Morning ReportSeptember, 10th 2015

Supervisor:Dr. Agus Thoriq, SpOG

DM Jaga:Rian

Morning Reportseptember 10th 2015

Case ResumeNORMAL LABOR

0

PATHOLOGIES LABOR

1. G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest active phase 1st stage of labor

2. G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor

Case 1Name : Mrs. IAge : 32 years oldAddress : NarmadaAdmitted : 09-09-2015 No. RM : 56-65-82

G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest active phase 1st stage of labor

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

09/09/2015

21.44 wita

Patient reffered from Narmada PHC with G5P2A2L2 39-40 weeks S/L/IU head presentation mother and fetal well being with inpartu arrest 1st stage active phase of labor. Patient confessed about abdominal pain since 20.00 (08/09/2015) history of water leaked out from her womb (-). History of blood slim (+), FM (+).

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

LMP : 08/12/2014EDD : 15/09/2015

History of ANC : 7x at PHCLast result: (13/08/2015) BP 120/90 mmHg, BW 78 kg, GW 36 w UFH 30 cm, head presentation, FHB (+)History of USG : 1x, at SpOGLast : 25/07/2015S/L/IU head presentation, female, GW 32-34 weeks, placenta at fundus gr II-III, amnion enough, clear, EFW 3200 g

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

General statusGC : wellconsciousness: CMBP : 120/80 mmHgPR: 82 bpmRR: 20 bpmT: 37.5°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 left sideL3 : headL4 : 4/5UFH: 35 cmEFW : 3720 gUC : 3x10’~30”FHB : 13-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest active phase 1st stage of labor

DM planning:Diagnostic : CTGTherapy :Pro amniotomyObservation progress

of laborMonitoring : VS mother,

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP co to SPVAdvice : amniotomyAcceleration if UC

inadequate

Amniotomy was done at 22.30

VT : Ø 5 cm, eff 50%, amnion (-), clear, head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

UC : 3x10’~30”

Oxytocin Drip starting from 8 dpm (23.30)

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetric History:I. Aterm/normal/polindes/

3900 g/female/7 yoII. Aterm/normal/polindes/

3500 g/male/3 yoIII. AbortusIV. AbortusV. This

Pelvic score = 6Dilatation of cervix : 2Length of cervix : 1Station : 1Consistency : 1Position : 1

Laboratory (09/09/2015 21.57):HB: 12.8 g/dl RBC: 4.15HCT: 37.5 %WBC: 15.78PLT: 235HbsAg: non reactiveBT : 2’15”CT : 6’30”

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronology at Narmada PHC (09/09/2015)05.00S :Patient 9 months of pregnancy come to PHC confessed abdominal pain since 20.00 (08/09/2015) bloody slim (+) amnion (-) FM (+)

O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.4°C

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 37 cmUC : 3x10’~25”FHB : 12-11-12VT : Ø 3 cm, eff 25%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.00S :Patient confessed abdominal pain

O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.6°C

UC : 3x10’~30”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

18.00S :Patient confessed abdominal pain

O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.5°C

UC : 3x10’~35”FHB : 12-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

A :G5P2A2L2 39-40 weeks S/L/IU head presentation with mother and fetal well being + arrest active phase 1st stage of labor

P :CIE mother about examination resultRL : D5 infusion 2:1Observation for mother and fetal well being, progress of labor

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

21.00S :Patient confessed abdominal pain

O :GC : wellconsciousness: CM

UC : 3x10’~35”FHB : 11-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

A :G5P2A2L2 39-40 weeks S/L/IU head presentation with mother and fetal well being + arrest active phase 1st stage of labor

P :CIE mother about examination resultCo to GP adviceRefer to NTB GH

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23.30 UC : 3x10’~30”FHB : 12-11-12

Drip Oxytocin 8 dpm

10/09/201500.00

UC : 3x10’~30”FHB : 12-12-13

Drip Oxytocin 12 dpm

00.30 UC : 4x10’~40”FHB : 12-12-13

VT : Ø 9 cm, eff 80%, amnion (-), not clear, head presentation, ↓HII, denominator transverse sagitalis suture, not palpable small part & umbilical cord

2 hours post amniotomy

Drip Oxytocin 12 dpm

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

00.55 Mother want to bearing down General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 92 bpmRR: 20 bpmT: 36,7°C

UC : 4x10’ ~40”FHB : 12-12-13

Sign of 2nd stage of labor (+) : crowning, anus pressure, opening of vulva, bulging of perineum

VT : not perform

G5P2A2L2 39-40 weeks S/L/IU head presentation with 2nd stage of labor

DM planning:Diagnostic : -Therapy : -Monitoring : VS mother,

UC, FHBCIE : suggest mother

to bearing down

Conduct mother to bearing down

At 01.00 Baby was born, male, A-S 3-5, 3900 g, BL 52 cm, HC 34 cm, anus (+) congenital anomaly (-)Baby rooming in NICU

Placenta was born uncompletely at 01.10 pro USG

Do the management of 4th stage of labor

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

03.00 GC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.4°C

UC : wellUFH : 1 fingers below umbilicalUO : not measuredActive bleeding (-)

