MR 26 November

7/24/2019 MR 26 November

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Morning ReportNovember 26th2014

Supervisor : dr. H. AgusThoriq Sp.!"

Medi#$% Students :

&i$n$ 'd$ &im$s(AS) R)S*M)

N!RMA+

+A,!R

-

ATH!+!"'(A+ +A,!R

1. G1P0A0L0 42-43 wks /S/L/IU head

presentation latent phase 1ststage o la!or

with se"ere ane#ia and s$sp. %a&roso#ia

2. G1P0A0L0 3'-40 wks /S/L/IU head

presentation with prolonged latent phase ola!or


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($se Report

(a#e ) %rs. S

*% ) 11-+'-,0

Age ) 2+ ears old

Address ) at$ Laar Lo#!ok arat

Ad#itted ) (o"e#!er 2+th2014 12)30 a#

iagnosis ) G2P1A0L0 3'-40 weeks/S/L/IU

head presentation latent phase 1ststage ola!or with se"ere ane#ia and s$sp.

#a&roso#ia


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I%5 SU657I85 9657I85 ASS5SS%5( PLA((I(G

2+/11/2014

12.00wita

Patient ro# o!stetri&depart#ent with G2P1A0L03'-40 weeks /S/L/IU headpresentation latent phase1st stage o la!or withse"ere ane#ia.Patient &oness lower

a!do#inal pain that spreadto :ank region sin&e2+/11/2014 0+.00 witahistor o #e#!raner$pt$red - !lood sli#- etal #o"e#ent ;.i


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2+/11/1412.30wita

P5 )Spina is&hiadi&a not pro#inent9s &o&&ge$s #o!ileAr&$s p$!is K'0

La! 5a#ination )= ) ,.2 g/dl*7 ) 3.'? 10,/L=7 ) 22.+HB7) 11.32 103/LPL ) 2,' 103/L=!SAg ) -Protein$ria ) -


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2+/11/2014

1+.00 wita

G7 ) wellG7S ) 548+%,P ) 110/?0 ##=gP* ) ?? !p#** ) 20 !p# ) 3,4o7U7 ) ; 2/10CD2+E

>= ) 13-13-13 1+, !p#

G2P1A0L0 3'-40 weeks with

headpresentation/S/L/IU with

se"ereane#ia;s$sp.

#a&roso#ia

9!ser"ation #other Jetal well !eing.

rans$sion P*7 1 kol

1,.00 wita %other &onesseda!do#inal pain ;

U7) ; 2/10CD2+E>=) 13-13-14 1,0 !p#8 ) F 2 e. 2+ HA#nion ; head palpa!le=I deno# $n&leari#palpa!le s#all part o

et$s or $#!ili&al &ord

9!ser"ation %other and!a! well !eing

% &o. to GP pro 7G GP&o to SP8 a!o$t res$lt o7G SP8 pro S7.

7I5 a#il

preparing 7S

1.30 wita General &ondition) GoodP ) 120/?0 ##=g=* ) ?4 !p#** ) 22 tp# ) 3,o7

7S !egan a! was !orn #ale B

3'00 gr L +0 AS ?-' an$s ; &ongenitalano#al -

Pla&enta deli"ered&o#pleted !leeding 1+0

&& Intraoperati Mnding) 7P a! was in (I7U


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1'.30 wita General &ondition) GoodP ) 120/?0 ##=g=* ) ?4 !p#** ) 22 tp# ) 3,o7U>= ) 1 Mnger !elow $#!ili&al

U7 ) ; wellLo&hia r$!ra ;U9 ) ,00 &&A&ti"e !leeding -a! was in (I7UG7) well =*) 1+4 !p# **) +3!p# ) 3,+ 07

2 ho$rs Post 7S 9!ser"ation %otherand !a! well!eing

S$ggest #other to#o!ili= ) 1 Mnger !elow $#!ili&$sU7 ) ; wellA&ti"e !leeding) -Lo&hia r$!ra ;U9 ) 100&&a! was in (I7UG7) well =*) 1+4 !p# **) +3!p#

) 3,+ 07

1 da post 7S 9!ser"ation %otherand !a! well!eing

S$ggest #other to#o!ili


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($se Report

(a#e ) %rs. N

*% ) ++ 0+ 1'

Age ) 2' ears old

Address ) Pag$tan %atara#

Ad#itted ) (o"e#!er 2+th 2014 0'.30

wita

iagnosis) G1P0A0L0 3'-40 wks /S/L/IUhead presentation with prolonged latent

phase o la!or



15/27


2+/11/2014

0'.30wita

Patient &a#e to 8O I*( G= &oness lowera!do#inal pain that spreadto :ank region sin&e 0+.30wita 2+/11/2014 historo Bater !roke ro# herwo#! - !lood sli# -.

