Morning ReportSeptember, 3rd 2015

Supervisor:Dr. H. AGUS THORIQ, SpOG

DM VK:tia

Morning Reportseptember 3rd 2015

Case ResumeNORMAL LABOR

0

PATHOLOGIES LABOR

1. G2P1A0L1 39-40 weeks S/L/IU head presentation with oligohidramnion + failure of drip oxytocin

Case 1Name : Mrs. NSSAge : 22 years oldAddress : Batu LayarAdmitted : 01-09-2015 No. RM : 12-25-21

G2P1A0L1 39-40 weeks S/L/IU head presentation with oligohidramnion + failure of drip oxytocin

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

01/09/2015

12.00 wita

Patient reffered from obstetric poly with G2P1A0H1 40-41 weeks S/L/IU head presentation. Patient not confessed about abdominal pain, history of water leaked out (+) since yesterday, history of bloody slim (-), FM (+).

History of DM (-), HT in pregnancy (-), asthma (-) and allergy (-).

LMP : 1/12/2014EDD : 8/9/2014

History of ANC : 8x at PosyanduLast result: (28/08/2015) BP 100/70 mmHg, BW 74 kg, GW 39-40 wk, UFH 32 cm, head presentation, FHB (+)

History of USG : 3x, at NTB GHLast : 01/09/2015S/L/IU head presentation, male, GW 39-40 weeks, placenta at fundus, AFI clear, minimal, EFW 3003 g

History of family planning: injection 3 monthNext family planning : injection 3 month

General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 22 bpmT: 36.6°C

Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema of lower extremity(-/-), warm acral (+/+).

Obstetric statusL1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH: 33 cmEFW : 3410 grUC : -FHB : 11-12-12VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G2P1A0L1 39-40 weeks S/L/IU head presentation with oligohidramnion

DM planning:Diagnostic : CBC,

HbsAg,, BT, CT, CTGTherapy :Pro induction with

oxytocin drip Monitoring : VS mother,

UC, FHB, observation progress of labor

CIE : CIE mother and family about diagnostic planning and therapeutic planning

13.50DM co to GP co to SPV

advice :CTG normal, drip

oxytocin

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetric History:I. Aterm/Polindes/midwife/

2700 g/18 years/female/liveII. This

Pelvic score = 5Dilatation of cervix : 1Length of cervix : 1Station : 1Consistency : 1Position : 1

Laboratory (01/09/2015 12.56):HB: 10.3 g/dl RBC: 3.90HCT: 32.3 %WBC: 8.37PLT: 229HbsAg: non reactiveBT : 1’50”CT : 6’30”

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.00 UC : -FHB : 12-12-11

Drip oxytocin 8 dpm

14.30 UC : -FHB : 11-12-12

Drip oxytocin 12 dpm

15.00 UC : -FHB : 12-12-12

Drip oxytocin 16 dpm

15.30 UC : 1x10’~15”FHB : 12-11-12

Drip oxytocin 20 dpm

15.30 UC : 1x10’~15”FHB : 12-12-13

Drip oxytocin 24 dpm

16.00 UC : 1x10’~15”FHB : 12-12-11

Drip oxytocin 28 dpm

16.30 UC : 2x10’~15”FHB : 12-12-12

Drip oxytocin 32 dpm

17.00 UC : 2x10’~15”FHB : 12-12-11

Drip oxytocin 36 dpm

17.30 UC : 2x10’~20”FHB : 11-11-12

Drip oxytocin 40 dpm

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

18.00 Patient confess about abdominal pain UC : -

FHB : 11-12-11VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

DM planning:Diagnostic :Therapy :Drip oxytocin 40 dpmMonitoring : VS mother,

UC, FHB, observation progress of labor

CIE : CIE mother and family about diagnostic planning and therapeutic planning

18.30 UC : 2x10’~20”FHB : 12-12-12

Drip oxytocin 40 dpm

19.00 UC : 2x10’~20”FHB : 11-12-12

Drip oxytocin 40 dpm

19.30 UC : 2x10’~20”FHB : 11-11-12

Drip oxytocin 40 dpm

20.00 UC : 3x10’~20”FHB : 11-12-11

Drip oxytocin 40 dpm

20.30 UC : 3x10’~20”FHB : 12-12-11

Drip oxytocin 40 dpm

21.00 UC : 3x10’~20”FHB : 12-12-12

Drip oxytocin 40 dpm

21.30 UC : 2x10’~25”FHB : 12-12-11

Drip oxytocin 40 dpm

22.00 UC : 2x10’~25”FHB : 12-12-11

Drip oxytocin 40 dpm

22.30 UC : 2x10’~25”FHB : 12-12-11

Drip oxytocin 40 dpm

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23.00 UC : 2x10’~20”FHB : 12-12-12

Drip oxytocin 40 dpm

23.30 UC : 2x10’~20”FHB : 11-12-12

Drip oxytocin 40 dpm

02/09/201500.00

GC : wellconsciousness: CMBP : 100/70 mmHgPR: 82 bpmRR: 20 bpmT: 36.6°C

UC : 2x10’~20”FHB : 11-11-12VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G2P1A0L1 39-40 weeks S/L/IU head presentation with oligohidramnion + failure of drip oxytocin

DM planning:Diagnostic : -Therapy :Pro CSMonitoring : VS mother,

UC, FHB, observation progress of labor

CIE : CIE mother and family about diagnostic planning and therapeutic planning

DM co to GP co to SPVAdvice : CS tomorrow

at 10.00

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

06.00 Mother confessed about abdominal pain

GC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.6°C

UC : -FHB : 12-11-12VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G2P1A0L1 39-40 weeks S/L/IU head presentation with oligohidramnion + failure of drip oxytocin

DM planning:Diagnostic : -Therapy :Pro CSInjection ampicillin 2

gr/IVMonitoring : VS mother,

UC, FHB, observation progress of labor

CIE : CIE mother and family about diagnostic planning and therapeutic planning

Suggest mother to laydown at the left side

10.00 Patient transffered to OK GC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.6°C

UC : -FHB : 12-11-12VT : Ø 1 cm, eff 10%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G2P1A0L1 39-40 weeks S/L/IU head presentation with oligohidramnion + failure of drip oxytocin

DM planning:Diagnostic : -Therapy :CIE :Monitoring :C Section begin at

10.00

At 10.05 Baby was born,male, BW 3450 g, BL 50 cm, A-S 7-9

Placenta was born completely at 14.10

Do the management of 4th stage of labor

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

12.30 Patient confessed about abdominal wound pain

GC : wellconsciousness: CMBP : 100/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.4°CUC : wellUFH : 2 fingers below umbilicalUO : 200 cc/2 hoursActive bleeding (-)

Baby in NICU :HR : 152x/minuteRR : 54x/minuteT : 36,3oC

2 hours post partum

DM planning:Diagnostic : Therapy :Injection ampicillin 1

gr/6 hoursInjection ketorolac 30

mg/8 hoursMonitoring : VS mother,

UC, UFH, UOCIE : suggest mother

to eat and drink

03/09/201507.00

Patient confessed about abdominal wound pain

GC : wellconsciousness: CMBP : 100/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.7°CUC : wellUFH : 2 fingers below umbilicalUO : 300 cc/4 hoursActive bleeding (-)Lochea rubra (+)

Baby in NICU :HR : 148x/minuteRR : 50x/minuteT : 36,5oC

1 day post partum DM planning:Diagnostic : Therapy :Injection ampicillin 1

gr/6 hoursInjection ketorolac 30

mg/8 hoursMonitoring : VS mother,

UC, UFH, UOCIE : suggest mother

to eat and drink

.. Thank You ..