MORNING REPORT

July 1st, 2015

Resident :
Gol/Cep/Til/Dof
Chief:
dr. TAW
Supervisor :
dr. Eka SpOG

EMERGENCY ROOM : 1
DELIVERY ROOM
Physiological Delivery : 4
Pathological Delivery
Pervaginam
Perabdominam

: : 1

Identity
Mrs. H/ 34 y.o/ 9 y.o.e/ Housewife
Mr. M/ 40 y.o/12 y.o.e/Tire repairman
Married 1x, 11 years
Address: Jl. Yulius Usman VI / 391, Kraton
Admission 1-7-2015 at 07.00 am

Patient reffered PKM

Ngempit with chief complain
fluid excess from birth canal

SUBJECTIVES
(30/6/15) 05.00 pm patient
complaint fluid excess from birth
canal stay at hom
(1/7/15) 06.00 am fluid excess
from birth canal more excessive
patient went to PKM Ngempit
suggested to RSUD Bangil.

SUBJECTIVES
History of Pregnancy
1. Premature/2000 gr/ Spontaneously
delivery/ Midwife/M/10 y.o/L
2. Aterm/3000 gr/CS dt Transverse lie/
Mitra Husada Hospital/F/4 y.o/L
3. This pregnancy
ANC :Midwife 5x (last controlled 24-12-13)
LMP ~ 38-39 weeks
Contraception : 3 months injection, stop 1
year ago

OBJECTIVES
BH
GA
BP

Head
Thorax
Abd

: 153 cm, BW :72 kg

: Good, CM
: BP : 110/70 mmHg , PR
: 82
x/m
RR : 20 x/m
Tax
: 36,6C Trect : 36,8C
: Conj. an -/- , ict -/: C/ S1-2 single murmur (-)
P/ RH
WH
: FU 32 cm, longitudinal lie U
FHR 152 bpm , EFW : 3100 gr,
uterine
contraction (+) rare, scar
pfanenstiel (+)

OBJECTIVES
GE
Insp

VT

:
:

amniotic fluid flow (+)

amniotic fluid flow from OUE (+)
amniotic fluid pooling at posterior
fornix
lacmus test : (+)
: 1 cm, eff 25%, HI, amniotic
membrane (-) greenish, head
presentation, denominator ~ difficult to
evaluate,
pelvic measurement ~ wnl

LABORATORY

CBC :15.440/14,2/40,3/239.000
PTT/APTT : 10,4 (12,0) / 21,3 (25,9)

NST
Baseline : 150 bpm
Variability : < 15 bpm
Acc : (-)
Dcc : (+)
Patologic CTG

USG
Fetal intrauterin S/L, head Below
BPD : 92,0 (37w5d)
AC : 338 (37w5d)
FL : 73,2 (37w3d)
EFW : 3326 gr
AFI : 3,5
Placenta implanted at fundus
Maturation grade III
Nuchal cord 2x

Assessment
G3P1102Ab000 gr 38-39 weeks S/L
+ PROM >12 hours
+ Previous CS
+ Fetal Compromised

Planning
PDx

PTx : Intra Uterine rescucitation

-O2

10 lpm , NRBM

-Mother left lateral recumbent

Proposed to termination with CS cito + post placental IUD

Tocolitic : kaltrofen supp II
CS Preparation :
IVFD RL 1000 cc
Insert DC
Tx Inj : Ceftriaxon Inj 1 gr(iv) skin test
Ranitidin Inj 1Amp (iv)
Metoclopramide Inj 1 Amp (iv)
Register to Operating room, Blood preparation

PMo : observation vital sign, subjective complain, FHR

PEd : CIE / informed consent
C/Supervisor --------------------- Acc dr.Eka,SpOG

OUTCOME

July 1st, 2015 at 08.00 am

Male baby born
3300 gr / 49 cm/
AS : 7-9

TERIMA KASIH