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MORNING REPORT September 29th 2011

Supervisor : dr. Juliawan, SpOG
Medical Students: Lili, Elin, Ika, Maria, Noval

Cases resume :

Normal Labor Phatologic Labor

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susp. Abdomen : scar (-). oligohydramnion. male.9°C Status Generalis: Eye : palor (-). spontant. bloodyslim (-). LMP : 05 – 01 – 2011 EDD : 12 – 10 – 2011 History of ANC : ± 9 x. doctor. striae (+). HbSAg . Aterm. History of DM (-). SpOG Last ANC : 28 – 09 – 2011 History of USG : 1 x (28-09-2011) History of family planning : pil Next family planning : IUD Obstetrical history : I. 3800 gr. Intrauterine retardation. Ronkhi (-/-). icteric (-) Thorax : Cor : S1S2 single reguler (murmur -). Bleeding (-). oligohydramnion.50 . BT. SC. Planning  Observe mother & fetal well being  DL. Advice from supervisor : ACC SC 29/9/ 2011 09. abortus III. doctor. 9 years old II. 11-11-12 (136 x/minute) VT : not done Assesment G4P3A1L2 38 week/S/L/IU head presentation with totalis placenta previa. warm acral (+) Obstetrical status : L1 : breech. Aterm. asthma (-). male. UFH: 25 cms L2 : fetal back on left side L3 : head L4 : 5/5 EFW : 2015 gr His: (-) FHR : (+). CT checked  Coass consult to GP pro SC  GP consult to supervisor pro SC. F : 35 years old : Ampenan CTH : September 29th 2011 At 09. 2 years old IV. susp. History rupture of membrane (+) since 2 week ago. 8 week. Intrauterine retardation. wheezing (-/-). FM (+).50 wita Subject Patient referred from Maternity Clinic with G4P3A1L2 38 week/S/L/IU head presentation with totalis placenta previa. 3200 gr. This Object General Condition : well Consciousness : CM BP : 130/90 mmHg PR : 84 x/minute RR: 22 x/minute T : 36. HT (-). (gallop -) Pulmo : vesikuler (+/+).Name Age Address Time : Mrs. linea nigra(+) Extremity : edema (-).

15.2 MCV : 98.6 MCH : 30.00 His : (-) DJJ : (+).00 His : (-) DJJ : 12-12-12 17.3 WBC : 11. 12-12-11 G4P3A1H2 38 week/S/L/IU head presentation with totalis placenta previa.8 PLT : 260 HbSAg : BT : 2’ 30” CT : 6’ 00” O A P 14. susp.58 HCT : 45.00 His : (-) DJJ : 12-11-12 .9 RBC : 4.00 His : (-) DJJ : 12-12-13 16. oligohydramnion.Time S Lab : DL:HGB : 13. Intrauterine retardation.

30 Baby was born.Time S O A SC began P 29/09 /2011 18. A-S : 6-8.50 SC Finished . congenital anomali (-).20 18. bleeding ± 400 cc Placenta weight: 400 gram 18. Amnion clear Placenta was born manually.. BW : 1800 gram BL : 45 cm Ballard score : SMK Anus (+). Male.

00 Wound pain GC : well cons : E4V5M6 BP : 110/80 mmHg PR : 92 x/minute RR : 20 x/minute T : 36.50 (-) GC : well cons : E4V5M6 BP : 110/80 mmHg PR : 88 x/minute RR : 20 x/minute T : 36.Subject Object Assesment Planning 20.5° C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 70 cc/hours 2 hour Post SC Observe mother and baby well being KIE mother to take a rest 30/9/ 2011 07.5° C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 45 cc/hours Baby in NICU : PR : 160 x/minute RR : 28 x/minute T : 36°C 1 day post SC Observe mother and baby well being KIE mother to take a rest .