Baby in NICU :HR : 142x/minuteRR : 44x/minuteT : 35,8oC

2 hours post partum + rest placenta

DM planning:Diagnostic : USGTherapy : Amoxicillin 3x500 mgMefenamic Acid 3 x

500 mgMonitoring : VS mother,

UC, UFH CIE : suggest mother

to eat and drink

07.00 Patient confessed about abdominal wound pain

GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.4°C

UC : wellUFH : 1 fingers below umbilicalUO : not measuredActive bleeding (-)

Baby in NICU :HR : 144x/minuteRR : 46x/minuteT : 36,1oC

1 day post partum + rest placenta

DM planning:Diagnostic : USGTherapy : -Monitoring : VS mother,

UC, UFH, UOCIE : suggest mother

to eat and drink

Case 2Name : Mrs. SAge : 34 years oldAddress : Gunung SariAdmitted : 09-09-2015 No. RM : 12-27-02

G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

09/09/2015

16.21 wita

Patient reffered from Gunung Sari PHC with G1P0AL0 41-42 weeks S/L/IU head presentation mother and fetal well being with post term. Patient confessed about abdominal pain since 09.00 (08/09/2015) history of water leaked out from her womb (+) since 10.00 (09/09/2015) History of bloody slim (+), FM (+).

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

LMP : 08/12/2014EDD : 15/09/2015

History of ANC : 7x at SpOG Last result: (08/09/2015) BP 100/80 mmHg, BW 45 kg, GW 39 w UFH 29 cm, head presentation, FHB (+)History of USG : 7x, at SpOGLast : 09/09/2015S/L/IU head presentation, male, GW 39-40 weeks, placenta at corpus posterior, amnion enough, not clear, EFW 3200 g

History of family planning: -Next family planning : -

General statusGC : wellconsciousness: CMBP : 100/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°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 left sideL3 : headL4 : 4/5UFH: 31 cmEFW : 3100 gUC : 2x10’~25”FHB : 12-11-12VT : Ø 3 cm, eff 25%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G1P0A0L0 39-40 weeks S/L/IU head presentation latent phase 1st stage of labor

DM planning:Diagnostic : CTGTherapy :Observation progress

of laborMonitoring : VS mother,

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP advice :Observation progress

of labor

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetric History:I. This

Pelvic ExaminationPromontorium unpalpableSpina ishiadica non prominemArcus pubis >90o

Os coccygeus mobile

Laboratory (09/09/2015 16.34):HB: 10.4 g/dl RBC: 3.92HCT: 32.2 %WBC: 10.31PLT: 252HbsAg: non reactiveBT : 2’00”CT : 5’10”

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronology at Gunung Sari PHC (09/09/2015)10.00S :Patient 9 months of pregnancy come to PHC confessed abdominal pain since 09.00 (09/09/2015) bloody slim (+)

O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 30 cmEFW : 2945 gUC : 1x10’~20”

VT : Ø 1 cm, eff 25%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

A :G1P0A0L0 39-40 weeks /S/L/IU head presentation mother and fetal well being with postterm

P :CIE mother about examination resultRL infusion 20 dpmRefer to NTB GH

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

19.30 Patient confess about abdominal pain

General statusGC : wellconsciousness: CMBP : 120/80 mmHgPR: 86 bpmRR: 22 bpmT: 36.5°C

UC : 3x10’~40”FHB : 11-11-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord

G1P0A0L0 39-40 weeks S/L/IU head presentation active phase 1st stage of labor

DM planning:Diagnostic :Therapy :Observation progress

of labor with partograph

Monitoring : VS mother, UC, FHB

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

23.30 Patient confess about abdominal pain

General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C

UC : 3x10’~40”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord

G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase

DM planning:Diagnostic :Therapy :Observation progress

of labor with partograph

Pro amniotomyMonitoring : VS mother,

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP co to SPV : not answered

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

01.30 Patient confess about abdominal pain

General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C

UC : 3x10’~45”FHB : 13-12-13VT : not perform

G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase

DM planning:Diagnostic :Therapy :Observation progress

of labor with partograph

Pro amniotomyMonitoring : VS mother,

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP co to SPV advice (02.00) : amniotomy

Acceleration

Amniotomy was done at 02.15

VT : Ø 4 cm, eff 50%, amnion (-), not clear, head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord

Oxytocin Drip starting from 8 dpm (02.45)

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

02.45 UC : 3x10’~30”FHB : 13-12-13

Drip Oxytocin 8 dpm

03.15 UC : 3x10’~30”FHB : 13-12-12

Drip Oxytocin 12 dpm

03.45 UC : 3x10’~30”FHB : 12-11-12

Drip Oxytocin 16 dpm

04.15 UC : 3x10’~35”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (-), not clear, head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord

2 hours post amniotomy

Drip Oxytocin 20 dpm

04.45 UC : 3x10’~35”FHB : 12-13-13

Drip Oxytocin 24 dpm

05.15 UC : 3x10’~35”FHB : 12-12-12

Drip Oxytocin 28 dpm

05.45 UC : 4x10’~40”FHB : 12-12-12

Drip Oxytocin 32 dpm

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

06.15 Mother confessed about abdominal pain

General statusGC : wellconsciousness: CMBP : 110/60 mmHgPR: 86 bpmRR: 20 bpmT: 36.8°C

UC : 4x10’~40”FHB : 13-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord

G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase suspect CPD

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

UC, FHBCIE : CIE mother and

family about diagnostic planning and therapeutic planning

DM co to GP co to SPVAdvice : observation

progress of labor for 2 hours if there is no progression C-Section

.. Thank You ..