>etal #o"e#ent ;.=istor o % - =-asth#a - allerg -.L%P ) 1,/02/20145 ) 23/11/2014=istor o A(7 ) ? ti#es atposand$Last *es$lt ) 04/11/14) P )'0/,0 ##=g 3? week

B +4 kg >= ;.=istor o USG ) 1 ti#e atSp9GLast res$lt) 1/11/2014

=istor o a#il planning )-(et a#il planning ) IU

9!stetri&al =istor )I. his

General Stat$s )G7 ) well G7S ) 548+%,P ) 100/,0 ##=gP* ) '? !p#** ) 22 !p#

) 3,'o75e ) ane#is - i&teri& -

7or ) S1S2single reg$lar#$r#$r - gallop -.P$l#o ) "esi&$lar ;/;whee


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Pelvic Evaluation :Spina ischiadica not prominentSacrum concaveOs coccygeous mobileArcus pubis > 900

PS) ,

ilatation) 1Length)17onsisten&) 2Position) 1Station) 1

La! 5a#ination )= ) 12.' g/dl*7 ) 4.33 10,/L

=7 ) 3?.+ HB7) 12.1 103/LPL ) 31+ 103/L=!SAg ) -) 2C1+E7) ,C10E


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1!0"ita

# General Status$% : "ell$%S : E&'()*+P : 110,-0 mm.gP/ : - bpm// : 1 bpm

: 230 4%5% : 6 10708.+ : 1 #1#1 1&& bpm;' : < cm3 e== (3 amnion ?;3head palpable3 denom [email protected] impalpable small part o==etal,umbilical cord

latent phase=irst stage o=labor

# Obs! )other and =etal "ellbeing!

# Obs! Progress o= labor# B) co! to $P pro %$3 $P coresult o= %$3 SP' adviceobservation progress o= labor!

12!0"ita

# General Status$% : "ell$%S : E&'()*+P : 11(,20 mm.gP/ : -- bpm// : 1 bpm : *3* 4%5% : 6 10708.+ : 1 #11#11 1* bpm;

' : < cm3 e== (3 amnion ?;3head palpable3 denom [email protected] impalpable small part o==etal,umbilical cord

prolonged latentphase =irststage o= labor

B) co to $P pro rehydration3 $Pagreed and co to SP'! SP'advice:#Pro acceleration%E patient and =amily

1-!00"ita

5% : 6 107(8.+ : 1 #11#1 1&0 bpm;

- /ehydration began /C: B( D :1


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0!0"ita

$% : "ell$%S : E&'()*+P : 11(,20 mm.gP/ : -- bpm// : 1 bpm : *3* 4%

5% : 6 10708.+ : 1 #11#11 1* bpm;5% : 6 107(8.+ : 1 #11#1 1&0 bpm;

- Acceleration began drip Oytocin - dpm

1!00"ita

5% : 6 107(8.+ : 1 #1#1 1&&bpm;

Brip oytocin 1 dpm

1!0

"ita

5% : 6 107(8

.+ : 1 #1#1 1&&bpm;

Brip oytocin 1* dpm

!00"ita

)other con=essed "aterleaFed out =rom her"omb

$% : "ell$%S : E&'()*+P : 11(,20 mm.gP/ : -- bpm// : 1 bpm

: *3* 4%5% : 6 10708.+ : 1 #11#11 1* bpm;5% : 6 107(8.+ : 1 #1#1 1(bpm;' : < cm3 e== (3 amnion #;meconeal3 head palpable3 denomunclear3 @.3 impalpable smallpart o= =etal,umbilical cord

Neglectedlatent phase oflabor

# Brip oytocin 0 dpm# %E patient and =amily# B) co to $P pro %S3 $P co! to

SP' advice %S at !0

22./0 $% : "ell Preparing 7S


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22./0 $% : "ell$%S : E&'()*+P : 110,20 mm.gP/ : -- bpm// : 1 bpm : *3* 4%5% : 6 10708.+ : 1 #11#11 1* bpm;

Preparing 7S 7I5 a#il

2/./0 7S !egan a! was !orn #ale B 3?00gr L AS ?-' an$s ;&ongenital ano#al -

Pla&enta deli"ered &o#pleted!leeding 1+0 &&

01./0 General &ondition) GoodP ) 100/?0 ##=g=* ) ?0 !p#

** ) 22 tp# ) 3,o7U>= ) 1 Mnger !elow $#!ili&alU7 ) ; wellLo&hia r$!ra ;U9 ) +00&&A&ti"e !leeding -!a! was in (I7U=*) 140 !p# ** ) +4/# ) 3,

7

2 ho$rs Post 7S 9!ser"ation %other and !a!well !eing

S$ggest #other to #o!ili


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I%5 SU657I85

9657I85 ASS5SS%5( PLA((I(G

261114

06.00

General &ondition) GoodP ) 110/?0 ##=g=* ) ?? !p#** ) 20 !p# ) 3,0o7U>= ) 1 Mnger !elow $#!ili&$s

U7 ) ; wellA&ti"e !leeding) -Lo&hia r$!ra ;U9 ) 100&&/a#!a! was in (I7U=*) 14, !p# ** ) +?/# ) 3,7

1 da post 7S 9!ser"ation %other and !a!well !eing

S$ggest #other to #o!ili


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MR 26 November

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