MORNING REPORT

July 24th, 2012

Supervisor: dr. Agus Thoriq, Sp.OG

Medical Students: ira, lanira, yan, rona, tari

CASE RESUME
NORMAL LABOR PATHOLOGIES LABOR 1. G1P0A0L0 37-38 weeks S/L/IU with PROM > 12 hours.

Name: Mrs. M Age: 23 yo Address: Narmada Admitted: July, 23th 2012 at 13.00

TIME 23/07/2 012 13.00

SUBJECTIVE Patient referred from Narmada PHC with G1P0A0 37-38 weeks S/L/IU with PROM. Patient confessed rupture of membrane since 01.00 (23/07/2012). Bloody slim (-), FM (+). No history of DM, HT, asthma. LMP: 05/11/2011 EDD: 12/08/2012 History of ANC: >4x at PHC Last ANC: 07/07/2012 History of USG: History of family planning: (-) Next family planning: implant/ Injection 3 months

OBJECTIVE General status: GC: well BP: 120/80 mmHg PR: 84 bpm RR: 22 T: 36,2 Eye : palor (-), icteric (-) Thorax : Cor : S1S2 single reguler (murmur -), (gallop -) Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (-/-), warm acral (+/+) Obstetrical status: L1: breech L2: back on the right side L3: head L4: 4/5 UFH: 29 cm EFW: 2790 g UC: FHB: 148 x/min VT: 1 cm, eff 25%, amnion (-) clean, head palpable HI, impalpable small part / umbilical cord. PS : 5 Lab HGB : 11.5 g/dl WBC : 7.8 HCT : 38.6 PLT : 25.0 HBsAg : (-)

ASSESTMENT G2P0A1L0 37-38 weeks S/L/IU head presentaion with PROM > 12 hours

PLANNING Obs mother & fetal well being Obs progress of labor DM co SPV, Pro CTG advice: - CTG; if reactive, induction with drip oxytocin

Obstetrical history: I. This

TIME

SUBJECTIVE Chronologist: 07.00 (23/07/2012) S: Patient came to Narmada PHC confessed rupture of membrane 200 cc. since 01.00 (23/07/2012) O: GC: well BP: 130/80 mmHg PR: 80 bpm RR: 22 T: 37,9 TFU: 30 cm UC: (-) FHB: 138 x/min VT: 2 cm, eff 20%, amnion (-) clean, head palpable HI. A: G1P0A0 37 1 st stage of labor, 32 week, S/L/IU with PROM P: Insert infus RL Ampi test 100 mg Ampi test (-), inj ampi 1 g IV Paracetamol 500 mg Reffered to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME 14.00

SUBJECTIVE

OBJECTIVE GC: well BP: 120/80 mmHg PR: 88 bpm RR: 22 T: 36,5 CTG: reactive

ASSESTMENT G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours.

PLANNING DM co to SPV advice acceleration: dryp oxytocin

15.30

UC: (-) DJJ: 11-12-12 (140) UC: (-) DJJ: 12-12-12 (144) Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved Abdominal pain came and relieved UC: 3x/10 ~ 25 DJJ: 13-12-12 (148) UC: 3x/10 ~ 30 DJJ: 13-13-12 (152) UC: 3x/10 ~ 30 DJJ: 12-13-13 (152) UC: 4x/10 ~ 35 DJJ: 12-13-13 (152) UC: 4x/10 ~ 35 DJJ: 13-12-13 (152) UC: 4x/10 ~ 35 DJJ: 13-12-12 (148)

G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours. G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours. G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours. G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours. G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours. G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours. G1P0A0 37-38 weeks S/L/IU with PROM > 12 hours

Dryp oxy began 8 tpm

16.00

Dryp oxy 12 tpm

16.30

Dryp oxy 16 tpm

17.00

Dryp oxy 20 tpm

17.30

Dryp oxy 24 tpm

18.00

Dryp oxy 28 tpm

18.30

Dryp oxy 32 tpm

19.00

maintenance oxy 32 tpm

TIME 19.30

SUBJECTIVE Abdominal pain ++ Mother want to bearing down

OBJECTIVE UC: 4x/10 ~ 40 DJJ: 12-12-13 (148) VT : VT: 10 cm, eff 100%, amnion (-) clean, head palpable H III +, impalpable small part / umbilical cord. doranteknusperjolvulka

ASSESTMENT 2nd stage of labor

PLANNING Dryp oxy 32 tpm Conduct mother to bearing down

Baby was born, male, AS 7-9, 2500 gram, 50 cm, Anus (+), congenital anomaly (-)
19.45 Placenta was born spontaneus, complete, bleeding 150cc 21.45 Delivery wound pain GC: well Cons: CM BP: 110/70 HR: 80 bpm RR: 20 tpm T: 36,5 C UC: + UFH: 2 finger below umbilicus AB: GC: well Cons: CM BP: 110/80 HR : 80 bpm RR : 20 tpm T : 36,4 C UFH : 2 finger below umbilicus UC : + AB : Baby rooming in: PR:144 RR: 46 T: 36,4 2 hours post partum Observed mother and baby well being Suggest mother to mobilisation.

24/05/ 2012 07.00

Delivery wound pain

One day post partum

Observed mother and baby well being Suggest mother to mobilisation, eat, and drink, medication.