MORNING REPORTSunday, January 31st, 2016 at 07.00 AM –Monday, February 1st, 2016 at 07.00 AM

Physiologic obstetrical patient : 2 casePathologic obstetrical patient : 4 casesGynecological patient : - casePassed Away : - caseTotal patient : 6 cases

Obstetric ward patients : 34 patientsGynecology and Oncology ward patients : 57 patientsICU patient : 3 patientTotal Patients : 94 patients

OBSTETRICS

1. 30-01-1602:00 PM

LSCS due to fetal distress Mrs.

PAJ/33/UA/ARP/MAND/ G2P1A0 39 weeks gestational age not inlabor + PROM 2

days SLF cephalic presentationHb : 10.4 g/dl

WBC : 9.200/mm3PLt :

304.000/mm3BS: 2

US ER (NIS):SLF cephalic presentationBiometry :BPD : 93 mm AC : 332mm EFW : 3190 gHC : 334mm FL : 72 mmPlacenta at anterior corpus of uterineAmniotic fluid was decrease, AFI 1,3 1,6 = 6,9 cm 1,8 2,2C/ 39 weeks gestational age SLF cephalic presentationM/ - Observed vital sign, FHR, inlabor sign - IVFD RL gtt xx/m - Laboratory examination - Ampicillin1g/6 hours iv

- Misoprostol 50mg/6 hours pvP/ Vaginal delivery

08:00 PM D/ G2P1A0 39 weeks gestational age not inlabor + PROM 2 days SLF cephalic presentation

Ø 0 cm M/ - Observed vital sign, FHR, inlabor sign - IVFD RLgtt xx/m - Ampicillin1g/6 hours iv - Misoprostol 50mg/6 hours pvP/ - Vaginal delivery

02:00 AM D/ G2P1A0 39 weeks gestational age inlabor 1st stages laten phase + PROM 2 days SLF cephalic presentation

Ø 2 cmUC 2x/10’/25”

M/ - Observed vital sign, FHR, contraction - IVFD RLgtt xx/m - Ampicillin1g/6 hours iv - Acceleration with oxytocin drip 5 IUP/ Vaginal delivery

06:00 AM D/ G2P1A0 39 weeks gestational age inlabor 1st stages laten phase + PROM 2 days SLF cephalic presentation

Ø 3 cmUC 2x/10’/25”

M/ - Observed vital sign, FHR, contraction - IVFD RLgtt xx/m - Ampicillin1g/6 hours iv - Acceleration with oxytocin drip 5 IUP/ Vaginal delivery

08:30 AM D/ G2P1A0 39 weeks gestational age inlabor 1st stages laten phase + PROM 2 days SLF cephalic presentation + fetal distress

Ø 4 cmUC 4x/10’/35”FHR I: 120x/m

FHR II: 105 x/mFHR III: 101 x/m

M/ - Observed vital sign, FHR, contraction - IVFD RLgtt xx/m - Acceleration oxytocin drip 5 IU stop - O2 5L/m - Latero positionP/ Abdominal deliveryConsult to Dr. H. Irawan Sastradinata, SpOG(K) Agree for abdominal delivery

10.25 AM Male life baby was born, BW 3500 gr, BL 48 cm, AS 2/0/0 FTAGA10.30 AM Placenta was delivered completely, PW 490 g, UCL: 48 cm, Ø19x 18cmHb : 9.1 g/dl

WBC : 15.000/mm3

PLt : 232.000/mm3

Mother was in good condition.

2 30-01-16 LSCS due to malpresentation Mrs. SAL/37/RA/ARP/COR

11.30 PM D/ G2P1A0 40 weeks gestational age not inlabor + PROM 3 days + secondary infertile 17 years SLF cephalic presentation

Hb : 10.9 g/dlWBC :

11.600/mm3

PLt : 311.000/mm3

CRP kuantitatif: <5

CRP Kualitatif: (-)

US ER (NIS):SLF cephalic presentationBiometry :BPD : 94 mm AC : 325mm EFW : 3671 gHC : 321mm FL : 74 mmPlacenta at posterior corpus of uterineAmniotic fluid was enoughC/ 40 weeks gestational age SLF cephalic presentationM/ - Observed vital sign, FHR, inlabor sign - IVFD RL gtt xx/m - Laboratory examination - Ampicillin1g/6 hours iv - induction with misoprostol 25 mg/6 hours pvP/ Vaginal delivery

