MORNING REPORT ??-??-2011

Morning ReportAugust 30th 2014Supervisor : dr. Agus Thoriq, Sp.OGMedical Students :Santi, Ria, Ayu, YuliCASE RESUMENORMAL LABOR1PATHOLOGY LABORG2P1A0L1 36-37 weeks/S/L/IU head presentation with PROM > 12 hoursG1P0A0L0 38 weeks/G/L-L/IU head presentation-head presentation with active phase of laborG2P1A0L0 A/S/L/IU head presentation with history of CS and asthma

Case 1Name: Mrs. NAge: 23 years oldAddress: Langko-LingsarAdmitted: 29-08-2014 No. RM: 11-37-57G2P1A0L1 36-37 weeks/S/L/IU head presentation with PROM > 12 hoursTimeSubjectObjectAssessmentPlanning29-08-201411.20Patient came to NTB GH reffered Sigerongan PHC with G2P1A0L1 36-37 weeks /S/L/IU head presentation with PROM > 12 hours

Patient confessed water come out from her vagina since 28-08-2014 (11.00). She didnt confess abdominal pain, bloody slim (-), and FM (+).

History of DM (-), HT (-), asthma (-).

LMP : 14-12-2013EDD : 21-09-2014

History ANC : 7x at PHCLast ANC : 29-08-2014 at PHCresult: BP : 100/80, weight: 55 kg, UFH: 27 cm, head presentation.General statusGC : wellGCS: CM (E4V5M6)BP : 120/80 mmHgHR: 88 x/mRR: 22 x/mT: 36,5 C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, M(-), G(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema (-/-), warm (+/+)

Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 29 cmEFW : 2790 gram

UC : -FHB : 13-13-13 (159x/min)

G2P1A0L1 36-37 weeks /S/L/IU head presentation with PROM > 12 hoursObs. Mother and fetal well beingDM co to GP pro CTG and Inj. Ampi 1 g/6 h, GP acc

Doing CTG Inj.ampi 1 gr/6hTimeSubjectObjectAssessmentPlanningHistory of USG :-

History of family planning : injection 3 monthsNext family planning : injection 3 month

History of obstetric :Preterm/ 2600/ male/ midwife/ NTB GH/ 4 years old/ lifeThis

VT : 1 cm, eff. 0 % amnion (-) clear, head palpable, HI, denom unclear, unpalpable small part of fetus/ umbilical cord

PS :Cervic dilatation 0 cm : 0Cerviks length 4 cm: 1 cerviks consistency soft: 2Cerviks position posterior: 0Station H I: 1

Total: 4

Lab:HGB = 12,2.9 g/dlRBC = 4,22 K/ulWBC = 13,62 M/ulHCT : 36,6 %PLT = 252 M/ulHBsAg = (-)

TimeSubjectObjectAssessmentPlanningChronologist : at Sigerongan PHC (29-08-2014 06.30)S : Patient confessed flank pain and abdominal pain since yesterday . Bloody slim (-) Water come out from her vagina (+) since yesterday , FM (+).O : GC : wellCons : CMBP : 100/80mmHgHR : 80x/mRR : 20x/mT : 36UFH : 27cmL1 : breechL2 : back on the left sideL3 : headL4 : 4/5FHB : 144x/mUC : -VT : 1cm, eff 25%, amnion (+), head palpable, HI, unpalpable small part of fetus/ umbilikal cord

A : G2P1A0L1 36 weeks/S/L/IU with PROM

P : amox 1 x 500 mg Reffered to NTB GH

TimeSubjectObjectAssessmentPlanningCo CTG to GP, GP co to SPV, adv: induction with drip oxy 5 IUCIE patient and family to induction14.00UC : -FHB : 11-12-12 (140x/min) Start drip oxytocin at 8 dpm14.30UC : -FHB : 11-11-12 ( 136x/min)Oxy drip: 12 dpm 15.00UC -FHB : 12-11-11 ( 136x/min)Oxy drip: 16 dpm 15.30Abdominal painUC : 2 x 10 ~ 30FHB : 11-11-12 (136 x/min) 5 cm, eff. 50 % amnion (-) clear, head palpable, HI, denom unclear, unpalpable small part of fetus/ umbilical cordOxy drip: 20 dpm 16.00Abdominal painUC : 3 x 10 ~ 25FHB : 12-12-12 (144 x/min)Oxy drip: 24 dpm 16.30Abdominal painUC : 3 x 10 ~ 30FHB : 12-11-12 (140 x/min)Oxy drip: 28 dpm 17.00Mother want to bearing downUC : 4 x 10 ~ 40FHB : 12-13-12 (148 x/min)Inspection : opening of vulva, bulging of perineum, pressure of anus 2nd of laborOxy drip: 32 dpm

Conduct the labor6TimeSubjectObjectAssessmentPlanning17.25Baby was born. male. 2600 gram. 48 cm, AS 7-9. Anus (+). Congenital anomaly(-).17.30UC : wellUFH : 2 finger bellow umbilicus3rd of laborPlacenta was born spontan. Complete. 500gram.Bleeding 200 cc19.30GC: well cons:E4V5M6BP: 110/70 mmHg PR: 82x/m RR: 20x/m T: 36,5 0CUC: (+) wellUFH: 2 fingers below umbilicus2 hours post partumObservation mother and baby well beingSuggest mother to eat and drink30-08-2014 07.00GC: well cons:E4V5M6BP: 110/70 mmHg PR: 84x/m RR: 20x/m T: 36,4 0CUC: (+) wellUFH: 2 fingers below umbilicusActive bleeding: (-)Lokea rubra +1 day post post partuObserved mother and baby well beingSuggest mother to eat and drinksuggest mother to breast feedingSuggest mother to mobilisation.Case 2Name: Mrs. ESAge: 28 years oldAddress: SumbawaAdmitted: 29-08-2014 No. RM: 11-37-38G1P0A0L0 38 weeks/G/L-L/IU head presentation-head presentation with active phase of laborTimeSubjectObjectAssessmentPlanning29-08-201410.30Patient come to NTB GH reffered Brangrea PHC with G1P0A0L0 39 weeks G/L-L/IU.Patient confessed abdominal pain since 28-08-14 (22.00), water come out from her vagina (-), bloody slim (+) 29-08-14 (03.00), and FM (+).

