Morning Report 30 December 2008

Supervisor : dr.H. Doddy A.K, SpOG

Medical Student: Amrul Maman

Cases resume : 1. 2.

PROM >12 hours+SC HISTORY+CPD Prolonged second stage+ breech presentation Normal delivery 1.

1 1 4

3.

Name address
Waktu

: Mrs. MALIHAH/25 years : LENENG, LOTENG

CTH

: 30-12-08 : 21.00

Subject

Object General status : General condition: well, Conciousness: CM BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,8 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range
Obstetric status : L1 : breech L2 : right back L3 : head L4 : was in pelvic inlet 4/5 UFH : 32 cm EFW : 3255 g UC : (-) Fetal Heart Rate : 158x/mnt VT: 1 cm, eff 10 %, amnionic membrane (-),AF (+) clear, head palpable, descend HI, unpalpable small organ.

Assesment G2P1A0H1 39-40 weeks/S/L with SC history + PROM >12 hours+CPD

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg
(22.30)Inform to doctor of ward to concul supervisor and at 22.45: Propose : observasion and prepared for SC tomorrow morning

09.30 pm

Patient refered by Praya Primary Health care with G2P1A0H1 39-40 weeks/S/L with PROM > 12 hours + SC hustory
Chronology : Patient felt abdominal discomfort and watery vaginal discharg when 09.00 am (30-12-2008), then patient taken to praya primary healt care center at 11.00 am (30/12-08). In praya PHCC found BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,8 C VT: 1cm, eff 10%, AF (-), clear, head palpable, denom unclear,descend HI, unpalpable small organ of fetal and umbilical cord. At 01.00 pm (30/12-2008) patient taken to praya General hospital. Becouse of in praya general hospital SPOG was absent patient advice referred to maaram general hospital. But patient couldnt decission and they discuss for long time. And they agree to referred to mataram general hospital at 08.30 pm (30/12-08).

Time

Subject

Object HBsAg (-) HB = 11,75 WB = 12.900 PLT = 285.000 HCT = 35,3

Assesment

Planning

Last menstrual period : 31-03-2008 EDD: 07-01-2009 ANC = routine in polindes History of family planning : injection for 3 months Familly planning = injection for 3 mounth

Obstetrical history : Obstetrical history : 1. male, SC (et causa CPD), 3000 g 3,5 years old. 2. This
11.45 pm

1. Advice superviser dr. doddy A K, SPOG(K), prepare SC for the patient. Then phoned VK to prepare SC UC : (-) FHB: 152 x/mnt PR: 82x/mnt G2P1A0H1 39-40 weeks with PROM+ SC history+CPD -Prepared sc - applied DC - ampi test (-),inj. A -a mphicilline 2 gr.

00.00 am

00.15 am

Taken patient to OK

Time

Subject

Object

Assesment SC begun

Planning

00.20

00.25

Baby was born with AS 6-8, weigh 2900 g, length 48 cm, plasenta born spontaniously, complete.

Time

Subject

Object

Assesment

Planning

00.45 am

BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C Eyes : an(-) ikt (-)

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

01.00 am

BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C Eyes : an(-) ikt (-)
BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C Eyes : an(-) ikt (-) BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C Eyes : an(-) ikt (-) BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C Eyes : an(-) ikt (-) BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C Eyes : an(-) ikt (-)

4thsage of labor
Obs mother well beibg Take meal if nausea and vomiting were absent.

01.15 am

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

01.30

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

02.00

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

03.00

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

Name address
Waktu

: Iq. Erik/28 years : Marong nyampe Praya Loteng

CTH

: 30-12-2008 : 7.40 pm

Subject

Object General status : General condition: well, Conciousness: CM BP: 110/67 mmHg RR: 20 x/mnt Pulse :88 x/mnt T: 36,5 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range
Obstetric status : L1 : head L2 : right back L3 : breech L4 : UFH : 33 cm, lingkar abdomen : 105 cm EFW : 3465g UC : (+), 2-3x/10 mnt40 Fetal Heart Rate : 146x/mnt VT: 8 cm, eff 75%, amnionic membrane (-), breech palpable, descend HII, unpalpable small organ and umbilical cord.

