MORNING REPORT 29th August 2012

Supervisor : dr. Edy Prasetyo Wibowo, SpOG Medical Students : Yan, Rona, Tari, Rifka, Santhi, Agung, Metha

CASE RESUME NORMAL LABOR PATHOLOGIC LABOR 2

1. G3P2A0L2, 41 42 weeks S/A/IU with PROM > 12 hours. 2. G8P7A0L6 A/S/L/IU with breech presentation, inpartu 2nd stage of labor

Case Report
Name Age Address MR Hospitalization : Mrs.S : 37 years old : Meninting, Batu Layar : 053523 : 28th August 2012

Time 28/08/12 11.30

Subject Patient from Obstetric Poli of NTB GH with G3P2A0L2 41-42 weeks S/L/IU head presentation + PROM. Patient confessed water came out from her womb, since 02.00 (28/08/2012), clear. Blood slim (-), abdominal pain (-), FM (+). History of DM (-), HT (-), asthma (-). LMP : 12/11/2011 EDD : 19/08/2012 History ANC : >4x in PHC Last ANC: 25/08/2012

Object General status GC : well GCS: E4V5M6 BP : 110/70 mmHg PR: 88 ppm RR: 20 rpm T: 36,1C Local status Eye : an (-/-), ict (-/-) Pulmo: ves (+/+), rh (-/-), wh (/-) Cor : S1S2 single regular M(-), G(-) Abd : striae albican (+), linea nigra (+), scar (-) Ext : edema (-/-) Obstetric status L1 : breech UFH: 30 cm EFW : 2945 gram L2 : back on the left side L3 : head L4 : 4/5 UC : FHR : 12.11.12 (140 bpm) VT : 2 cm, eff. 25 %, Amnion (+) leakage, head palpable, HI, unpalpable small part and/or umbilical cord of the fetus.

Assessment G3P2A0L2 41 42 wk S/L/IU with PROM

Planning -Obs. Progress of labor until more than 12 hours since ROM -Skin test ampicilin (-) Inj. ampicillin1 g

History USG : 2x at RSUP NTB. 1. 1st USG (19-03-2012), Result: EDD on 29-08-2012 2. 2nd USG (28-08-2012) Result: S/L/IU, head presentation, EFW 3000 gr, female, AFI 8,3. History of family planning: contraceptive pill. Next family planning: contraceptive pill.

Time

Subject Obstetric History: 1. Female, aterm, spontaneous, midwife, 3500 gram, 16 yo, alive. 2. Male, aterm, spontaneous, midwife, 3400 gram, 10 yo, alive. 3. This

Object PS: 5 -Cervical dilatation: 1 -Cervical effacement: 1 -Cervical consistency: 1 -Cervical position 1 -Fetal station: 1 Lab result at 28/08/2012: Hb = 11,0 g/dl Rbc = 4,13 M/uL Leu = 8,69 M/uL Plt = 270 K/uL Hct = 36,0% HbSAg = (-) 12.00,

Assessment

Planning

Chronology (28/0/8/2012) 08.00 in Meninting PHC S: Patient confessed water came out from her womb since 02.00 (28/08/2012). O: General status : GC mild, con. CM, BP 110/80 mmHg, PR 80 x/minute, RR 20 x/minute, T 36,5 C. Obstetric status: Leopold L1: breech TFU: 32 cm EFW: 3255 gram L2 : back on the left L3 : head L4 : 5/5 UC : (-) FHR : 12-11-11 (136x/mnt) VT : 1 cm, eff. 10 %, amnion (+) leakage, head palpable, denom: unclear, HI. A: G3P2A0L2 38-39 weeks S/L/IU head presentation + PROM

Time 14.50

Subject

Object UC : FHB : 12.12.12 (144 x/minute)

Assessment G3P2A0L2 41 42 wk S/L/IU with PROM >12 hours.

Planning - DM consult to SPV pro drip Oxytocin if CTG, result reactive and PS 5 acc

15.00

UC: FHB: 12.12.11 (140x/minute) CTG result reactive UC: FHB: 12.12.11 (140x/minute) UC: FHB: 12.12.12 (144x/minute) UC: FHB: 12.11.11 (136x/minute) UC: 2x/10 ~ 20 FHB: 11.11.11 (132x/minute) UC: 2x/10 ~ 30 FHB: 11.12.12 (136x/minute) UC: 3x/10 ~ 40 FHB: 12.12.11.(136x/minute) UC: 3x/10 ~ 40 FHB: 12.12.12.(144x/minute)

Drip Oxytocin (1st flash): -8 dpm -12 dpm

15.30

16.00

-16 dpm

16.30

- 20 dpm

17.00

-24 dpm

17.30

-28 dpm

18.00

-32 dpm

18.30

-32 dpm

Time 19.00

Subject

Object UC: 4x/10 ~ 40 FHB: 12.11.11 (136x/minute) UC: 4x/10 ~ 40 FHB: 12.12.13 (148x/minute) UC: 4x/10 ~ 40 FHB: 12.12.12 (144x/minute) VT: 9 cm, eff 75%, amnion (-), head palpable, H II (+), unpalpable small part and/or umbilical cord of the fetus. Seen fetuss head out from vulva (Doran, teknus, perjol, vulka)

Assessment

Planning -32 dpm

19.30

-32 dpm

20.00

-32 dpm

20.30

Patient want to bearing down.

2nd stage of labor

-Lead mother to bearing down Baby was born at 20.35. Female. 3000 gram. 45 cm, AS 7-9. Anus (+). Congenital anomaly (-).

20.35

3rdstage of labor

Placenta was born spontaneous at 20.45. Complete. 300gram. Bleeding 100cc

Time 22.35

Subject

Object GC : well BP : 110/70 mmHg PR : 100 bpm RR : 24 dpm Temp : 36,3C UC : + UFH : at umbilicus. Active bleeding: -

Assessment 2 hours post partum

Planning -Obs. Mother and baby well being. -CIE mother to eat and drink. -Suggest mother to breast feeding.

29-082012 07.00

GC : well BP : 100/60mmHg PR : 88 bpm RR : 24 dpm Temp : 36,2C UC : + UFH : at umbilicus Active bleeding: Baby rooming in: PR: 144 bpm RR: 40 dpm T: 36 C

1 day post partum

-Obs. Mother and baby well being. - CIE mother to mobilization, eat and drink. -Suggest mother to breast feeding.