Morning Report September 1st 2014

Morning ReportSeptember 1st 2014Supervisor : dr. Edi Prasetyo Wibowo, SpOGDM: Dayu, Rila, Faisol

Name: Ms. KAge: 27 thAddress: Karang Raden, KLUAdmitted : 31st August 2014RM : 54-56-90Diagnose: G1P0A0L0 40-41 weeks S/L/IU head presentation with neglected 2nd stage of labor + history of ROMTime SubjectiveObjectiveAssessmentPlanning31st August 2014

14.00Patient come to NTB GH referred from KLU GH with G1P0A0L0 40 weeks S/L/IU head presentation PROM + macrosmia + LHMPatient confessed intermiten abdominal pain (-), water leak out from her womb (+) since 22.00 WITA (30-08-2014), bloody slim (-), FM (+)History : DM (-), HT (-), Asthma (-), allergy (-)

LMP : 22 11 2013 EDD : 29 08 2014

ANC history : 3 X at Tanjung PHC Last ANC : 31st August 2014, BP : 110/80 mmHg, BW : 65 kg, UK : 40 weeks, UFH : 40 cm, Presentation : head, back at left

USG History : -

Familiy planning history : - Next family planning : inj. 3 month

Obstetrical history :I. This

General statusGC : wellGCS : E4V5M6BP : 110/80 mmHgPR : 92 bpmRR : 20 tpmT : 36,1 0C Eye : anemis (-/-), ikteric (-/-)Cor : S1S2 single, M (-), G (-)Pulmo : Vez (+/+), Whz (-/-), Rh (-/-)Abdomen : striae gravidarum (+), linea nigra (+), scar (-)Extremity :Upper : oedem (-/-), warm (+/+)Lower : oedem (-/-), warm (+/+)

Obstetrical StatusL1 : breechL2 : back at leftL3 : headL4 : 5/5UFH : 33 cmEFW : 3410 grUC : -FHB : 11-11-12 (136 bpm)BH : 148 cmG1P0A0L0 40-41 weeks S/L/IU head presentation with PROM + LHM

Obs. Mother and fetal well beingCIE family

DM Co to GP, GP co to SPV, SPV advice : pro CTG. If CTG reactive, pro induction (oxytocin drip)Inj. Ampicilin 1 gr i.v / 6 hours3Time SubjectiveObjectiveAssessmentPlanningChronologist 31st of August 2014 at KLU GH (10.15)S/Patient came to KLU GH referred from Tanjung PHC with G1P0A0L0 40 weeks S/L/IU head presentation with PROM 11 hoursPatient confessed abdominal pain (-), water leak out from her womb (+) since 22.00 WITA (30-08-2014), bloody slim (-), FM (+)

O/GC : wellGCS : E4V5M6BP : 120/80 mmHgPR : 80 bpmRR : 20 tpmT : 36,70CBH : 148 cm

VT : 1 cm, Eff : 10%, Amnion (-) clear, head presentation, denom unclear, HI, Impapable small part of fetus/umbillical cord

PS : 4Cervix Dilatation : 1Cervix length : 0Cervix position : 1Station : 1Cervix Consistency : 1

PE : seems normalSpina ischiadica : not prominentOs coxygeus : mobileArcus pubis : >90o

Lab result :HB : 11,3 g/dLHCT : 34,6 %WBC : 10,79 x 103/uLPLT : 190 x 103/uLHbsAg : (-)Time SubjectiveObjectiveAssessmentPlanningUFH : 33 cmEFW : 3410 grL1 : breechL2 : back at leftL3 : headL4 : 4/5HIS : -FHR : 12-12-12 (144 bpm)

VT : 1 cm, Eff : 25%, Amnion (-) clear, head presentation, denom unclear, HI, Impapable small part of fetus/umbillical cord

