Transcript
Morning ReportJuly, 21st 2014
Supervisor:dr. I Made Putra Juliawan, Sp.OG
DM Jaga:Zia, Yid, Santi, Ayu
Morning ReportJuly 21st 2014
Case ResumeNORMAL LABOR
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PATHOLOGIES LABOR
1. G3P1A1L1 37-38 wks/S/L/IU with history of ROM + history of CS
2. G1P0A0H0 40 weeks/ S/L/IU head presentation + prolong 2 nd stage of labor and failed of VE
Case 1Name : Mrs. NAge : 16 years oldAddress : Gn.sari, LobarAdmitted : 21-07-2014 No. RM : 54-48-09
G2P0A1L0 29-30 weeks/S/L/IU head presentation + PROM > 24 hours
Time Subject Object Assessment Planning21-07-201412.00
Patient come to policlinic NTB GH, referred from Sigerongan PHC with G2P1A0L1 A/S/L/IU head presentation with suspect macrosomia.
Patient confessed water come out from her womb since 17-08-2014 (02.00 am), bloody slim (-), abominal pain (+) and FM (+).
No history of DM, HT, asthma.
LMP : 24 January 2014EDD : 03 November 2014
History ANC : 8x at PosyanduLast ANC : 18-08-2014result: BP : 110/70, BW 41 kg, 29-30 weeks, UFH 23 cm, head presentation, FHB (+)
General statusGC : wellGCS: CM (E4V5M6)BP : 120/80 mmHgHR: 84 x/mRR: 20 x/mT: 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 (-/-), warm (+/+)
Obstetric statusL1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH: 35 cmEFW : 3720 gram
UC : (-)FHB : 12-12-12 (144x/min)
G2P1A0L1 A/S/L/IU with latent phase
•Obs. Mother and fetal well being•Pro CTG
•Preop CS
Time Subject Object Assessment PlanningHistory of USG : 1xLast USG (18-08-2014): S/L/IU head presentation, female, placenta at fundus grade II, 28-30 weeks , EFW 1377 gr, EDD : 01/11/2014
History of family planning : -Next family planning : injection
History of obstetric :I. AB 3 monthsII.This
VT: Ø 2 cm, eff. 25%, amnion (+), head palpable, denom unclear, ↓H1, unpalpable small part/umbilical cord
Lab:HGB = 10.7 g/dlRBC = 3.86 K/ulWBC = 8.81 M/ulHCT : 32.7 %PLT = 196 M/ulHBsAg = (-)
Time Subject Object Assessment
Planning
14.00 - •Do CTG•Co to GP, acc drip
16.00 Abdominal wound pain
•GC: well•BP: 120/80 mmHg •HR: 82 bpm •T 36,70C •RR 20 x/m•UC: 2x/10’ ~ 20”•FHB: 11-12-12
•Start acceleration (oxytocin drip) 8 dpm
16.30 •UC: 2x/10’ ~ 20”•FHB: 12-12-12
•Oxytocin drip 12 dpm
17.00 •UC: 2x/10’ ~ 20”•FHB: 12-11-12
•Oxytocin drip 16 dpm
17.30 •UC: 2x/10’ ~ 20”•FHB: 12-12-12
•Oxytocin drip 20 dpm
Time Subject Object Assessment
Planning
17.30 Patient confessed abdominal pain
•UC: 4x/10’ ~ 40”•FHB: 13-13-12 (152x/mnt)•VT: Ø 8 cm, eff. 80%, amnion (-) clear, head palpable, denom unclear, ↓H1, unpalpable small part/umbilical cord
Active phase of labor
•Left lateral decubitus•Suggest mother to eat & drink
20.00 •GC: well•BP: 120/80 mmHg •HR: 82 bpm •T 36,70C •RR 20 x/m•UC: 4x/10’ ~ 40”•FHB: 12-12-12
•Oxytocin drip 32 dpm
20.30 •UC: 4x/10’ ~ 40”•FHB: 12-12-12
•Oxytocin drip 32 dpm
21.00 •UC: 4x/10’ ~ 40”•FHB: 12-12-12
•Oxytocin drip 32 dpm
Time Subject Object Assessment
Planning
21.30 - •UC: 4x/10’ ~ 40”•FHB: 12-12-12•VT: Ø 6 cm, eff. 25%, amnion (+), head palpable, denom unclear, ↓H1, unpalpable small part/umbilical cord
•Oxytocin drip 32 dpm•Ganti drip flash II
22.00 Patient confessed water came out from her womb
Mother wants to bearing down
•UC: 4x/10’ ~ 40”•FHB: 12-11-11•VT: Ø complete, eff. 100%, amnion (-) clear, head palpable, denom unclear, ↓H2, unpalpable small part/umbilical cord• Inspection: perineum bulging, opening vulva,
•Oxytocin drip 32 dpm•Conduct the labor
22.30 Baby was born, male, 3500 gram, 50 cm, A-S 7-9, caput (-), anus (+), anomaly congenital (-).Placenta was born spontaneous, complete.Bleeding ± 100 ccPerineum intact
Time Subject Object Assessment Planning
01.30 Abdominal pain •GC: well •GCS: E4V5M6•BP: 110/70 mmHg •PR: 79x/m• RR: 20x/m •T: 36,6 0C•UC: (+) well•UFH: 2 fingers below umbilicus•Active bleeding: (-)•UO: 150cc/ 2 hours•Lokea rubra (+) 10cc
2 hours post partum
•Observation mother and baby well being•Suggest mother to eat and drink•Suggest mother to mobilization•Suggest mother to early breast feeding
22-07-2014 7.00 am
Abdominal wound pain
•GC: well cons:E4V5M6•BP: 100/60 mmHg •PR: 80x/m• RR: 20x/m •T: 36,8 0C•UC: (+) well•UFH: 2 fingers below umbilicus•Active bleeding: (-)•UO: 60cc/hour•Lokea rubra (+) 5 cc
Baby:Pulse : 144 bpmRR : 52x/mT : 36,7 C
1 day post partum •Observed mother and baby well being•Suggest mother to mobilization•Suggest mother to eat and drink
.. Thank You ..
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