

G4P1A2H1 39 - 40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor

Prepare CS 21.00 - Insert DC. - Inj. Ampicillin 2g/IV. - CIE patient tp CS and use IUD, patient acc.- Check BT, CT

CS beganBaby was born (22.45, 03/09/2012). Male. 3400 g. 51 cm. AS 7-9. Anus (+). Congenital anomaly (-). Placenta was born. Spontaneously at 22.43,Complete. Bleeding ± 400cc

CS finish at 23.00 (03/09/2012)

Time Subject Object Assessment Planning

04/09/2012

01.00

Patient confessed wound pain

GC : wellCons : Compos MentisBP : 110/70 mmHgPR : 96 bpmRR : 24 bpmT : 36 0 CActive bleeding : (-)Lochia rubra : (+)UFH : at umbilicusUC : (+) wellUO : ± 50 cc/hours

2 hours post CS • Observed mother and baby well being

• Suggest mother to take a rest, eat and drink, mobilisation.

07.00 Patient confessed wound pain

GC : well Cons : Compos MentisBP: 110/80 mmHg PR : 88 bpm RR : 24 bpm T : 36,8 oCUFH : 2 fingers below umbilicusUC : (+) wellActive bleeding : (-)Lochia rubra : (+)UO : ± 50 cc/hours

Baby in NICU :GC : wellPR : 132 bpmRR : 44 bpmT : 36,2OC

One day post CS • Observed mother and baby well being

• Suggest mother to mobilisation, eat, and drink, medication.