MR 20 Agustus 2014.pptx

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 ..