MORNING REPORT September 26th 2011

Supervisor : dr. Juliawan, SpOG

Medical Student: Lili, Elin, Ika, Maria, Noval

Cases resume : Click to edit Master subtitle style Normal Labor

Phatologic Labor

G1P0A0H0 A/S/L/IU breech presentation with latent phase first stage of labor + history rupture of membrane + prolapse umbilical1. cord

3/27/13

Name Age Address Time

: Mrs. F : 35 years old : Ampenan Subject

CTH

: September 29th 2011 At 09.50 wita

Object

Assesment

Planning

G1P0A0H0 A/S/L/IU 29/9/ Patient referred from Maternity ClinicGeneral Condition : well with G4P3A1H2 38 week/S/L/IU breech presentation with 2011 Consciousness : CM 09.50 breech presentation with latent phaseBP : 120/80 mmHg PR : 84latent phase first stage of first stage of labor + history rupture ofx/minute labor + history rupture of membrane + prolapse umbilical cord.RR: 20 x/minute T : 36,8C membrane + prolapse umbilical cord Patient confessed abdominal pain, since 16.00 (26/09/2011),Status Generalis: bloodyslim (-). History ruptureEye : palor (-), icteric (-) of membrane (+) since 2 weekThorax : ago, FM (+). History of DM (-),Cor : S1S2 single reguler (murmur HT (-), asthma (+). -), (gallop -) Pulmo : vesikuler (+/+), wheezing LMP : 5 (-/-), EDD : Ronkhi (-/-). Abdomen : scar (-), striae (+),linea History of ANC : > 4 x, midwife nigra(+) Last ANC : August 2011 Extremity : edema (-), warm acral History of USG : never (+) History of family planning : Next family planning : IUD Obstetrical history : I. This Obstetrical status : L1 : head, UFH: 27 cms, AC : 90 cm L2 : fetal back on right side L3 : breech L4 : breech on pelvic inlet EFW : 2430 g His: (+), 2 x 10 30 FHR : (+), 10-10-10 (120 x/minute) VT : 3 cms, eff 25%, amnion (-) greeny, breech palpable HI, palpable umbilical cord.

Observe mother & fetal well being DL, HbSAg checked Coass consult to GP Injeksi Ampicilin 1 gr/IV & pro SC GP ACC inj Ampicilin 1 gr/iv GP consult to supervisor pro SC. Advice from supervisor : ACC SC

3/27/13

Time

S
Chronologist : Lab : DL:HGB : 11,7 RBC : 3,98 HCT : 33,7 MCV : 84,7 WBC : 17,30 PLT : 226 HbSAg : -

3/27/13

Time

A
SC began

27/09/2 011 01.45 02.00

Baby was born, Female., A-S : 5-7. BW : 2700 g Anus (+), congenital anomali (+) ; CTEV dextra Amnion meconeal Placenta was born manually, bleeding 200 cc Intraoperation : uterus arcuata

02.15

SC Finished

3/27/13

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Subject 04.15 (-)

Object

Assesment

Planning

GC : well cons : E4V5M6 2 hour Post SC BP : 100/70 mmHg PR : 92 x/minute RR : 20 x/minute T : 36,6 C UFH : 2 finger above umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 100 cc/hours 1 day post SC GC : well cons : E4V5M6 BP : 130/70 mmHg PR : 80 x/minute RR : 20 x/minute T : 36,5 C UFH : 2 finger above umbilicus Uterine consistency firm Operation wound good Active bleeding (-) Urine output: 65 cc/hours Baby in NICU : PR : 150 x/minute RR : 28 x/minute T : 36C

Observe mother and baby well being KIE mother to take a rest

27/9/20 Wound pain 11 07.00

Observe mother and baby well being KIE mother to take a rest

3/27/13