Morning Report

December 10th 2012

Supervisor : dr. Rusdhy A.H., Sp.OG Medical Students :

Furqan, Vera, Era
CASES RESUME NORMAL LABOR PATHOLOGY LABOR 3 1. G1P0A0H0 36-37 weeks S/L/IU head presentation Arrested Latent Phase, 1st stage of labour with history ROM + polyhidramnion + Drip Failure

Identity
Name : Mrs. R Age : 25 years Old Address : Kayangan, North Lombok Admitted on: December, 10th 2012 (01.30 wita)

TIME 10/12/ 2012 01.30

SUBJECTIVE Patient referred from Kayangan PHC with G1P0A0H0 36-37 weeks S/L/IU with PROM > 12 hours Patient confessed abdominal pain that spread to waist since 23.00 (08/12/2012). History water leaked from her womb (+). Bloody slim (+), FM (+). No history of DM, HT, asthma. LMP : 29-3-2012 EDD : 05-01-2012 History of ANC : >4x at Posyandu History of USG : never History of family planning : (-) Next family planning : Injection 3 months. Obstetrical History : I. This

OBJECTIVE General Status GC : well Consciusness : CM BP : 130/80 mmHg PR : 80 bpm RR : 24 bpm T : 37oC Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single reguler, M (-), G (-) Pulmo : vesikuler (+/+), wheezing (/-), ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+) Obstetrical Status L1 : breech L2 : back on the left side L3 : head L4 : 5/5 UFH : 36 cm EFW : 3565 g UC :FHB : 10-11-14 (140 bpm) VT : 1 cm, eff 10%, amnion (-), head palpable H I, denominator unclear, impalpable small part / umbilical cord.

ASSESSMENT G1P0A0H0 36-37 weeks S/L/IU head presentation with PROM> 12 hours

PLANNING Observe mother and fetal well being. Observe progress of labor. Inj Ampi (at PHC) GP consult to SPV: induction with oxytosin drip Observation proggress of labour CTG Rehydration

TIME

SUBJECTIVE Chronologist at Kayangan PHC : 22.15 (08/12/2012) S : Abdominal pain spread to frank since 23.00 (8/12/2012). History rupture of membrane (+), bloody slim (+),FM (+). O : GC : well BP : 100/60 mmHg PR : 86 bpm RR : 20 bpm T : 38oC L1 : breech L2 : back on the left side L3 : head L4 : 4/5 UFH : 32 cm UC : 1x/10~20 FHB : 11-11-12 (136 bpm) VT : 1 cm, amnion (+) , head palpable HI , denom unclear, unpalpable small part / umbilical cord. A : G1P0A0H0 36-37 weeks S/L/IU head presentation with PROM > 12 hours P: Tell mother and family about examination Consurlt GP: advice RL 20 tpm Inj. Ampi Reffered to GH NTB (22.40 wita)

OBJECTIVE Pelvic Evaluation : Spina ischiadica not prominent Os coccigeous mobile Pubic arch > 900 PS: 5 Dilatation cervix : 1 Cervix Length: 2 Station: 0 Consistency: 1 Position: 1 Lab Evaluation HB : 9,4g/dl RBC : 4,19 M/dl HCT : 30,9 % WBC : 20,1 K/dl PLT : 349 K/dl HbSAg : (-)

ASSESSMENT

PLANNING

TIME 03.00 03.30 04.00

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING Set IVFD D5 with 5 IU of Oxytosin

UC: 2x/10~25 FHR: 12-12-12 UC: 2x/10~25 FHR: 12-11-12

8 dpm 12 dpm

04.30
05.00 05.30 06.00 06.30

UC: 2x/10~30 FHR: 12-11-12

UC: 2x/10~30 FHR: 13-14-13 UC: 2x/10~30 FHR: 12-14-14 UC: 2x/10~30 FHR: 12-12-13 UC: 3x/10~35 FHR: 12-13-14 VT: 2 cm, eff 25%, amnion (-), head palpable, HI, inpalpable small part of fetal and umbilical cord G1P0A0H0 3637 weeks S/L/IU head presentation Latent Phase, 1st stage of labour with history ROM.

16 dpm
20 dpm 24 dpm 28 dpm 32 dpm - Observation mother and fetal well being - Observe patient 4 hours later

07.30

Patient confessed intermittent abdominal pain

Result of USG: Fetal S/L/IU head presentation BPD: 35 w 6 d AC: 39 w 6 d FL: 88 mm Amnion (+), polihydramnion placenta at posterior fundus

- Consul SPV - Observation and continue drip

TIME 10.30

SUBJECTIVE Patient confessed intermittent abdominal pain

OBJECTIVE UC: 3x/10~40 FHR: 158 bm VT: 2 cm, eff 50%, amnion (-), head alpable, HI, impalpable small part of fetal and umbilical cord

ASSESTMENT G1P0A0H0 3637 weeks S/L/IU head presentation Latent Phase, 1st stage of labour with history ROM + polyhidramnion

PLANNING Consul SPV: continue induction Change to 2nd flash 32 dpm

14.00

UC: 3x/10~30 FHR: 12-13-13 VT: 2 cm, eff 50%, amnion (-), head palpable, HI, impalpable small part of fetal and umbilical cord

14.30
15.00

2nd flash finished

Consul SPV Observation and change IVFD to RL, if there is SC, patient will be followed Consul SPV: SC at 21.00 wita Pre op Patient: - Set DC - Inj Ami 2 gr/IV - Shave pubic hair CIE patiern and family VT: 2 cm, eff UC: 2x/10~25 FHR: 12-12-12 50%, amnion (+), head G1P0A0H0 3637 weeks S/L/IU head

16.00

20.30

TIME 21.10

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING CS began Baby was born (21.30), Male, BW:3250 g/50 cm, anus (+), AS: 7-9 Placenta was born manually, complete, bleeding 500 cc

10.00

Patient confessed can not move her leg

GC: well Cons: CM BP: 110/80 HR: 84 bpm RR: 24 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus Urine output: 100 cc Baby in NICU PR: 120 RR: 50 T: 36,7

2 hours post SC

Observed mother and baby well being Suggest mother to mobilisation.

11/12/2 012 07.00

GC: well BP: 110/80 HR: 80 bpm RR: 20 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus Urine output: 100 cc

1 day post SC

Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.