Morning Report

10 January 2009

Supervisor : dr. Agus Thoriq , SpOG

Medical Student: MIFTAH Hadyan

Cases resume : 1. 2. 3 4. Breech presentation PROM > 12 H

1 2 1.

Name / Age Address

Time 22.00

: Mrs. Nuriati / 28 years old : Lingsar

Subject Object General status : General condition: well, Conciousness: CM BP: 120/80 mmHg RR: 20 x/mnt Pulse :884x/mnt T: 36,8 C Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : head L2 : left back L3 : breech L4 : breech descencus4/5 UFH 32 cm AC: 86 cm EFW : 2752 g UC : 3x/10 ~40 Fetal Heart Rate : 152 x/mnt VT : DC 6 cm, eff 75 %, AM (+), breech & foot palpable, descencus HI, umbilical cord or small part of fetal unpalpable, Z-A score: 6 o Paritas : 1 o History of breech presentation: 0 o Estimate Fetal Weight : 2 o Old of pregnacy: 0 o Station : 1 o Cervix dilatation : 2

CTH

: 10 January 2009 : 22.00

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Report to supervisor: advice : o Pervaginam labor

Time
Assesment

Patient came to emergency care unit with 9 month of pregnacy and confess abdominal discomfort chronologis : Patient confess abdominal discomfort since 08.00, intermient & more often. vaginal discharge (-) Obstetric history: 1. Male, aterm, spontan, 3700 g, 6,5 years 2. This LMP : 14 april 2008 EDD : 21 january 2009

G2P1A0H1 38-39 weeks/S/L, breech presentation, 1st stage of labor active phase

Time 22.50

Subject Patient confess abdominal discomfort more often

Object UC : 4x/10 ~ 50 FHB : 154 x/mnt

Assesment G2P1A0H1 38-39 weeks/S/L, breech presentation, 1st stage of labor active phase

Planning Observation mother and fetal well being.

23.00

Patient confess abdominal discomfort more often

Doran, teknus, perjol, vulka Foot appear in vulva

G2P1A0H1 38-39 weeks/S/L, breech presentation, 2nd stage of labor

Conducted to labor

mother

23.10

Baby was born, female, AS: 7-9, W: 3000 g, L: 48 cm,

3th stage of labor

Obsevation 3th stage of labor

23.15

Placenta was born spontaneusly, complete, Uterus contraction well, fundus : 2 digit under umbilicus. BP : 110/70 mmHg

4th stage of labor

Obsevation 4th stage of labor

Time 24.15

Subject

Object General status : well BP: 120/70 mmHg, PR: 88 /mnt UC: well, Fundus : 2 digit under umbilical

Assesment 4th stage of labor

Planning Obsevation 4th stage of labor

01.15

General status : well BP: 120/70 mmHg, PR: 88 /mnt UC: well, Fundus : 2 digit under umbilical

4th stage of labor

Obsevation 4th stage of labor Remove patient to melati room

07.00

Patient felt body weak

General status : weak GCS : E4V5M6 BP : 80/50 mmHg PR : 100 x/mnt Bleeding pervaginam (+), UC : weak

HPP + hipotensi

IVFD RL rapid drop Injection oxytocin 1 ampul/im

07.10

Patient felt body weak

Applied IFVD RL rapid drop. Take blood sample for examination.

HPP + hipotensi

Lab examination : DL

Time 07.20

Subject Patient felt body weak

Object General status: weak BP : 90/50 mmHg PR : 100 x/mnt Active bleeding (-) UC : weak General status : weak BP : 100/60 mmHg PR : 92 x/mnt Active bleeding (-) UC : weak General status : weak BP : 100/60 mmHg PR : 92 x/mnt

Assesment HPP + hipotensi

Planning Observation Vital sign + bleeding

07.30

Patient felt body weak

HPP

Observation Vital sign + bleeding

08.00

Patient felt body weak

HPP

Observation Vital sign + bleeding

08.50

Patient felt body weak

General status : weak BP : 100/60 mmHg PR : 92 x/mnt UC : weak Hb: 7,6 g%

HPP

Report to supervisor, Advice : Drip oxytocin 2 ampul in 1 fls RL Metergin 1 ampul/iv Citotec 3 tablet/rectal Tranfusion 1 kolf PRC

Time 09.00

Subject Drip 2 ampul oxytocin in 1 fls RL. Injection 1 ampul metergin

Object General status : weak BP : 100/60 mmHg PR : 92 x/mnt Active bleeding (-) HPP

