Morning Report October 07th 2009

Supervisor : dr. Edy P.W., SpOG

Medical Student: Titin, Halida, Idham, Holis

Cases resume :
G1P0A0 with prolonged 2nd stage G1P0A0 with susp.big baby Normal labor

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1.

Name Age Address

Waktu

: Mrs. Zohrah : 22 years : johar pelita - sesela Subject Patient came to emergency care unit of NTB province hospital (12.20) with G1P0A0 A/S/L laten phase 1st labour + watery vaginal discharge + febris cronologis : Patient felt abdominal pain ( since 0510-2009) and watery vaginal discharge at 07.00 am (07-10-2009), then she went to gunung sari PHC at 11.00 am (07-10-2009). Bloody show (-) , the fetal movement was active. History of febris (-). History of malaria -, history of thipoid -. The examination gunung sari PHC General status : well BP : 120/70 mmHg Pulse =88 x/mnt RR: 20 x/mnt Temp = 38,6C UFH = not mention it FHB = 171 x/mnt 11.00 WITA VT : 3 cm, eff 25 %, amnionic membrane (-), head palpable, descend HI, unpalpable small organ and umbilical cord. Terapi in PHC: Injeksi ampi 1 gr in PHC Paracetamol 1 tab in PHC 12.00 patient referred to mataram GH

CTH

: 07 10 2009 :

Object

Assesment G1P0A0 Aterm/single/ life + laten phase of 1st stage labor + watery vaginal discharge + febris + fetal tachicardy

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Resusitation intra uterine CTG post resusitation Base line 156

13.00

In emergency room : General status : General condition: well, Conciousness: E4V5M6 BP: 130/80 mmmHg RR: 20 x/mnt Pulse :80 x/mnt T: 37,6 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech TFU; 31 cm L2 : left back L3 : head L4 : 4/5 EFW : 3100 g UC : 3x/10 ~35 FHB : 173 x/mnt VT : 3 cm, eff 25 %, amnionic membrane (-,) dry, head palpable, descend HI, unpalpable small organ and umbilical cord. Pelvic evaluation; Promontorium not prominent Spina isciadica not prominent Arcus pubis > 90 Os coxigeus mobile

Time

Subject

Object

Assesment

Planning

History of family planning : (-) Familly planning = injection 3 month ANC Routine at posyandu > 4 x

Obstetrical history : 1.This

Lab. result: HB = 10 gr% WB = 23.700 PLT = 249.000 HCT = 32,5 HBsAg (-)

17.00

Abdominal pain >>>

UC : (+) 3x/1035 FHB : 144x/mnt L4 : 3/5

VT : 9 cm, eff 90 %, amnionic membrane (-,) dry, head palpable, descend HII,denominator fontanella minor left anterior. unpalpable small organ and umbilical cord

G1P0A0 Aterm/single/ life + active phase of 1st stage labor + watery vaginal discharge

-Observation mother and fetal well being -Evaluation 1 hours again -Left laterl position -Educated mother to drinking and eating.

18.00

Abdominal pain +++ Mother want to bearing down

UC : (+) 3-4 x/1040 FHB : 144x/mnt L4 : 3/5

VT : complete, amnionic membrane (-,) dry, head palpable, descend HII,denominator fontanella minor left anterior. unpalpable small organ and umbilical cord.

G1P0A0 Aterm/single/ life + 2nd stage of labor

Squating position

Time

Subject

Object

Assesment G1P0A0 Aterm/single/ life + prolonged 2nd stage of labor

Planning Report to supervisor Propose vacum extraction Proposed agreed

20.00

Abdominal pain +++

UC : (+) 4 x/1040 FHB : 154x/mnt L4 : 2/5

VT : complete, amnionic membrane (-,) dry, head palpable, descend HIII,denominator fontanella minor left anterior. unpalpable small organ and umbilical cord.

20.30

2 nd stage of labor

Baby was born with vacum extraction male, 3300 gram, A`S : 6-8 Amniotic fluid green thin Nuchal cord baby sent to NICU Placenta compleete was born

3 rd stage of labor
22.30

Active bleeding

BP = 120/70 RR: 20 x/mnt Pulse 84 x/mnt UFH = 1 fingers below the umbilical UC = good

IV stage of labor

Observation VS and subjective complain

Time

Subject

Object

Assesment

Planning Observation VS and subjective complain

07.00 am

Subjective complain Active bleeding -

BP = 110/70 RR: 22 x/mnt Pulse 84 x/mnt UFH = 2 fingers below the umbilical UC = good Wound episiotomy: dry baby: HR : 120 RR: 36x/mnt T: 36.7 c

1st day of vacum extraction