A/G1P0A0L0 40 weeks S/L/IU head presentation PROM > 12 hours + macrosmia + LHM

P/ IVFD RL flash I 28 dpmInj. Ampicilin 1 gr i.v / 6 hours (09.30 WITA)FOTO CTG14.30General statusGC : wellGCS : E4V5M6BP : 120/80 mmHgPR : 80 bpmRR : 20 tpmT : 36,8 0C

UC : -FHR : 12-12-13 (148 bpm) Obs. Mother and fetal well beingCo to GP, advice : Resuscitation intrauterineRe-CTG, if reactive start drip oxy14.45Resuscitation intrauterineRL : D5% (2 :1)O2 5 lpm

FOTO CTG ke 217.30General statusGC : wellGCS : E4V5M6BP : 1 mmHgPR : 84 bpmRR : 22 tpmT : 35,8 0C

UC : -FHR : 13-13-12 (152 bpm) CTG was reactiveDM co to GP, GP co to SPV, advice : Start Oxy drip 8 dpm

Time SubjectiveObjectiveAssessmentPlanning18.00HIS : 3x10~35FHB : 11-11-12VT : . 3cm, eff 50%, amnion (-), head presentation, H1, denom unclear, impapable small part of fetus/umbillical cordinpartuObservation mother n fetal well beingObservation progres of labor12 tpm18.30HIS : 4 x 10~40FHB : 12-12-12

Observation mother n fetal well being12 tpm19.30HIS : 4 x 10~40FHB : 12-13-12Observation mother n fetal well being12 tpm20.00HIS : 4 x 10~40FHB : 12-12-12Observation mother n fetal well being12 tpm20.30HIS : 4 x 10~45FHB : 12-12-13

Observation mother n fetal well being12 tpm21.00 HIS : 4 x 10~45FHB : 12-12-11Observation mother n fetal well being12 tpmTime SubjectiveObjectiveAssessmentPlanning21.30HIS : 4x10~45FHB : 12-11-1212 tpm

22.00HIS : 4x10~45FHB : 12-11-12VT : . 10 cm, eff 100 %, amnion (-), head presentation, H2, denom unclear, impapable small part of fetus/umbillical cord

2nd stage of labor

CIE patient and familyObs. Mother and fetal well being Suggest mother to drink and eat

24.00HIS : 4x10~45FHB : 11-11-12General statusGC : wellGCS : E4V5M6BP : 110/70 mmHgPR : 84 bpmRR : 20 tpmT : 36,70COU : 300 cc, gross hematuriaVT : . 10 cm, eff 100 %, amnion (-), head presentation, H2, denom unclear, impapable small part of fetus/umbillical cord

Prolonged 2nd stage of labor + susp. RUI12 tpmUse cateterDM co to GP, GP co to SPV, advice : observation 2hr more, if H3 pro vacum, if still H2 pro CS

Time SubjectiveObjectiveAssessmentPlanning24.30 Abdominal pain (+)HIS : 2x10~15FHB : 11-12-12

DM co to GP pro CS, GP co to SPV: acc CSPreparation operation

02.30CS beganBaby was born (03.47):male, 3900 gram, HC 36cm, BL : 53 cm, as: 7-9 anus (+), anomali congenital (-)

Plasenta was born manually, complete, 500 gr, bleeding + 150cc

Baby in NICU

Time SubjectiveObjectiveAssessmentPlanning05.30General statusGC : wellGCS : E4V5M6BP : 210/110 mmHgPR : 92 bpmRR : 20 tpmT : 36 0COU : 450 ccUC : (+) wellUFH : umbilicus2 hours post CSObs. Mother and fetal well beingBed rest for next 8 hour

6.30General statusGC : wellGCS : E4V5M6BP : 150/110 mmHgPR : 92 bpmRR : 20 tpmT : 36 0COU : 600 ccUC : (+) wellUFH : 1 below of umbilicusBaby In NICUGC : wellHR : 138 bpmRR : 48 x/mntT : 36,4 C1 day post CSContinue observationTab. As.Mefenamat 3x1Tab. Amoxicilin 3x1Suggest mother to mobilization