Assesment

Planning Observation vital sign Pro tranfusion 1 kolf PRC

10.00

Patients family did not got citotec

General status : weak BP : 100/60 mmHg PR : 88 x/mnt UC : well Active bleeding (-)

HPP

Pro tranfusion 1 kolf PRC

Time

Subject

Object

Assesment

Planning

Name Age Address

Waktu

Mrs. Feni Indrayani 23 years : lingsar Subject

CTH

: 10-01-09 : 12.00 am

Object

Assesment

Planning

12.00 am

Patient reffered by PKM cakranegara with G2P1A0H1 single/life + KPD + Post date Cronology: Patient came to polindes Bertais at 11.00 am (10-01-09) with watery vaginal discharge + abdominal discomfort since 11.00 pm (09-0109) , then she reffered to PKM cakranegara and she got an examination: General condition : well BP : 110/70 Pulse: 84 x/ RR: 20x/ VT : VT : 1 cm Last menstrual period : forgot-032008 History of family planning: injection for 3 month Family planning: IUD ANC : routine in PKM and polindes Obstetrical History : 1. , spontan, midwife,2500 g, 6 years 2. This

General status General condition : well Conciousness : CM BP: 110/70 Pulse: 84x/ RR: 20x/ Temp: 37 C Eyes :an -/-, ict-/Cor/pulmo : normal Lower Extremitas : edema Obstetric status :

G2P1A0H1 A/S/L intra uterine + PROM >12 hours

Observation maternal and fetal well being. Check Lab: DL, and HBSAg Report to supervisor (01.30 am) : Proposed: induction with oxytocin drip 5 IU Advice :agreed

Test ampi (-) inj ampi 1 gr/IV

L1 : breech L2 : left back L3 : head L4: entered pelvic inlet, descend 4/5. UFH: 30 cm EFW : 2945 g Uterine contraction: (+) 2x/1025 FHB : 150 x/mnt VT : 1 cm, eff 20 %, amniotic membran (-), head palpable, descend HI, Denom havent clear, small organ and umbilical cord unpalpable

Time

Subject

Object

Assesment G2P1A0H1 A/S/L intra uterine + PROM >12 hours

Planning

Pelvic score = 6 Servic dilatation 1 = 1 Servic length 2 = 1 Consistency soft = 2 Position mid = 1 Station H1 (-1) = 1 Lab. result: HBsAg (-) Hb : 13 WB = 8700 PLT = 244.000 HCT = 33,9

Time

Subject

Object

Assesment

Planning

02.30 pm

Abdominal pain (+)

UC FHR

: (+)2x/1025 : 148 x/mnt

G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours

Started induction with oxy drip 5 UI, 8 drops/mnt

03.00 pm

Abdominal pain (+)

UC FHR

: 2x/10~25 : 154 x/mnt

oxy drip drops/mnt

UI,

12

03.30 pm

Abdominal pain (+)

UC FHR

: 2x/10~35 : 156 x/mnt

oxy drip drops/mnt

UI,

16

04.00 pm

Abdominal pain (+) more often

UC FHR

: 3x/10~40 : 148 x/mnt

oxy drip drops/mnt

UI,

20

04.30 pm

UC FHR

: 4x/10~45 : 150 x/mnt

oxy drip drops/mnt

UI,

20

Time

Subject

Object

Assesment

Planning

05.00 pm

Abdominal pain (+) more often

UC FHR

: 4x/10~45 : 148 x/mnt

G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + PROM >12 hours G2P1A0H1 A/S/L intra uterine + History of vaginal discharge + II stage of labor

oxy drip drops/mnt

UI,

20

05.30 pm

Abdominal pain (+) more often

UC FHR

: 5x/10~45 : 148 x/mnt

oxy drip drops/mnt

UI,

20

05.45 pm

Abdominal pain (+) more often doranteknusperjolvulka

UC : 5x/10~45 FHR : 140 x/mnt VT : completed, eff 100 %, amniotic membran (-), head palpable, descend HIII, Denom UUK

KIE mother and family Conduct mother to bearing down

06.00

Baby was born: , spontaneusly, Birth weight: 3000 g, length:50 cm, AS:7-9 III stage of labor Injection I oxy 10 IU im

06.15 pm 06.30 pm 06.35 pm

Injection II oxy 10 IU im

Placenta was born with manual placenta, kesan not completed, UC well

Time

Subject

Object

Assesment

Planning

07.00 pm

BP = 110/70 RR: 20 x/mnt Pulse 80 x/mnt Temp: 37 UFH = 3 fingers below the umbilical UC = good lochia (+)

1V stage of laor