mr 13082015

Morning ReportAugust, 13th 2015

Supervisor:dr. Gede made punarbawa, Sp.OG

DM Jaga:febri, rian

Morning Reportaugust 10th 2015

Case ResumeNORMAL LABOR

0

PATHOLOGIES LABOR

1. G1P0A0L0 42-43 weeks S/L/IU, head presentation 1st stage latent phase with oligohidramnion + hypertension in pregnancy

2. G2P1A0L1 33-34 weeks S/L/IU, head presentation 1st stage latent phase with partus prematur imminemt

Case 1Name : Mrs. EAge : 19 years oldAddress : Gunung Sari Admitted : 11-08-2015 No. RM : 56-50-89

G1P0A0L0 42-43 weeks S/L/IU, head presentation 1st stage latent phase with oligohidramnion + hypertension in pregnancy

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

11/08/201523.12 wita

Patient reffered from Penimbung PHC to NTB GH with G1P0A0L0 40-41 weeks S/L/IU head presentation with post term. Patient confessed abdominal pain spread to the flank (+) since 21.00 10/08/2015, water leaked out from her womb (+) since 09.00 11/08/2015, bloody slim (+) since 10/08/2015, FM (+).

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

LMP : 22/10/2014EDD : 29/7/2015

History of ANC : 10x at PosyanduLast result: (06/08/2015) BP 90/60 mmHg, GW: 41 weeks, UFH 30 cm, head presentation, FHB (+), BW: 78 kg

General statusGC : wellconsciousness: CMBP : 150/100 mmHgPR: 80 bpmRR: 20 bpmT: 36,5°C

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

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 31 cmEFW : 3100 grUC : FHB : 11-12-12VT : Ø 1 cm, eff 25%, amnion (-), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

PS : 5


DM planning:Observation for mother

and fetal well being

DM co to GP co to SPV drip oxytocin

CIE planning • CIE mother and

family about diagnostic planning and therapeutic planning

• Suggest mother to lie down the left side, eat and drink


History of USG : 2x, at SpOGLast : 11/08/2015Result : S/L/IU, head presentation GW: 42-43 weeks, EFW: 3022 gr, amnion not clear, minimal, placenta at fundus gr III, EDD 27/07/2015Result : G1P0A0 42-43 weeks S/L/IU postterm, severe oligohidramnionHistory of family planning: -Next family planning : Inj 3 month

Obstetric History:I. This

Laboratory (11/08/2015 23.56):HB: 12,3 g/dl RBC: 4.71HCT: 37.2 %WBC: 10.03PLT: 261HbsAg: non reactiveProteinuria : -

Chronologist : at Penimbung PHC (11-08-2015)

13.00 WITAS : Patient confessed

abdominal pain that spread to the flank, bloody slim (+), history of water leaked (-) since 10/08/2015 at 23.00. Mother can still feel the FM (+).

O : GC : wellCons : CMBP : 110/70mmHgHR : 80x/mRR : 16x/mT : 36oC


Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 1/5UFH: 32 cmEFW : 3255 grUC : -FHB : 11-12-11VT : Ø 1 cm, eff 25%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

A : G1P0A0L0 42-43 weeks S/L/IU, head presentation with mother and fetal well being with postterm

P : Infus RL 28 tpmReffered to NTB GH


02.00 General statusGC : wellconsciousness: CMBP : 150/90 mmHgPR: 84 bpmRR: 20 bpmT: 36,7°C

UC : 1x10’ ~10”FHB : 11-12-12


Drip Oxytocin 8 dpm

02.30 UC : 1x10’ ~10”FHB : 11-12-12

Drip oxytocin 12 dpm

03.00 UC : 1x10’ ~10”FHB : 11-12-12


03.30 UC : 1x10’ ~10”FHB : 11-12-12



04.00 UC : 2x10’ ~10”FHB : 12-11-11


04.30 UC : 2x10’ ~10”FHB : 12-12-12


05.00 UC : 2x10’ ~10”FHB : 12-12-12


05.30 UC : 2x10’ ~10”FHB : 12-11-12


06.00 GC : wellconsciousness: CMBP : 130/100 mmHgPR: 88 bpmRR: 20 bpmT: 37°C

UC : 2x10’ ~10-15”FHB : 12-12-12

VT : Ø 1 cm, eff 25%, amnion (-), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord



06.30 UC : 2x10’ ~10-15”FHB : 12-12-12


07.00 UC : 2x10’ ~10-15”FHB : 12-12-12



07.30 GC : wellconsciousness: CMBP : 130/100 mmHgPR: 88 bpmRR: 24 bpmT: 36.8°C

UC : 2x10’ ~10”FHB : 12-12-12




08.00 UC : 2x10’ ~10”FHB : 12-12-12


08.30 UC : 2x10’ ~10”FHB : 12-12-12

2nd flash Drip oxytocin 40 dpm

09.00 GC : wellconsciousness: CMBP : 130/100 mmHgPR: 84 bpmRR: 22 bpmT: 36.8°C

UC : 2x10’ ~20”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (-), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

G1P0A0L0 42-43 weeks S/L/IU, head presentation 1st stage active phase with oligohidramnion + hypertension in pregnancy



09.30 UC : 2x10’ ~20”FHB : 12-11-11


10.00 UC : 3x10’ ~20”FHB : 12-11-11


10.30 UC : 3x10’ ~20”FHB : 11-11-12


11.00 UC : 3x10’ ~25”FHB : 12-12-11


11.30 UC : 3x10’ ~30”FHB : 12-11-12


12.00 UC : 3x10’ ~30”FHB : 12-11-12


12.30 UC : 3x10’ ~30”FHB : 12-12-12



13.00 Patient confess about water leaked out from her womb

GC : wellconsciousness: CMBP : 130/80 mmHgPR: 84 bpmRR: 20 bpmT: 36.8°C

UC : 3x10’ ~40”FHB : 12-12-13VT : Ø 9 cm, eff 75%, amnion (-), head presentation, ↓HII, denominator unclear, not palpable small part & umbilical cord

G1P0A0L0 42-43 weeks S/L/IU, head presentation 1st stage active phase with oligohidramnion + hypertension in pregnancy


and fetal well beingEvaluation 1 hour

again for dilatation of cervix

14.00 Mother want to bearing down GC : wellconsciousness: CMBP : 140/80 mmHgPR: 88 bpmRR: 20 bpmT: 36.8°C

UC : 3x10’ ~45”FHB : 12-12-13VT : Ø 10 cm, eff 100%, amnion (-), head presentation, ↓HII, denominator unclear, not palpable small part & umbilical cord

2nd stage of labor Lead mother to deliveryBaby was born at 14.25 spontan male, BW 2900 gr, BL 48 cm, A-S 6-8Do the 3rd stageactive management


14.30 Placenta born spontaneous UFH : 2 fingers below umbilical 3rd stage of active management

DM planning:Do the 4th stage

management

16.30 Mother confess about abdominal pain


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

4th stage of management

• Observation general condition and vital sign

• Observation UC, UFH, and lochea

• CIE mother to eat and drink

13/8/201507.00

Mother confess about abdominal pain


UC : wellUFH : 2 fingers below umbilicalUO : not measuredLochea rubra (+)




• CIE mother to breast feeding

• CIE mother to mobilization

Case 2Name : Mrs. NAge : 35 years oldAddress : Cakranegara Admitted : 12-08-2015 No. RM : 05-63-52

G2P1A0L1 33-34 weeks S/L/IU, head presentation 1st stage latent phase with partus prematur imminemt


12/08/2015

01.10 wita

Patient came by herself confessed about intermittent abdominal pain spread to the flank (+) since 17.00 (11/08/2015), water leaked out from her womb (-), bloody slim (+), FM (+).

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

LMP : 20/12/2014EDD : 27/9/2015

History of ANC : 5x at PoskesdesLast result: (22/07/2015) BP 100/70 mmHg, BW: 67 kgGW: 30-31 weeks, UFH 20 cm, head presentation, FHB (+) 13-13-13

History of USG : 1x, at SpOGLast : 12/08/2015Result : S/L/IU, head presentation back at the left side, GW: 30-33 weeks, EFW: 2025 gr, amnion clear, enough, placenta at fundus posterior

General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 96 bpmRR: 20 bpmT: 36,5°C

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

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 26 cmEFW : 2325 grUC : 1x10’ ~ 20”FHB : 13-12-13VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord



and fetal well being

DM co to GP co to SPV advice nifedipine 20 mg SD followed by 3x10 mg

CIE planning • CIE mother and

family about diagnostic planning and therapeutic planning

• Suggest mother to lie down the left side, eat and drink


History of family planning: -Next family planning : Inj 3 month

Obstetric History:I. Aterm/female/SC/2200 gr/11

years/liveII. This

Laboratory (12/08/2015 01.38):HB: 11.0 g/dl RBC: 4.00HCT: 32 %WBC: 12.37PLT: 306HbsAg: non reactive


UC : 1x10’ ~10”FHB : 12-12-12

VT : not do


DM Planning : USG

08.00 USG done by SPVResult : Fetal S/L/IU head presentation, back at the left side, GW : 30-33 weeks, EFW : 2025 gr, placenta at fundus posterior, AF clear and enough.

Advice :Inj Ampicillin 1gr/6 hoursInj Dexamethasone 10 mg/12 hours for 1 dayCheck CBC at 13/08/2015


Inj Ampicillin 1 gr/6 hoursInj Dexamethasone 10mg/12 hoursObservtion for mother and fetal well being


08.30 Inj Ampicillin 1 gr Inj Dexamethasone 10mg


UC : 1x10’ ~20”FHB : 12-12-13

VT : not do


Observtion for mother and fetal well beingInj Ampicillin 1 gr

20.20 Mother confessed about abdominal


UC : 3x10’ ~25-30”FHB : 12-11-12


Observation for mother and fetal well being20.30Inj. Ampicillin 1 grInj Dexamethasone 10 mg

23.00 UC : 3x10’ ~30”FHB : 11-11-12

VT : Ø 3 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

1st stage latent phase

Observation for mother and fetal well being


13/08/201501.10

Mother want to bearing down GC : wellconsciousness: CMBP : 110/80 mmHgPR: 92 bpmRR: 20 bpmT: 36.7°C

UC : 3x10’ ~35”FHB : 11-11-12


2nd stage of labor Lead mother to deliveryBaby was born at 01.20 spontan male, BW 1500 gr, BL 43 cm, A-S 7-9Do the 3rd stageactive management

01.25 Placenta born spontaneous UFH : 2 fingers below umbilicalRuptur perineum gr I

3rd stage of active management

DM planning:Do the 4th stage

management



UC : wellUFH : 1 fingers below umbilicalUO : not measuredActive bleeding (-)

4th stage of management







UC : wellUFH : 2 fingers below umbilicalUO : not measuredLochea rubra (+)




• CIE mother to breast feeding

• CIE mother to mobilization

.. Thank You ..

Documents

mr 13082015