05.30 AM D/ G2P1A0 40 weeks gestational age not inlabor + PROM 3 days secondary infertile 17 years SLF cephalic presentation

M/ - Observed vital sign, FHR, inlabor sign - IVFD RL gtt xx/m - Misoprostol 25 mg/6 hours pvP/ Vaginal delivery

01.30 PM D/ G2P1A0 40 weeks gestational age not inlabor + PROM 3 days secondary infertile 17 years SLF cephalic presentation + failed induction

M/ - Observed vital sign, FHR, inlabor sign

- IVFD RL gtt xx/mP/ Abdominal deliveryConsult to Dr. H. Iskandar Zulqarnain, SpOG(K) Agree for abdominal delivery

05.20 PM Male life baby was born, BW 3250 gr, BL 50 cm, AS 8/9 FTAGA05.25 PM Placenta was delivered completely, PW 500 g, UCL: 49 cm, Ø 19x

18cmHb : 10.6 g/dl

WBC : 22.700/mm3

PLt : 297.000/mm3

Mother was in good condition.

3. 31-01-1601:00 AM

LSCS due to malpresentation Mrs. NUR/19/UA/ ARP/CGHD/ G1P0A0 40 weeks gestational age not inlabor with PROM 6 hours + SLF cephalic presentation

Hb : 10.0 g/dlWBC :

10.300/mm3PLT :

235.000/mm3CRP kuantitatif:

<5CRP Kualitatif: (-)

US ER (NIS):SLF cephalic presentationBiometry :BPD : 94 mm AC : 325 mm EFW : 3147 gHC : 320 mm FL : 75 mmPlacenta at anterior corpus of uterineAmniotic fluid was decrease, AFI: 0,4 1,5 = 6,1 cm 1,9 2,2C/ 40 weeks gestational age SLF cephalic presentationM/ - Observed vital sign, FHR - IVFD RLgtt xx/m - Ampicillin1g/6 hours iv - Laboratory examination - Oxytocin drip 5 IUP/ Vaginal delivery

05:00 AM D/ G1P0A0 40 weeks gestational age not inlabor with PROM 10 hours + SLF cephalic presentationM/ - Observed vital sign, FHR - IVFD RLgtt xx/m

- Ampicillin1g/6 hours iv - Oxytocin drip 5 IUP/ Vaginal delivery

09:00 AMØ 2 cm

UC 2x/10’/25”

D/ G1P0A0 40 weeks gestational age inlabor 1st stages laten phase with PROM 14 hours + SLF cephalic presentationM/ - Observed vital sign, FHR - IVFD RLgtt xx/m - Ampicillin1g/6 hours iv - Oxytocin drip 5 IUP/ Vaginal delivery

01:00 PMØ 2 cm

UC 2x/10’/25”

D/ G1P0A0 40 weeks gestational age inlabor 1st stages laten phase with PROM 18 hours + SLF cephalic presentationM/ - Observed vital sign, FHR - IVFD RLgtt xx/m - Ampicillin1g/6 hours iv - Oxytocin drip 5 IUP/ Vaginal delivery

05:00 PMØ 2 cm

UC 2x/10’/25”

D/ G1P0A0 40 weeks gestational age inlabor 1st stages with prolong laten phase + PROM 22 hours + SLF cephalic presentationM/ - Observed vital sign, FHR - IVFD RLgtt xx/mP/ Abdominal deliveryConsult to Dr. H. Irawan Sastradinata, SpOG(K) Agree for abdominal delivery

11:05 PM Female life baby was born, BW 2900 gr, BL 47 cm, AS 8/9 FTAGA11:08 PM Placenta was delivered completely, PW 500 g, UCL: 49 cm, Ø19x 18cmHb : 10.6 g/dl

WBC : 22.700/mm3

PLt : 297.000/mm3

Mother was in good condition.

4. 31-01-1607:00 AM

LSCS due to total placenta previa Mrs.

EUI/34/RA/ ARP/RICD/ G4P3A0 35 weeks gestational age not inlabor with APH cb total placenta previa + recurrent bleeding + SLF cephalic presentation

Hb : g/dlWBC : /mm3PLt : /mm3

US ER (FOR):SLF cephalic presentationBiometry :BPD : 80 mm AC : 316 mm EFW : 2550 gHC : 311 mm FL : 63 mmPlacenta at posterior corpus expand to OUIAmniotic fluid was enoughC/ 35 weeks gestational age SLF cephalic presentation + total placenta previaM/ - Observed vital sign, FHR, contraction - IVFD RLgtt xx/m - Cefriaxone1g/12 hours iv - Laboratory examinationP/ Abdominal deliveryConsult to Dr. H. Azhari, SpOG(K) Agree for abdominal delivery

01:05 PM Female life baby was born, BW 2900 gr, BL 47 cm, AS 8/9 FTAGA01:08 PM Placenta was delivered completely, PW 500 g, UCL: 48 cm, Ø19x 18cm

Hb : g/dlWBC : /mm3PLt : /mm3

Mother was in good condition.

5. 31-01-1601:30 PM

Brandt Andrew’s manuevre Mrs. IIS/42/UA/RIC/RNI

Hb : g/dlWBC : /mm3PLt : /mm3

D/ P5A0 post spontaneous delivery (outside) + retained placenta cb incarserated placentaM/ - Observed vital sign, contraction, bleeding - O2 5L/m - IVFD RLgtt xx/m - Laboratory examinationP/ Brandt Andrew’s manuevre

Hb : g/dlWBC : /mm3PLt : /mm3

Mother was in good condition.

6 31-01-1604.00 PM

Spontaneus delivery Mrs.

AND/37/UA/FEL/RNID/ G5P4A0 37 weeks gestational age not inlabor with

hiperthyroid SLF cephalic presentationHb : 11,1 g/dl

WBC : 13.700/mm3

PLt : 242.000/mm3

T3 total: 0,51ng/mL

T4 total: 1,88 mg/dL

Free T4: 0,68ng/dL

TSH: 0,30mIU/ml

US ER (DIK):SLF cephalic presentationBiometry :BPD : 91 mm AC : 318 mm EFW : 2778 gHC : 312 mm FL : 64 mmPlacenta at anterior corpusAmniotic fluid was enoughC/ 37 weeks gestational age SLF cephalic presentation

M/ - Observed vital sign, FHR, uterine contraction - IVFD RL gtt xx/m - Laboratory examination - Consul to internal departmentP/ Vaginal deliveryInternal department reply:C/ Subclinic hiperthyroidP/ - Th/ Obgyn department - Laboratory examination free T4, TSH, next month

08.00 PM D/ G5P4A0 37 weeks gestational age not inlabor with hiperthyroid SLF cephalic presentation

M/ - Observed vital sign, FHR, uterine contraction - IVFD RL gtt xx/mP/ Vaginal delivery

01-02-1600.00 AM

D/ G5P4A0 37 weeks gestational age inlabor 1st stages laten phase with hyperthyroid SLF cephalic presentation

Ø 2 cm M/ - Observed vital sign, FHR, uterine contraction

UC 2x/10’/25” - IVFD RL gtt xx/mP/ Vaginal delivery

04.00 AM D/ G5P4A0 37 weeks gestational age inlabor 1st stages laten phase with hiperthyroid SLF cephalic presentation

Ø 3 cmUC 2x/10’/25”

M/ - Observed vital sign, FHR, uterine contraction - IVFD RL gtt xx/mP/ Vaginal delivery

08.00 AM D/ G5P4A0 37 weeks gestational age inlabor 1st stages active phase with hiperthyroid SLF vertex presentation

Ø 4 cmUC 3x/10’/35”

M/ - Observed vital sign, FHR, uterine contraction - IVFD RL gtt xx/mP/ Vaginal delivery

00.00 PM D/ G5P4A0 37 weeks gestational age inlabor 1st stages active phase with hiperthyroid SLF vertex presentation

Ø 8 cmUC 4x/10’/40”

M/ - Observed vital sign, FHR, uterine contraction - IVFD RL gtt xx/mP/ Vaginal delivery

01.30 PM D/ G5P4A0 37 weeks gestational age inlabor 2nd stages with hiperthyroid SLF vertex presentation

Partograph M/ Conduct the labor01:40 PM Female life baby was born, BW 3000 g, BL 45 cm, AS 8/9 FTAGA01.50 PM Placenta was delivered completely, PW 500 g, UCL: 47 cm,

Ø18x 19cmHb : g/dl

WBC : /mm3PLt : /mm3

Mother and baby were in good condition