Morning Report

July 3rd 2012

Supervisor : dr. Made Mahayasa, Sp.OG Medical Students :

Yan, Wiwid, Novi, Sapto, Ika, Ira, Lani
CASE RESUME NORMAL LABOR PATHOLOGY LABOR 3 1. G1P0A0L0 40-41 weeks S/L/IU with prolonged 2nd stage of labor. 2. G4P1A2L1 42-43 weeks S/L/IU with severe preeclampsia 3. G1P0A0H0 A/S/L/IU with neglected active phase 1st stage of labor & eclampsia.

Case Report
Name

: Mrs. L

RM
Age

: 044809
: 26 years old

Address : Ampenan Admitted : October 2nd 2012

TIME 02/10/ 2012 23.30

SUBJECTIVE Patient referred from Midwife with G1P0A0L0 37-38 weeks/S/L/IU mother and fetal well with inpartu active phase 1st stage. Patient confessed abdominal pain that spread to frank since since 08.00 (02/10/2012). and water came out from her womb since 19.00 (02/09/2012). Bloody slim (+), FM (+). No history of DM, HT, asthma. LMP : Forgot EDD : History of ANC : > 4x at Polindes Last ANC : 25/009/2012 History of USG : History of family planning : (-) Next family planning : injection 3 months. Obstetrical History : I. This

OBJECTIVE General Status : GC : well BP : 120/80 mmHg PR : 80 bpm RR : 20 bpm T : 36,5oC Eye : anemis (-/-), icteric (-/-) Cor : S1S2 single regular, murmur (), gallop (-). Pulmo : vesicular (+/+), wheezing (/-), ronkhi (-/-). Abdomen : scar (-), stria gravidarum (+), linea nigra (+). Extremity : edema (-/-), warm acral (+/+). Obstetrical Status : L1 : breech L2 : back on the left side L3 : head L4 : 4/5 UFH : 32 cm EFW : 3250 gram UC : 4x/10 ~45 FHB : 12-12-12 (144 bpm) VT : 8 cm, effacement 75%, amnion (-) clear, head palpable HII+, denominator unclear, impalpable small part and umbilical cord.

ASSESSMENT G1P0A0L0 A/S/L/IU active phase 1st stage of labor with history of rupture membrane + mild anemia

PLANNING Observation mother & fetal well being. Observation progress of labor Cek DL, HBsAg

Chronologist : (-)

TIME

SUBJECTIVE

OBJECTIVE PE : Spina ischiadica prominent Os coccygeus mobile Arcus pubis > 90o Lab Examination : Hb : 8,6 g/dl RBC : 4,12 x 106/L HCT : 30,1 % WBC : 12,59 x 103/L PLT : 288 x 103/L HbSAg: (-) not

ASSESSMENT

PLANNING

03.00

Mother wants to bearing down

UC : 4x/10 ~45 FHB : 12-11-11 (136 bpm) VT : complete, amnion (-), head palpable HII+, caput (+), impalpable small part and umbilical cord. UC : 4x/10 ~40 FHB : 12-12-12 (144 bpm) VT : complete, amnion (-), head palpable HIII+, caput (+), impalpable small part and umbilical cord.

2nd stage of labor

Suggest mother to eat and drink. Suggest mother to squatting down.

04.00

Mother feels bearing down

tired

to

Prolonged 2nd stage of labor

DM consult to SPV : pro VE SPV advice : acc VE

TIME 11.30

SUBJECTIVE Patient confessed abdominal pain

OBJECTIVE UC : 2x/10 ~25 FHB : 12-12-12 (144 bpm) VT : 9 cm, effacement 90%, amnion (-), head palpable HII+, caput (+), impalpable small part and umbilical cord.

ASSESSMENT G1P0A0L0 4041 weeks S/L/IU with prolonged active phase 1st stage of labor with history of rupture membrane + mild anemia 2nd stage of labor

PLANNING Observation mother & fetal well being. CTG reactive DM co to GP, GP advice : acceleration with drip oxytocin.

12.30

Mother wants to bearing down

UC : 4x/10 ~30 FHB : 12-11-11 (136 bpm) VT : complete, amnion (-), head palpable HII+, caput (+), impalpable small part and umbilical cord. UC : 4x/10 ~30 FHB : 12-11-12 (140 bpm) UC : 4x/10 ~30 FHB : 12-12-12 (144 bpm) UC : 4x/10 ~30 FHB : 12-11-11 (136 bpm)

Drip oxytocin began 8 tpm Suggest mother to eat and drink. Suggest mother to squatting down. Drip oxytocin 12 tpm Drip oxytocin 16 tpm Drip oxytocin 20 tpm

13.00 13.30 14.00

Patient confessed abdominal pain Patient confessed abdominal pain Patient confessed abdominal pain

14.30

Mother feels tired to bearing down

UC : 4x/10 ~30 FHB : 12-12-12 (144 bpm) VT : complete, amnion (-), head palpable HIII+, caput (+), impalpable small part and umbilical cord.

Prolonged 2nd stage of labor

GP consult to SPV : pro VE SPV advice : acc VE

TIME 15.00

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING VE began VE succeed in 2 times traction. Perineum episiotomy (+) Baby was born, male, 3500 gram, 50 cm, A-S 6-8, caput (+) on occiput, anus (+), anomaly congenital (-). Placenta was born spontaneous, complete. Bleeding 150 cc Rupture perineum grade II

17.00

Patient confessed delivery wound

GC : well BP : 120/90 mmHg PR: 80 bpm RR : 20 bpm T : 36.7C UFH : 2 fingers below the umbilicus Lochea rubra : (+)

2 hours post VE

Observe mother and baby well being. Suggest mother to take a rest, eat, and drink.

TIME 03/07/ 2012 07.00

SUBJECTIVE Patient confessed delivery wound

OBJECTIVE GC : well BP : 110/70 mmHg PR : 72 bpm RR : 20 bpm T : 36.2C UFH : 2 fingers below the umbilicus Lochea rubra : (+) Baby in NICU : GC : well PR : 120 bpm RR : 52 bpm T : 36,4oC

ASSESSMENT 1st day post partum

PLANNING Observe mother and baby well being. Suggest mother to take a rest, eat, and drink.