MORNING REPORT ??-??-2011

Morning ReportFebruary 10th 2015Supervisor : dr. Agus Thoriq, Sp.OGMedical Students :

CASE RESUMENORMAL LABOR1PATHOLOGY LABORCase ReportName: Mrs. UKRM: 555028Age: 36 years oldAddress: Abian Tubuh, CakranegaraAdmitted: February 10th 2015

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING10/2/2015

08.00Patient referred from Risa GH with G4P3 41-42 week S/L. Patient confessed abdominal pain since 10/02/2015 at 02.00, history of water leaked out(-), bloody slim (-), FM (+).No history of DM, HT, asthma.

LMP : forgetEDD : -

History of ANC : > 4x at PHCLast ANC : 5/02/2015Result: BP:120/80, GW:39-40 week, FHB:+ (140x/m)History of USG : 3xLast USG : 09/02/2015Result GW:41-42 weekHistory of family planning : Oral contraceptionNext family planning : Injection 3 months

Obstetrical History :Aterm/spontan/house/3500//20 yoAterm/spontan/PHC/midwife/3500//3500/16 yo Aterm/spontan/GH/midwife/4 yothis

General Status :GC : wellBP : 110/80 mmHgPR : 80 bpmRR : 16 bpm T : 36,5oCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesiculer (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).

Obstetrical Status :L1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 34 cm EFW : 3565 gramUC : (-)FHB : 12-12-13 (148 bpm)VT : 1 cm, effacement 25%, amnion (+), head palpable HI, denominator unclear, impalpable small part and umbilical cord.G4P3A0L3 41-42 week S/L/IU head presentationObservation mother & fetal well being.DM co GP pro CTG, advice : ACC CTG reactive, termination with oxytocin drip. 3TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNINGChronologist :Risa GH (9-2-2015) 18.30S :-O : -USG :-A : G4P3 41-42 weeks S/LP : Pro termination and refer to NTB GHPS : 5Cervix dilatation 1 cm : 1Cervix length 1 cm : 2Cervix consistency moderate : 1Cervix position posterior : 0Station H I : 1

Lab Examination (10/02/2015) HB : 11,4 g/dl RBC : 4,51 x 106/L HCT : 36,4 % WBC : 8,12 x 103/LPLT : 355 x 103/LHbSAg : (-)4

10-2-2015 (09.30)TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING10.15Abdominal pain came and relievedUC : 1x10-10FHB : 11-11-11 (132 bpm)DM co CTG to GP, GP advice induction ocxtocyn 5 IU in D5% 8 dpm10.30Abdominal pain came and relievedUC : 1x10-10FHB : 12-12-11 (140 bpm)Drip oxytocin 8 tpm began11.00Abdominal pain came and relievedUC : 2 x 10 ~ 25FHB : 11-11-11 (132 bpm)Drip oxytocin 12 tpm11.30Abdominal pain frequentlyUC : 3 x 10 ~ 35FHB : 12-11-11 (136 bpm)VT : 2 cm, eff 50%, amnion (+), head palpable HI, denominator unclear, impalpable small part and umbilical cordG4P3A0L3 41-42 week S/L/IU head presentationLaten phase 1st Stage of labor-Drip oxytocin 16 tpm maintananceObservation mother and fetal well beingObservation progress of labor

12.00Abdominal pain frequently

UC : 3 x 10 ~ 40FHB : 12-12-11 (140 bpm)Drip oxytocin 16 tpm12.30Abdominal pain frequentlyUC : 4 x 10 ~ 40FHB : 11-11-11 (132 bpm)Drip oxytocin 16 tpm13.00Abdominal pain frequently

UC : 4 x 10 ~ 40FHB : 11-12-11 (136 bpm)Drip oxytocin 16 tpm13.30Abdominal pain frequently

UC : 4 x 10 ~ 40FHB : 11-12-11 (136 bpm)

Drip oxytocin 16 tpm

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING14.00Abdominal pain frequently

UC : 4 x 10 ~ 40FHB : 11-12-11 (136 bpm)

Drip oxytocin 16 tpm

14.30Abdominal pain frequently

UC : 4 x 10 ~ 40FHB : 11-12-11 (136 bpm)

Drip oxytocin 16 tpm

15.00Abdominal More frequentlyUC : 4 x 10 ~ 45FHB : 12-12-11 (140 bpm) VT : 6 cm, eff 75%, amnion (+), head palpable HI, denominator unclear, impalpable small part and umbilical cordDrip oxytocin 16 tpm15.30Water leaked out from her wombUC : 4 x 10 ~ 45FHB : 12-12-11 (140 bpm) VT : 10 cm, eff 100%, amnion (-), head palpable, HIII, small part of fetus / umbilical cord7TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING15.40Abdominal pain frequently

UC : 4 x 10 ~ 45FHB : 11-12-11 (136 bpm)Baby shown on vulva, with diameter 5 cm. pressure of anus, opening vulva

nd stage of labor

Conduct of Labor

15.50Baby was born, female 2800 gr, BL: 48 cm, Anus +, Anomali (-), A-S 7-9.

Placenta was born complete. Bleeding about 200 cc.

18.00GC: wellGCS: E4V5M6BP: 110/70 mmHgPR: 88 bpmRR: 22 rpm T: 37,10 C

UC (+) wellUFH 2 finger bellow umbilicalActive bleeding (-)UO: 50cc/hours2 hours post partum

Obs. Mother well beingObservation GC, VS, bleeding

11/02/2015GC: wellGCS: E4V5M6BP: 110/70 mmHgPR: 84 bpmRR: 21 rpm T: 36,8 CUC: (+) wellUFH: 2 finger bellow umbilicalLochea (+)

Baby:GC : wellPR : 132 bpmRR : 44 bpmT : 36,2 0C1 day post partum

Obs. Mother well beingSuggest mother to eat and drink, and medicationmobilistation

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Kurva LubchencoTHANK YOUTIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING