MORNING REPORT

September 14th, 2012

Supervisor : dr. Agus Rusdhy Hariawan Hamid, Sp.OG

Medical Students : Jun, Erma, Dini H, Dini F, Jatna
CASES RESUME NORMAL LABOR PATHOLOGY LABOR 1 1. G4P1A2L1 A/S/L/IU head presentation with laten phase 1st stage of labor + history CS 11 years ago + History rupture of membrane 2. G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours 3. G3P2A0H2 A/S/L/IU with PROM >12 hours

Name: Mrs.N Age: 27 yo Address: Kapu, Jenggara, Tanjung, KLU Admitted: September, 14th 2012 at 11.00 wita

TIME 14/09/ 2012 (11.00)

SUBJECTIVE Patient referred from Tanjung GH with G3P2A0L1 36-37 weaks/S/L/IU with PROM > 12 hours. Patient confessed rupture of membrane since 20.00 (13/09/2012). Abdominal pain (-). Bloody slim (-), FM (+). No history of DM, HT, asthma. LMP: forgot EDD : History of ANC: > 4 X posyandu Last ANC : 06-09-2012 Result : normal History of USG: never

OBJECTIVE General status: GC: well BP: 110/70 mmHg PR: 80 bpm RR: 20 T: 36,5OC Eye : anemis (-), icteric (-) Thorax : Cor : S1S2 single regular (murmur ), (gallop -) Pulmo : vesicular (+/+), wheezing (/-), Ronchi (-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (-/-), warm acral (+/+) Obstetrical status: L1: breech L2: back on the left side L3: head L4: 4/5 UFH: 29 cm EFW: 2790 g UC : FHB: 11-11-11 (132 x/min) VT: 2 cm, eff 10 %, amnion (-), head palpable HI, impalpable small part / umbilical cord.

ASSESTMENT G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

PLANNING Obs mother & fetal well being skin test ampi (-) Inj. Ampicillin 1 gr /6 hour IV DM announce to SPV pro induction with oxytocin drip if CTG reactive, advice: acc induction with drip oxytocin if CTG reactive

History of family planning : pill Next family planning : injection 3 month

Obstetrical history: I. , Premature, 2500 gram, RSU Tanjung, 12 yo II. , Aterm, 2500 gram, midwife, death 3 month III. This

TIME

SUBJECTIVE Chronology: 09.30 (14/09/2012) S: Patient referred from midwife came to Tanjung GH confessed rupture of membrane since 19.30 (13/09/2012). Bloody Slim (-). Abdominal pain (-). History of DM (-), asthma (--), HT (-) LMP: forgot EDD: O: GC: well BP: 100/70 mmHg PR: 80 bpm RR: 20 bpm T: 36,4oc L1: breech TFU : 27 cm L2: back on the left side TBJ : 2480 g L3: head L4: 4/5 23.30 (13-09-2012) UC: FHB: 12-12-11 (140 x/min) VT: 1 cm, eff 25 %, amnion (-), head palpable HI, denom unclear, impalpable small part / umbilical cord. 08.30 (14-09-2012) UC: FHB: 11-12-12 (140 bpm) VT: 1 cm, eff 25 %, amnion (-), head palpable HI, denom unclear, impalpable small part / umbilical cord. A:G3P2A0L1 36-37 weaks/S/L/IU with PROM > 12 hours. P: infuse RL 20 dpm inj. Ampicillin 1 gr (IV) 23.20 wita Obs mother & fetal well being Refer to NTB GH

OBJECTIVE PS: 5 Cervic dilatation 2 cm : 1 Cervix length 1 cm : 2 Cervix consistency moderate : 1 Cervix position posterior : 0 Station H I : 1

ASSESTMENT

PLANNING

Lab: HB: 13,1 g/dl RBC : 4,46 M/dl WBC : 6,7 K/dl PLT : 165 K/dl HbSAg: (-)

TIME 13.00 -

SUBJECTIVE

OBJECTIVE GC: well BP: 120/80 mmHg PR: 88 bpm RR: 20 T: 36,5 CTG: reactive UC: FHR: 11-12-13 (144 bpm )

ASSESTMENT G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

PLANNING Flash I Drip oxy began 8 dpm

13.30

UC: FHR: 12-12-12 (144 bpm)

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours G3P2A0L1 A/S/L/IU head presentation with PROM > 12 hours

Drip oxy 12 dpm

14.00

UC: FHR: 12-11-11 (136 bpm)

Drip oxy 16 dpm

14.30

UC: FHR: 11-11-12 (136 bpm)

Drip oxy 20 dpm

15.00

Abdominal pain came and relieved

UC: 2x/10 ~ 20 FHR: 12-12-12 (144 bpm)

Drip oxy 24 dpm

15.30

Abdominal pain came and relieved

UC: 2x/10 ~ 30 FHR: 12-11-12 (140 bpm)

Drip oxy 28 dpm

TIME 16.00

SUBJECTIVE Abdominal pain came and relieved

OBJECTIVE UC: 3x/10 ~ 30 FHR: 12-12-12 (144) VT: 3 cm, eff 25%, amnion (-), head palpable HI, impalpable small part of fetal/ umbilical cord UC : 3x/10 ~ 35 FHR : 12-12-13 (148 bpm) G3P2A0L1 A/S/L/IU head presentation latent phase 1st stage of labor with history rupture of membrane

PLANNING Drip oxy 32 dpm CTG, result: reactive

16.30

Abdominal pain came and relieved

Drip oxy 36 dpm

17.00

Abdominal pain came and relieved

UC: 3x/10 ~ 35 FHR: 12-13-13 (152 bpm)

Drip oxy 40 dpm

17.30

Abdominal pain came and relieved

UC: 4x/10 ~ 35 FHR: 12-12-12 (144 bpm) UC: 4x/10 ~ 35 FHR: 12-13-12 (148 bpm) UC: 4x/10 ~ 35 FHR: 12-11-13 (144 bpm)

Drip oxy 40 dpm

18.00

Abdominal pain came and relieved

Drip oxy 40 dpm

18.30

Abdominal pain came and relieved

Drip oxy 40 dpm

19.00

Abdominal pain came and relieved

UC: 4x/10 ~ 35 FHR: 12-12-12 (144 bpm) UC: 4x/10 ~ 35 FHR: 11-12-11 (136 bpm)

Flash II Drip oxy 40 dpm

19.30

Abdominal pain came and relieved

Drip oxy 40 dpm

TIME 20.00

SUBJECTIVE Abdominal pain came and relieved

OBJECTIVE UC: 4x/10 ~ 35 FHR: 13-12-13 (152 bpm) VT: 8 cm, effacement 75 %, amnion (-), head palpable HII denominator LOA, impalpable small part of fetal / umbilical cord G3P2A0L1 A/S/L/IU head presentation active phase 1st stage of labor with history rupture of membrane

PLANNING Drip oxy 40 dpm

20.30

Abdominal pain came and relieved Abdominal pain ++ Mother want to bearing down doran

UC: 4x/10 ~ 45 FHR: 12-12-12 (144 bpm) UC: 4x/10 ~ 45 FHR: 12-12-12 (144 bpm) Teknus perjol vulka 2nd stage of labor

Drip oxy 40 dpm

21.00

Drip oxy 40 dpm Conduct mother to bearing down Baby was born, male, AS 7-9, 2750 gram, 48 cm, Anus (+), congenital anomaly (-) Placenta was born spontaneous, complete, perineum intak bleeding 150cc

21.35

23.35

Delivery wound pain

GC: well Cons: CM BP: 120/70 HR: 84 bpm RR: 24 tpm T: 36,5 C UC: + UFH: 1 finger below umbilicus GC: well Cons: CM BP: 120/80 HR : 80 bpm RR : 20 tpm T : 36,4 C UFH : 1 finger below umbilicus UC : + Baby rooming in PR: 120 RR: 44 T: 36,7

2 day post partum

Observed mother and baby well being Suggest mother to mobilisation.

15/09/ 2012 (07.00)

Delivery wound pain

1 day post partum

Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.