Morning Report Serotinus

Supervisor: dr. Doddy Aryo Kumboyo, SpOG

DM: Titin, Sandi, Armand, Rara

MORNING REPORT24TH OF DECEMBER

2013

• Name : Mrs. S• Age : 20 yo• Address :Kayangan• Addmitted :December 23th 2013• RM :529250

PATIENT IDENTITY

G1P0A0L0 42-43 weeks S/L/IU head presentation

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23/12/2013

11.30 WITA

Patient came to Pregnancy Policlinic NTB GH referred from Kayangan PHC with G1P0A0L0 42 weeks S/L/IU with serotinus. Abdominal pain (-) history rupture of membrane (-), bloody slim (-), FM (+).No history of DM, HT, asthma.

LMP : 28/02/2013 EDD : 05/12/2013

History ANC : > 7x at PHCLast ANC : 21/12/2013USG : 1x at NTB GH. Result : placenta grade III, BPD 92, AC 30, FL 74, Amnion sufficient turbid, EFW 2700.History of family planning : (-)Next family planning : Injection 3 months

History of Obstetric :1. This

General Status :GC : wellBP : 120/80 mmHgPR : 88 bpmRR : 20 bpmTemp : 36,7oC

Eye : palor (-/-), icteric (-/-)Cor : S1S2 single reguler, murmur (-), gallop (-).Pulmo : vesikuler (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).

Obstetric Status :L1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 30 cmEFW : 2945 gramUC : (-)FHB : 12-11-11 (140 bpm)VT: Ø 1 cm, eff 25%, amnion (+), head palpable ↓HI, impalpable small part / umbilical cord.

G1P0A0L0 42-43 weeks S/L/IU head

presentation

• Observation mother & fetal well being.

• CTG • DM co to SPV Pro

Induction of labor with oxytocin drip, SPV advice: induction with drip oxytocin

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23/12/2013

@ Kayangan PHCSubjective : 9 months pregnant woman confessed abdominal pain since 21/12/2013 at 08.00 WITA,LMP 28/02/2013, EDD 07/12/2013.

Objective:General condition : WellGCS: CMBP : 110/70 mmHgPR : 82 x/mRR : 22 x/mTemp : 36,5 ◦C

UFH: 30 cm, breech palpable in fundus, back of right side, FHR: (+), regular,12-11-12 (140x/m), UC (-), VT not doing.

Assesment:G1P0A0L0 42 weeks S/L/IU head presentation with serotinus.

PS: 6Dilatation Servix 1Eff 1Station 1Consistency 2Position 1 PE: seem normalSpina ischiadica not prominentArcus pubis > 900

Os Coxygeus mobile

Lab Result:Hb : 11,4 gr/dlHCT : 34,5%RBC : 4,81M/uLPLT : 320 K/uLWBC : 14,53 K/uL

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

14.00 - GC: wellBP: 120/80 mmHgPR: 82 bpmRR: 20 T: 36,8

UC: -FHR: 11-11-12 (136)

Drip oxy began 8 dpm flash I

14.30 - UC: -FHR: 11-11-11 (132)

Drip oxy 12 dpm

15.00 - UC: 2x/10’ ~ 25”FHR: 12-11-12 (140)

Drip oxy 16 dpm

15.30 Abdominal pain came and relieved

UC: 3x/10’ ~ 30”FHR: 11-12-12 (140)

Drip oxy 20 dpm

16.00 Abdominal pain came and relieved

UC: 3x/10’ ~ 35”FHR: 11-11-11 (132)

VT: Ø 3 cm, eff 25%, amnion (+), head palpable ↓HI, impalpable small part / umbilical cord.

G1P0A0L0 42-43 weeks S/L/IU head presentation with latent phase of labor

Drip oxy 24 dpm

16.30 Abdominal pain came and relieved

UC: 3x/10’ ~ 35”FHR: 12-11-11 (136)

Drip oxy 28 dpm

17.00 Abdominal pain came and relieved

UC: 3x/10’ ~ 35”FHR: 11-11-11 (132)

Drip oxy 32 dpm

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

17.30 Abdominal pain came and relieved

UC: 3x/10” ~ 35”FHR: 12-11-12 (140)

Drip oxy 36 dpm

18.00 Abdominal pain came and relieved

UC: 3x/10” ~ 35”FHR: 11-11-12 (136)

Drip oxy 40 dpm

18.30 Abdominal pain came and relieved

UC: 4x/10” ~ 40”FHR: 12-12-12 (144)

Drip oxy 40 dpm

19.00 Abdominal pain came and relieved

UC: 4x/10” ~ 40”FHR: 12-12-12 (144)

Drip oxy 40 dpm

19.30 Abdominal pain came and relieved

UC: 4x/10” ~ 40”FHR: 12-11-12 (140)

Drip oxy 40 dpm

20.00 Abdominal pain came and relieved

UC: 4x/10” ~ 40”FHR: 12-12-12 (144)VT: Ø 8 cm, eff 75%, amnion (+), head palpable ↓HII, impalpable small part / umbilical cord

G1P0A0L0 42-43 weeks S/L/IU head presentation with active phase of labor

Drip oxy 40 dpm Flash II

20.30 UC: 4x/10” ~ 40”FHR: 12-12-12 (144)

Drip oxy 40 dpm

21.00 UC: 4x/10” ~ 40”FHR: 12-12-12 (144)

Drip oxy 40 dpm

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

21.30 Abdominal pain came and relieved

UC: 4x/10” ~ 40”FHR: 12-11-12 (140)

Drip oxy 40 dpm

22.00 Mother want to bearing down Inspection: Crowning 2nd stage of labor

Conduct Labor

Baby was born, at 22.05, female, BW 2900 gram, BL 54cm, A-S 7-9, sign of postmature stage I, congenital anomali (-)

Placenta born spontan, complete, 500 gram

Active bleeding (-)

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

24.00 General condition : well BP: 120/80 PR : 80 x / mRR : 20x/mT: 36,8

UFH: 2 finger below umbilicusUC: (+) wellActive bleeding (-)

P1A0L1 2 hours post partum

Obs mother well beingObs for VS and bleeding, uterine contraction

24/12/201307.00

- General condition : well BP: 120/80 PR : 80 x / mRR : 20x/mT: 36,8UFH: 2 finger below umbilicusUC: (+) wellActive bleeding (-)

Babies in RoomingPR: 148 bpmRR: 50 x/mTemp :36,6 ◦C

P1A0L1 1st day post partum

Obs. Mother and baby well being

CIE: explanation about result of examination, drink n eat, ASI exclusive, and mobilization

Skin Exfoliate Long Nail