MORNING REPORT

Thursday, January 21st, 2016 at 03.30 PM

Friday, January 22nd, 2016 at 07.00 AM
Physiologic obstetrical patient
Pathologic obstetrical patient
Gynecological patient
Passed Away
Total patient

: - case
: 4 cases
: - case
: - case
: 4 cases

Obstetric ward patients

Gynecology and Oncology ward patients
ICU patient
Total Patients

: 34 patients
: 57 patients
: 3 patient
: 94 patients

OBSTETRICS
1.

20-01-16
06:00 AM
1 cm
UC: 2/10/25
Hb : 8.1 g/dl
WBC :
18.400/mm3
PLt :
264.000/mm3
MCV: 67,2 fL
MCH: 20 pg
MCHC: 30 g/dL

10:00 AM
2 cm

LSCS due to fetal distress

Mrs. NUR/28/UA/SYA
D/ G1P0A0 38 weeks gestational age inlabor1st stage laten
phase + moderate anemia SLF cephalic presentation
US ER (DIK):
SLF cephalic presentation
Biometry :
BPD : 91mm
AC : 325mm
EFW : 2960 g
HC : 317mm
FL : 72mm
Placenta at anterior corpus of uterine
Amniotic fluid was enough, SP : 4.2 cm
C/ 38 weeks gestational age SLF cephalic presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RLgtt xx/m
- Laboratory examination
P/ Vaginal delivery
PRC Transfusion
D/ G1P0A0 38 weeks gestational age inlabor1st stage laten
phase + moderate anemia SLF cephalic presentation
M/ - Observed vital sign, FHR, uterine contraction

UC 2x/10/30

02:00 PM

3 cm
UC 3x/10/30

06:00 PM
4 cm
UC 4x/10/35

09:00 PM

4 cm
UC 4x/10/35
FHR I: 182x/m
FHR II: 178 x/m
FHR III: 183 x/m
Amnion fluid:
Green

10.05 PM
10.08 PM
Hb : 10.0 g/dl
WBC :
12.600/mm3
PLt :
234.000/mm3

- IVFD RLgtt xx/m

P/ - Vaginal delivery
D/ G1P0A0 38 weeks gestational age inlabor1st stage
prolonged laten phase + moderate anemia SLF
cephalic presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RLgtt xx/m
- Acceleration with amniotmy and oxytocin drip
P/ Vaginal delivery
D/ G1P0A0 38 weeks gestational age inlabor1st stage active
phase + moderate anemia SLF cephalic presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RLgtt xx/m
- Evaluation with modified WHO partograph
P/ Vaginal delivery
D/ G1P0A0 38 weeks gestational age inlabor1st stage active
phase + moderate anemia SLF cephalic presentation +
fetal distress
M/ - Observed vital sign, FHR, uterine contraction
- O2 6 L/m
- Latero position
- Stop oxytocin drip

P/ Abdominal delivery
Consult to Dr. H. Abadi, SpOG(K) Agree for abdominal delivery
Female life baby was born, BW 2800 gr, BL 48 cm, AS 2/5/7 FTAGA
Placenta was delivered completely, PW 450 g, UCL: 48 cm, 19x 18cm
Mother was in good condition, baby was in neonatus ward

21-01-16

LSCS due to PPHD NYHA IV

04.00 PM

Mrs. ASI/19/RA/SYA
D/ G1P0A030 weeks gestational age not inlabor + severe preeclampsia +
dyspnea cb PPHD NYHA IV SLF cephalic presentation

BP : 170/100
mmHg
IG: 5
BS: 2

07.00 PM

Hb : 12.2 g/dl
WBC :
17.600/mm3
PLT :
395.000/mm3
SGOT: 36U/L
SGPT:24U/L
LDH: 715U/L
AsamUrat:
11,50mg/dL
Protein Urine: ++

08.30 PM
08.35 PM
Hb : 10.5 g/dl
WBC :
30.200/mm3

US ER (FOR):
SLF cephalic presentation
Biometry :
BPD : 79mm
AC : 261mm
EFW : 1580 g
HC : 281mm
FL : 58mm
Placenta at posterior corpus of uterine
Amniotic fluid was enough, SP : 3.2 cm
C/ 30 weeks gestational age SLF cephalic presentation
M/ Stabilization 3 hours
Observed vital sign, FHR
O2 12L/m NRM
IVFD RL gtt x/ m
Furosemide inj 20 mg iv
Laboratory examination
Consult to internal medicine and ophthalmologic department
P/ - Abdominal delivery after stabilization
Internal department assesment:
C/ Acute lung oedema cb PPHD + Hypertension stage II
P/ Furosemide 20mg/24 Hours IV
Digoxin 0,125mg/24 Hours IV
Consult to consultant on duty
Advice: Consult to Fetomaternal division
Consult to Fetomaternal supervisor
Abdominal delivery after stabilization
D/ G1P0A0 30 weeks gestational age not inlabor + severe preeclampsia +
dyspnea cb PPHD NYHA IV + partial HELLP syndrome SLF cephalic
presentation

Male life baby was born, BW 1400 gr, BL 41 cm, AS 3/5/8 PTAGA
Placenta was delivered completely, PW 260 g, UCL: 42 cm, 15x
16cm
Motherreferred to ICU, Baby referred to NICU

3.

22-01-16
00:05 AM

Hb : 12.3 g/dl
WBC :
10.100/mm3
PLt :
277.000/mm3

4.

22-01-16
02:30 AM

Hb : 12.3 g/dl
WBC :
10.100/mm3
PLt :
277.000/mm3

Conservative Management
Mrs. WID/27/RA/ RIC
D/ G1P0A0 33 weeks gestational age notinlabor with PROM
11 hours + oligohydramnios SLF cephalic presentation
US ER (FOR):
SLF cephalic presentation
Biometry :
BPD : 81mm
AC : 242mm
EFW : 2060 g
HC : 248 mm
FL : 61mm
Placenta at anterior corpus of uterine
Amniotic fluid was decrease, AFI: 0,6 0,5 = 3,1 cm
0,9 1,1
C/ 33 weeks gestational age SLF cephalicpresentation
M/ - Observed vital sign, FHR
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Dexamethason 6 mg/ 12 hours iv (2 days)
- Laboratory examination
P/ US Confirmation
Expectative Management

Mrs. NAN/34/RA/ RIC

D/ G5P2A2 27 weeks gestational age with second trimester
bleeding + prior CS 1x (o.i total placenta previa) SLF
cephalic presentation
US ER (FOR):
SLF cephalic presentation
Biometry :
BPD : 68 mm
AC : 204 mm
EFW : 800 g
HC : 240 mm
FL : 45 mm
Placenta at posterior corpus expand to OUI
Amniotic fluid was enough
C/ 27 weeks gestational age SLF cephalicpresentation
M/ - Observed vital sign, FHR, contraction

- IVFD RLgtt xx/m

- Cefriaxone1g/12 hours iv
- Dexamethason 6 mg/ 12 hours iv (2 days)
- Nifedipine 10mg/6 hours p.o
- Laboratory examination
P/ US Confirmation
GYNECOLOGY