Kpd

Morning Report

21 February 2009

Supervisor : dr. Agus Thoriq, SpOG Medical Student:

1. Ghea2.Hadian

1.

Cases resume :

1. Preterm + Breech presentation + PROM 32. Neglected in active phase of 1st stage of labor 13. Mola hidatidosa 14. Normal labor

sName / Age : Mrs. Sinati / 27 years old Admitted : 07. 09.2011

Address : Gubuk Baru, Lombok Utara Time : 22.00

Time Subject Object Assesment Planning

7/9/2011

16.30

Patient refered from GH Tanjung (midwife: Winarni) with G1P0A0H0 A/T/M 39 weeks head presentation With KPD and IUFD, abdominal pain since 22.00 (04-9-09). History rupture of membrane (-), abdominal pain (+) , bloody slim (+), FM (-), AM (-). History of HT (-), DM (-), Asthma (-)LMP : forgotEDD : -History of ANC : History of family planning : -Next family planning : IUDHistory of obstetric 1. This

Chronologis:10.30Patient came to GH Tanjung with Keluar air banyak dari jalan lahir sejak + 2 hari yang lalu 19.00 Wita ( 5-7-2011) abdominal pain since 22.00 (04-9-09).Examination in PHC:General status: wellBP: 120/70 mmHg PR: 92 x/mntRR: 20 x/mnt UFH: 35 cm , head palpableVT: 7 cm, eff 75 %, AM (-), ↓HII , DJJ ( - )Co to doctor :Adv :Observasi 3 jam lagi jika tidak ada kemajuan rujukGrojok infus RL fles 1KIE keluarga jika tidak ada kemajuan rujuk

General status :•General condition: well•Conciousness: CM•BP: 120/80 mmHg•RR: 20 x/mnt•PR: 88x/mnt•T: 36,8’ C Eyes : an(-), ikt (-)Cor -Pulmo : in normal range

Obstetric status :L1 : breech UFH: 32cmL2 : left backL3 : headL4 : 4/5EFW : 3255g UC : 3x10,,,30’Fetal Heart Rate : (-)VT: 7 cm, eff 75 %, AM (-), head palpable . ↓HI

Lab result:Hb: 12 g%WBC: 18.77mm3PLT: 113000/mm3HCT: 34,9 %HBsAg: (-)

G1P0A0H0 A/T/IUFD inpartu kala 1 fase aktif

Observation mother Laboratorium

examination DL, HBsAg


12.20Ganti infus RL fles II 28 tpm13.30VT : Ø 8cm, eff 75%, AM (-), head presentation, ↓HII Unpalpable small part or umbilical cordAG1P0A0H0 A/T/M 39 weeks head presentation With KPD and IUFDPKIE keluarga untuk di rujukReffered to GH

19.30 UC : 2x10,,,30’FHB : -

sName / Age : Mrs. Jumakyah / 21 years old Admitted : 21 February 2009

Address : Mataram Time : 20.30


20.30

Patient refered by midwife (Nuri M) with G1P0A0H0 41weeks/S/L/IU active phase of 1st stage of labor + susp big baby

chronologis : 09.30 (21-2-09)Patient came to widwife (Nuri) with confess abdominal discomfort since 22.00 (20-2-09), bloody show(+), fetal movement (+), vaginal discharge (-)Examination:BP: 120/P PR: 84 x/mntRR: 24 x/mnt t: 36,5 ‘CPalpation: UFH: 35 cm, breech palpable in fundus, right back, head presentation, descensus 3/5EFW: 372 0 gUC: 3x/10’ ~ 35”Auscultation: FHB 144 x/mnt

10.00 (21-2-09)VT : CD 2 cm, eff 30 % , AM (+), head palpable, SS trasverse presentation, small part of fetal or umbilical cord unpapableAss: G1P0A0H0 41 weeks/S/L/IU head laten phase of 1st stage of labor

14.00 (21-2-09)BP: 110/70 mmHg PR: 84 x/mntRR: 24 x/mnt t: 36,6 ‘CUC: 3x/10’ ~ 35” FHB: 144 x/mntVT: CD 4 cm, eff 30 %, AM (+), head descensus HI, small part of fetal or umbilical cord unpapable

16.00 (21-2-09)Vaginal discharge (+), clearBP: 110/70 mmHg PR: 84 x/mnt t: 36,6 ‘CUC: 3x/10’ ~ 40” FHB: 144 x/mntVT: CD 6 cm, eff 60 %, AM (-), head descensus HII, small part of fetal or umbilical cord unpapable