Assesment G2P1A0H1 Aterm/Single/life/intra uterin inpartu active phase of first stage of labor with breech presentation + history of watery vaginal discharge

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Inform to supervisor : Propose : observation Adviced : agreed

7.50 pm

Patient refered by RSU Praya with G2P1A0H1 Aterm/Single/life/intra uterin with breech presentation + susp big baby. Patient said pregnancy for 9 month
Chronology : 30 des 08 3.00 pm Patient came to PKM MUJUR with abdominal pain since 8.00 pm (29 des 08) and watery vaginal discharge at 01,00pm(30 des 08) VT : 6 cm, amnionic membrane (), breech palpable, descend HII, unpalpable small organ and umbilical cord. UC : 4x/10/40 (3.30pm)Advis doktersent patient to RSU Praya Drugs: RL 28 drops/mnt, inj ampi 1 gr IV 4.00pm Because In RSU Praya SpOG were absentsent patient to RSU Mataram with diagnose G2P1A0H1 Aterm/Single/life/intra uterin with breech presentation + susp big baby But patient couldnt decission and they discuss for long time. And they agree to referred to mataram general

Time

Subject

Object HBsAg (-) HB = 11,75 WB = 11.000 PLT = 285.000 HCT = 35,3

Assesment

Planning

Last menstrual period : forgot ANC = 4x in PKM History of family planning : Familly planning = IUD

Obstetrical history : 1. Female, P.spt, midwife, 2300g 8 years old 2. This

9.50 pm

Patient felt abdominal pain

UC : (+), 2-3x/10 mnt35 Fetal Heart Rate : 154x/mnt VT: complete, eff 100%, amnionic membrane (-), breech palpable, descend HII, unpalpable small organ and umbilical cord. UC : (+), 2-3x/10 mnt40 Fetal Heart Rate : 156x/mnt VT: complete, eff 100%, amnionic membrane (-), breech palpable, descend HII, unpalpable small organ and umbilical cord.

G2P1A0H1 Aterm/Single/life/intra uterin inpartu second stage of labor with breech presentation + history of watery vaginal discharge G2P1A0H1 Aterm/Single/life/intra uterin inpartu + prolonged second stage of labor with breech presentation + history of watery vaginal discharge

Observation

10.50 pm

Report to supervisor, proposed SC, adviced agreed Prepare paient to SC DC, ampi 2g IV,

Time

Subject

Object

Assesment

Planning

00.00 am 00.40

Sent patient to operating room

SC Begun

01.00 am

Baby was born, male, 3400gr, body length 49cm, head length 34cm, AS : 7-9 Placenta was born, manual, complete, amniotic fluid unclear, jlh sedikit

Time

Subject

Object

Assesment

Planning

1.15 am

BP: 120/70 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C UFH = 2 fingers below the umbilical BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C UFH = 2 fingers below the umbilical BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C UFH = 2 fingers below the umbilical BP: 120/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C UFH = 3 fingers below the umbilical BP: 110/70 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C UFH = 3 fingers below the umbilical UC = good BP: 110/60 mmHg RR: 20 x/mnt Pulse :82 x/mnt T: 37,C UFH = 3 fingers below the umbilical UC = good lochia (+)

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

4thsage of labor Obs mother well beibg Take meal if nausea and vomiting were absent.

01.30 am

01.45 am

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

2.00 am

4thsage of labor

Obs mother well beibg Take meal if nausea and vomiting were absent.

4thsage of labor

02.30

Obs mother well beibg Take meal if nausea and vomiting were absent.

3.00 am

4thsage of labor

Mother and baby is good Condition