Blured vision (-). N A : 24 years old : Pringgarata CTH : September 29th 2011 At 20. 12-12-12 (140 x/minute) VT : Φ - . wheezing (-/-). UFH: 28 cms L2 : fetal back on left side L3 : head L4 : 4/5 EFW : 2790 gr His: (-) FHR : (+). warm acral (+) Assesment G1P0A0H0 37-38 week/S/L/IU head presentation with PEB Planning  Observe mother & fetal well being  DL. LMP : 16 – 01 – 2011 EDD : 23 – 10 – 2011 History of ANC : 8 x. History rupture of membrane (-). bloodyslim (-).Bolus MgSO4 40% 4 gr/IV .45 Obstetrical status : L1 : breech. Advice from supervisor : ACC SC 29/9/ 2011 20. HT (-). HbSAg . UL. striae (+). Abdominal pain (-). asthma (-). SGPT. midwife Last ANC : August History of USG : never History of family planning :Next family planning : injection for 3 month Obstetrical history : I.Drip MgSO4 40% 6 gr in 500 cc RL 28 dpm . (gallop -) Pulmo : vesikuler (+/+). Ronkhi (-/-). SGOT. extremity udem. This Object General Condition : well Consciousness : CM BP : 175/100 mmHg PR : 90 x/minute RR: 22 x/minute T : 36. History of DM (-). vomiting (-). icteric (-) Thorax : Cor : S1S2 single reguler (murmur -). linea nigra(+) Extremity : edema (-). FM (+).Name Age Address Time : Mrs.Nifedipin 3 x 10 mg .Insert DC Advice: ACC  GP consult to supervisor pro SC.7°C Status Generalis: Eye : palor (-). Abdomen : scar (-). BUN SC checked  Coass consult to GP pro: . Headache since 2 week ago.45 wita Subject Patient referred from Pringgarata PHC with G1P0A0H0 36-37 week/S/L/IU head presentation with PEB. nausea (-).

30 S: Patient confessed headache since 2 week ago.0 Nitrit : Protein : +3 Glukosa : Keton : Urobilinogen : Bilirubin : Darah : +2 Assesment Planning .04 HCT : 36.8 Ureum : 25 SGOT : 39 HBsAg : (-) UL: BJ : 1010 pH : 6. Patient came to NTB GH for ANC in 28-9-2011 and rejected to opname O: General Condition : well Consciousness : CM BP : 180/120 mmHg.5°C Obstetric status : L1 : breech.00) Object Pelvic score: 2 Cervix dilatation 0 (0) Cervix length 2 cms (1) Consistency rigid (0) Location mid (1) Station -3 (0) Lab: DL: HGB : 11. TFU : 30 cm L2: fetal back on left side L3 : head L4 : 4/5 DJJ: 150 x/minute A: G1P0A0H0 36-37 week/S/L/IU head presentation with PEB P: .3 MCV : 89.Drip MgSO4 6 gram 28 dpm (20.2 RBC : 4.54 PLT : 196 Kreatinin : 0. T : 36.9 MCH : 27. PR : 88x RR: 20.Nifedipin 10 mg (20.9 WBC : 14.Time Subject Chronologist : 29/9/2011 19.00) .7 MCHC : 30.

45 TD : 180/100 mmHg N : 88 x/minute RR : 20 x/minute T : 36.7°C His : (-) DJJ : (+). 12-12-12 UO : 30 cc/hours .7°C His : (-) DJJ : (+). 12-12-11 UO : 30 cc/hours A P 21.45 TD : 170/110 mmHg N : 80 x/minute RR : 20 x/minute T : 36. 12-13-13 UO : 35 cc/hours  Prepare to SC 23.7°C His : (-) DJJ : (+).Time S O TD : 170/100 mmHg N : 88 x/minute RR : 20 x/minute T : 36.45 22.

00 SC Finished . bleeding ± 250 cc 01. congenital anomali (-). A-S : 6-8.00 00. Amnion clear Placenta was born manually. BW : 2200 gram BL : 48 cm Ballard score : SMK Anus (+).30 Baby was born..Time S O A SC began P 30/9/2 011 00. Female.

5°C 1 day post SC Observe mother and baby well being KIE mother to take a rest .00 Wound pain GC : well cons : E4V5M6 BP: 170/100 mmHg PR : 112 x/minute RR : 20 x/minute T : 37° C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 43 cc/hours Baby in NICU : PR : 140 x/minute RR : 24 x/minute T : 36.2° C UFH : 2 finger below umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 50 cc/hours 2 hour Post SC Observe mother and baby well being KIE mother to take a rest 31/9/ 2011 07.Subject Object Assesment Planning 03.00 (-) GC : well cons : E4V5M6 BP : 170/80 mmHg PR : 80 x/minute RR : 20 x/minute T : 37.