18.45 (21-2-09)Patient bearing down every felt abdominal discomfortBP: 110/70 mmHg PR: 84 x/mnt t: 37,0 ‘CUC: 4x/10’ ~ 45” FHB: 144 x/mntVT: CD 6 cm, eff 60 %, AM (-), head descensus HII, small part of fetal or umbilical cord unpapableAss: G1P0A0H0 41 weeks/S/L/IU head active phase of 1st stage of labor + susp big babyTx: amoxicilin 1000 mg, paracetamol 500 mg

ANC: LMP: 10-5-09EDD: 17-2-09

Obstetric history:1.This

Planning for Family planning:

General status :•General condition: well,•Conciousness: CM•BP: 140/90 mmHg•RR: 20 x/mnt•PR: 80 x/mnt•T: 37,8’ C Eyes : an(-), ikt (-)Cor -Pulmo : in normal rangeExtremity: udema (-)

Obstetric status :L1 : breech UFH: 35 cmL2 : right backL3 : headL4 : head descencus 4/5EFW : 3720 g UC : 3x/10 ~ 40”Fetal Heart Rate : 15-16-16 VT : CD 7 cm, eff 75 % portio udema, AM (-), head palpable descensus HII, caput (+), umbilical cord or small part of fetal unpalpable

Pelvic evaluation:Spina ischiadica: unpalpableCoxigis: mobileSimpisis: > 90O

lab result:Hb: 11,2 g%WBC: 23.000/mm3PLT: 272.000/mm3HCT: 34,1 %Protein : +1

G1P0A0H0 A/S/L/IU head presentation neglected in active phase of 1st stage of labor + Mild Preeklamsia

Observation mother and fetal well being.

Laboratory examination : DL, HBsAg, UL

Resucitation intrauterin (RL 2 fls + D5% 1 fls) rapid drop

CTG Report to supervisor

proposed SC, supervisor agreed

sTime Subject Object Assesment Planning

14.00 (21-2-09)BP: 110/70 mmHg PR: 84 x/mntRR: 24 x/mnt t: 36,6 ‘CUC: 3x/10’ ~ 35” FHB: 144 x/mntVT: CD 4 cm, eff 30 %, AM (+), head descensus HI, small part of fetal or umbilical cord unpapable

16.00 (21-2-09)Vaginal discharge (+), clearBP: 110/70 mmHg PR: 84 x/mnt t: 36,6 ‘CUC: 3x/10’ ~ 40” FHB: 144 x/mntVT: CD 6 cm, eff 60 %, AM (-), head descensus HII, small part of fetal or umbilical cord unpapable

18.45 (21-2-09)Patient bearing down every felt abdominal discomfortBP: 110/70 mmHg PR: 84 x/mnt t: 37,0 ‘CUC: 4x/10’ ~ 45” FHB: 144 x/mntVT: CD 6 cm, eff 60 %, AM (-), head descensus HII, small part of fetal or umbilical cord unpapableAss: G1P0A0H0 41 weeks/S/L/IU head active phase of 1st stage of labor + susp big babyTx: amoxicilin 1000 mg, paracetamol 500 mg

ANC: LMP: 10-5-09EDD: 17-2-09



Pelvic evaluation:Spina ischiadica: unpalpableCoxigis: mobileSimpisis: > 90O

lab result:Hb: 11,2 g%WBC: 23.000/mm3PLT: 272.000/mm3HCT: 34,1 %Protein : +1

sTime Subject Object Assesment Planning

Ass: G1P0A0H0 41 weeks/S/L/IU head active phase of 1st stage of labor + susp big baby

Tx: amoxicilin 1000 mg, paracetamol 500 mg

Patient than refered to Mataram General Hospital

ANC: LMP: 10-5-09EDD: 17-2-09




21.30 Abdominal discomfort (+), febris (+)

General status: wellFHB: 13-13-14UC : 3x/10’ ~ 45”

Skin test cefotaxim(-)Injection cefotaxim 2 gApplied DC

22.00 Sended patient to operation Room

22.55 Baby was born, female, W: 3300 g, L: 50 cm, AS: 7-9, Caput (+), AM: Clear

Placenta was born completely.

23.30 General status: wellBP: 110/60 mmHg PR: 88 x/mntUC: wellUFH: 3 cm under umbilicusActive bleeding (-)

4th stage of labor •Observation mother and baby well being•Baby in NICU

Kpd

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