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Morning Report

July 3rd 2012

Supervisor : dr. Made Mahayasa, Sp.OG Medical Students :
Yan, Wiwid, Novi, Sapto, Ika, Ira, Lani
CASE RESUME NORMAL LABOR PATHOLOGY LABOR 3 1. G1P0A0L0 40-41 weeks S/L/IU with prolonged 2nd stage of labor. 2. G4P1A2L1 42-43 weeks S/L/IU with severe preeclampsia 3. G1P0A0H0 A/S/L/IU with neglected active phase 1st stage of labor & eclampsia.

L  RM  Age : 044809 : 26 years old  Address : Ampenan  Admitted : October 2nd 2012 .Case Report  Name : Mrs.

wheezing (/-). Extremity : edema (-/-). Bloody slim (+). denominator unclear. FM (+). impalpable small part and umbilical cord. This OBJECTIVE General Status : GC : well BP : 120/80 mmHg PR : 80 bpm RR : 20 bpm T : 36. Obstetrical Status : L1 : breech L2 : back on the left side L3 : head L4 : 4/5 UFH : 32 cm EFW : 3250 gram UC : 4x/10’ ~45’’ FHB : 12-12-12 (144 bpm) VT : Ø 8 cm.5oC Eye : anemis (-/-). and water came out from her womb since 19. icteric (-/-) Cor : S1S2 single regular. stria gravidarum (+). amnion (-) clear. head palpable ↓ HII+. asthma. warm acral (+/+). effacement 75%. • Observation progress of labor • Cek DL. LMP : Forgot EDD : History of ANC : > 4x at Polindes Last ANC : 25/009/2012 History of USG : History of family planning : (-) Next family planning : injection 3 months. linea nigra (+). gallop (-). HBsAg Chronologist : (-) . Obstetrical History : I. ASSESSMENT G1P0A0L0 A/S/L/IU active phase 1st stage of labor with history of rupture membrane + mild anemia PLANNING • Observation mother & fetal well being. No history of DM.00 (02/09/2012). Pulmo : vesicular (+/+). murmur (). Abdomen : scar (-). HT. ronkhi (-/-). Patient confessed abdominal pain that spread to frank since since 08.TIME 02/10/ 2012 23.00 (02/10/2012).30 SUBJECTIVE Patient referred from Midwife with G1P0A0L0 37-38 weeks/S/L/IU mother and fetal well with inpartu active phase 1st stage.

• Suggest mother to squatting down. amnion (-). amnion (-). head palpable ↓ HII+. 04. 2nd stage of labor • Suggest mother to eat and drink.59 x 103/µL PLT : 288 x 103/µL HbSAg: (-) not ASSESSMENT PLANNING 03.00 Mother feels bearing down tired to Prolonged 2nd stage of labor DM consult to SPV : pro VE SPV advice : acc VE . caput (+). head palpable ↓ HIII+. caput (+). UC : 4x/10’ ~40’’ FHB : 12-12-12 (144 bpm) VT : Ø complete.12 x 106/µL HCT : 30. impalpable small part and umbilical cord.1 % WBC : 12.00 Mother wants to bearing down UC : 4x/10’ ~45’’ FHB : 12-11-11 (136 bpm) VT : Ø complete.TIME SUBJECTIVE OBJECTIVE PE : Spina ischiadica prominent Os coccygeus mobile Arcus pubis > 90o Lab Examination : Hb : 8.6 g/dl RBC : 4. impalpable small part and umbilical cord.

• Suggest mother to squatting down. caput (+). Prolonged 2nd stage of labor GP consult to SPV : pro VE SPV advice : acc VE . Drip oxytocin 12 tpm Drip oxytocin 16 tpm Drip oxytocin 20 tpm 13. head palpable ↓ HII+. head palpable ↓ HII+.TIME 11.30 14.30 Mother wants to bearing down UC : 4x/10’ ~30’’ FHB : 12-11-11 (136 bpm) VT : Ø complete. caput (+). GP advice : acceleration with drip oxytocin. caput (+).30 SUBJECTIVE Patient confessed abdominal pain OBJECTIVE UC : 2x/10’ ~25’’ FHB : 12-12-12 (144 bpm) VT : Ø 9 cm. • CTG reactive • DM co to GP. amnion (-). amnion (-). ASSESSMENT G1P0A0L0 4041 weeks S/L/IU with prolonged active phase 1st stage of labor with history of rupture membrane + mild anemia 2nd stage of labor PLANNING • Observation mother & fetal well being. impalpable small part and umbilical cord. impalpable small part and umbilical cord.30 Mother feels tired to bearing down UC : 4x/10’ ~30’’ FHB : 12-12-12 (144 bpm) VT : Ø complete. amnion (-). UC : 4x/10’ ~30’’ FHB : 12-11-12 (140 bpm) UC : 4x/10’ ~30’’ FHB : 12-12-12 (144 bpm) UC : 4x/10’ ~30’’ FHB : 12-11-11 (136 bpm) • Drip oxytocin began 8 tpm • Suggest mother to eat and drink. head palpable ↓ HIII+.00 13.00 Patient confessed abdominal pain Patient confessed abdominal pain Patient confessed abdominal pain 14. impalpable small part and umbilical cord. 12. effacement 90%.

A-S 6-8. 50 cm. eat. anus (+). Perineum episiotomy (+) Baby was born. • Suggest mother to take a rest. . caput (+) on occiput. and drink.TIME 15. anomaly congenital (-). male. complete. Placenta was born spontaneous. 3500 gram.00 Patient confessed delivery wound GC : well BP : 120/90 mmHg PR: 80 bpm RR : 20 bpm T : 36. Bleeding ± 150 cc Rupture perineum grade II 17.7°C UFH : 2 fingers below the umbilicus Lochea rubra : (+) 2 hours post VE • Observe mother and baby well being.00 SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING VE began VE succeed in 2 times traction.

and drink. eat.2°C UFH : 2 fingers below the umbilicus Lochea rubra : (+) Baby in NICU : GC : well PR : 120 bpm RR : 52 bpm T : 36. • Suggest mother to take a rest. .4oC ASSESSMENT 1st day post partum PLANNING • Observe mother and baby well being.TIME 03/07/ 2012 07.00 SUBJECTIVE Patient confessed delivery wound OBJECTIVE GC : well BP : 110/70 mmHg PR : 72 bpm RR : 20 bpm T : 36.