MORNING REPORT

MAY 28st 2012

Supervisor: dr. Agus Thoriq, Sp.OG

Medical Students: Rani, Hasaniah, Heri, Fadil, Zihni, Ayu CASE RESUME NORMAL LABORG5P4A0H3 Preterm, S/L/IU, with PPROM PATHOLOGIC LABOR 1 1

Name : Mrs. M RM: 034361 Age : 38 Years Old Address : Arong-arong, Mataram Hospital Admission: May 28th 2012

TIME May 28st 2012 15.00

SUBJECTIVE Patient referred from Dasan Agung PHC with PROM. Patient confessed history rupture of membrane (+) at 06.00, clear, odorless. Abdominal pain (-), bloody slim (+). FM (+). History of DM (-), HT (-), asthma (-). LMP : /11/2011 EDD : /8/2012 History of ANC : >4x at PHC Last ANC : 16/4/2012 History USG: (+) at Sp.OG. EDD: 27/7/12 History of family planning : Next family planning : spiral Obstetric status : 1. Aterm, male, TBA, 6 months, + 2. Aterm, female, midwife, spontan, 2700g, 18 yo 3. Aterm, male, midwife, spontan, 2900g, 14 yo 4. Aterm, female, midwife, spontan, 2800g, 11 yo 5. this

OBJECTIVE General status GC/GCS: well/E4V5M6 BP: 120/70 mmHg RR: 22 tpm HR: 84 bpm t: 36,4 0C Eyes: anemis -/- , icteric -/Cor: S1S2 single murmur(),gallop (-) Pulmo: ves (+/+), Wheezing (-/-), Rhonki (-/-). Abdomen: striae gravidarum (+), linea nigra (+) Lower extremity: oedem (-/-), warm acral (+/+) Obstetric status UFH: 25 cm EFW:2015g L1: breech L2: back on the right side L3: head L4: 4/5 His: (-) DJJ: 11-11-12 (136 bpm) VT: 1 cm, eff 10%, amn (-) clear, head palpable at H1, denominator unknown, unpalpable small part of fetal/umbilical cord

ASSESTMENT G5P4A0H3 Preterm, S/L/IU, with PPROM

PLANNING obs mohter and fetal well being. Consult to SpOG: conservative Bed rest total Obs. Rectal temp. Inj. Ampicillin 2g/iv Inj. Dexamethason 10mg/iv Pro USG move to melati

TIME

SUBJECTIVE Chronologist : 28/05/2012 - 09.00 Subjective: Patient 8 months of pregnancy confess rupture of membrane at 06.00, clear and odorless, abdominal pain (28/5/2012).FM (+). Objective: GC: well BP: 130/80 mmHg HR: T: Obstetrical status: UFH: 27cm, Assessment: PROM 11.00 Refer to Mataram GH

OBJECTIVE Laboratory examination: Hb: 13,6 HCT: 39,4 RBC: 4,28 WBC: 7,97 PLT: 384 HBsAg: -

ASSESTMENT

PLANNING

RR: -

TIME 21.00

SUBJECTIVE Patient confess abdominal pain

OBJECTIVE General status GC/cons: well/CM BP: 120/60 mmHg RR: 20 tpm HR: 80 bpm T: 36,7 0C His: (+) 2-4x/10 30 DJJ: 11-11-12 (136 bpm) Bloody slim (+) VT: 3 cm, eff 50%, amn (-), head palpable at H1, denominator unknown, unpalpable small part of fetal/umbilical cord

ASSESMENT Latent phase 1st stage of labor with history of rupture membrane

PLANNING Move to Teratai Obs. Mother and fetal being Obs. Progress of labor

21.45

Patient wants to bearing down

General status GC/cons: well/CM His: (+) 4x/10 40 DJJ: 12-12-13 (144 bpm) VT: complete, amn (-) clear, head palpable HIII, denominator unknown, unpalpable small part of fetal/umbilical cord Doranteknusvulkaperjol

2nd stage of labor

Conduct mother to bearing down

TIME 21.50

SUBJECTIVE

OBJECTIVE

ASSESMENT

PLANNING Baby was born spontaneus, life, female, 1900 gram, BL : 45 cm, A-S : 7-9. Ballard score 22 (33), anus(+), anomaly kongenital (-) Plasenta was born spontaneus, complete, 500 gram. Lochea 100 cc

23.50

Patient still weak

GC: well BP: 130/90 HR: 80 RR: 20 T: 37 UC: good (+) UHF: 1 finger below umbilicus Active vaginal bleeding: -

2 h post partum

Continue observation GS

07.00

Patient still weak

GC: well BP: 110/60 HR: 100 RR: 18 T: 36,4 UC: good (+) UHF: 2 finger below umbilicus Active vaginal bleeding: -

1 day post partum

Obs. Mother well being CIE patient to mobilisation Mefenamat Acid 500mg 3x1 Amoxicillin 500mg3x1

Baby in NICU HR: 124x/mnt RR:40x/mnt T: 36,1