MORNING REPORT May 5th 2012

Supervisor : dr. A. Rushdy A.H., Sp.OG

Medical Student:

Fahmi, Ira, Nana, Nisia, Hasaniah, Heri, Rani, Fadil, Wiwid

Normal Labor Patologyc

1 G2P1A0L1, 37 38 weeks, A/S/L/IU with Prolong 2nd stage of Labor

Cases Resume

G2P1A0L1, 37 38 weeks, A/S/L/IU with prolong 2nd stage of labor

Patologic Case

Identity
NAME : Mrs. S Age :31 yo Admitted: May 5th 2012, 22.30 WITA Address : Gangga KLU

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04/05 /2012 22.30 (VK IRD)

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General Status : GC : well BP : 120/80 mmHg PR : 98x/mnt RR : 24x/mnt T : 37.3C Eyes : an (-/-), icterus (-/-) Pulmo : ves (+/+), Rh(-/-), Wh(-/-). Cor : S1S2 single/reguler, M(-/-), G(-/-). Abdomen : scar (-), striae (+), linea nigra (+) Extremity : edema (-/-///-), warm acral (+/+//+/+). Obstetrical status : L1 : breech L2 : back on the left side L3 : head L4 : 3/5 UFH : 32 cm EFW : 3.255 grams UC : 3 x 10 40 FHB : 12-12-12 (144x/mnt)

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G2P1A0H1 36-37 weeks with prolong 2nd stage of labor

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Intrauterine resusitation Inj. Ampicillin (in PHC) Laboratory check (DL, HBsAg) Co. to GP, advice :

Patient referred from Gangga PHC, with G2P1A0H1, A/S/L/IU with prolong 2nd stage of labor. Patient confessed abdominal pain, since 11.00 (4/5/12). History of rupture membrane (+) since 11.00 (04/05/2012). History of HT (-), DM (-), asma (-). LMP : 20 8 - 2011 EDD : 27 5 2012 History of ANC : > 4x in midwife Last ANC : 17 4 - 2012 History of family planning : pil about 1 year Next familly planning : implant USG : (-) Obstetrical History : 1. 9 month/female/2.500grams/ midwife/RSUD KLU/life 2. This

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VT : completed, amnion (-) clear, head palpable, HII+, caput (+), unpalpable small part of fetal and umbilical cord

Chronologist : Patient came to PHC confessed amenorea for 9 month and confessed abdominal pain since 4/5/2012 (11.00), history of rupture membran (+) on 4/5/2012 (11.00). Bloody slim (+). BP : 120/80 mmHg PR : 88x/mnt RR : 20x/mnt T : 36.5 UFH : 30 cm L1 : breech L2 : back on the left side L3 : head L4 : 3/5 UFH : 32 cm EFW : 3.255 grams UC : 3 x 10 <40 FHB : 136/mnt

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15.00 VT : 7 cm, eff 75% amnion (-) , head palpable, HII, unpalpable small part of fetal and umbilical cord 17.00 RL ( flash I) gerojok Inj. Ampicillin 1 gr/IV 17.15 RL (flash II) 18.00 UC : 3 x 10 <40 FHB : 134x/m4nt VT : completed, eff 100% amnion (-) , head palpable, HIII, caput (+), unpalpable small part of fetal and umbilical cord Referred to RSUP NTB

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20.00

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Lab: HB: 9,1 RBC : 3,90 HCT: 27,3 WBC: 15,98 PLT: 307 Protein urine (+++)

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PEB + Susp. CPD

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- CTG : tacicardy

21.30

- Co to SPV, advice : treat as PEB, pro CS. - Drip MgSO4 1st flash, 28 tpm - Further observation

22.00