History of DM (-), HT (-), asthma (-).

LMP : 4-12-2013EDD : 11-09-2014

History ANC : >9x at posyanduLast ANC : 28-08-2014result: BP : 120/80, 38 weeks, mothers and fetals condition is well.

History of USG : 2x at doctorLast : 12-08-14 : result : gemeli, head presentation-head-presentation : EFW : 2416 gram, 1808 gram.General statusGC : wellGCS: CM (E4V5M6)BP : 120/100 mmHgHR: 88 x/mRR: 22 x/mT: 36,8 C

Local statusEye : an (-/-), ict (-/-)Pulmo: ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, M(-), G(-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema (+/+), warm (+/+)

Obstetric statusL1 : breech, breechL2 : back on the left and right sideL3 : headL4 : 4/5UFH: 34 cm

UC : 3 x 10 ~ 25FHB : I. 12-13-13 (152x/min) II. 12-11-11 (140 x/min)G1P0A0L0 38 weeks/G/L-L/IU head-head presentation with active phase of labor Obs. Mother and fetal well beingObservation progress of laborObs. with partograf

TimeSubjectObjectAssessmentPlanningHistory of family planning : -Next family planning : injection 3 months

History of obstetric :This

VT : 6 cm, eff. 60 % amnion (-) clear, head palpable, HI, denom unclear, unpalpable small part of fetus/ umbilikal cord

Pelvic examination:Promontorium unpalpableSpina ischiadica not prominentOs coccygeus mobileArcus pubic > 90 degree

PS :Cervic dilatation 5 cm : 2Cerviks length 3 cm: 1Cerviks consistency mild : 1Cerviks position posterior: 0Station H I: 1Total: 5

Lab:HGB = 12.4 g/dlRBC = 4,20 K/ulWBC = 13.74 M/ulHCT : 30=7.0 %PLT = 269 M/ulHBsAg = (-)TimeSubjectObjectAssessmentPlanningChronologist : at Brangrea PHC (29-08-2014 02.00)S : Patient confessed abdominal pain since 28-08-14 (22.00), water come out from her vagina (-), bloody slim (+) 29-08-14 (03.00), and FM (+).O : GC : wellCons : CMBP : 110/70mmHgHR : 84x/mRR : 20x/mT : 36,5L1 : breech, breechL2 : back on the left and right sideL3 : headL4 : 4/5UFH : 33cm AC: 92 cmEFW : 3630 gramFHR 1: 140x/m FHR 2: 126 x/mUC : 3x10-20

VT : 1cm, eff 10%, amnion (-), head palpable, HII, unpalpable small part of fetus/ umbilikal cord.

A : G1P0A0L0 +/- 39 weeks G/L-L/IU

P : Obs. Mother and etal well being, RL 20 tpm, refferd to NTB GHTimeSubjectObjectAssessmentPlanning14.30Abdominal pain

UC : 3x 10 ~ 30FHB : I 13-12-13 ( 148/min) II 11-11-12 (136x/min)VT : 8cm, eff 75%, amnion (-), head palpable, HI, unpalpable small part of fetus/ umbilikal cord.Prolong active phase -Obs. Mother and fetal well being-DM pro CTG, GP acc, CTG result is reactive GP co to SPV, SPV advice : acceleration-Obs. Proggest of labor

16.30UC : 3x 10 ~ 30FHB : I 12-12-12 ( 144x/min) II 12-11-11 (136x/min) -Start drip oxytocin at 8 dpm

17.00UC : 4 x 10 ~ 30FHB : I 12-12-13 ( 148x/min) II 11-12-12 (140x/min)Oxy drip: 12 dpm

17.30UC : 4 x 10 ~ 30FHB : I 12-12-12 ( 144x/min) II 12-12-11 (140x/min) Oxy drip: 16 dpm

18.00UC : 4 x 10 ~ 30FHB : I 12-12-12 ( 144x/min) II 12-12-11 (140x/min) Oxy drip: 20 dpm

18.30UC : 4 x 10 ~ 40FHB : I 12-12-12 ( 144x/min) II 12-12-11 (140x/min) VT : 9 cm, eff 80%, amnion(-), head palpable, HII, unpalpable small part of fetus/ umbilikal cord.Prolong active phase

Oxy drip: 24 dpm TimeSubjectObjectAssessmentPlanning19.30UC : 4 x 10 ~ 40FHB : I 11-12-13 ( 144x/min) II 12-13-12 (148x/min)Oxy drip: 24 dpm

20.30Mother wont to bearing down

UC : 4 x 10 ~ 40FHB : I 11-12-11 ( 136x/min) II 12-12-12 (144x/min) Inspection : opening of vulva, bulging of perineum, pressure of anus 2nd stage of labor (first baby)Conduct mother to bearing down20.55First baby was born. female. 1500 gram. 44 cm, AS 4-6. Anus (+). Congenital anomaly(-).UFH : 1 finger above umbillicusUC : 4 x 10 ~ 40FHB : I 11-12-11 ( 136x/min)VT : 9cm, eff 90%, amnion (-), head palpable, HII, unpalpable small part of fetus/ umbilikal cord.21.20Mother wont to bearing down

Inspection : opening of vulva, bulging of perineum, pressure of anus 2nd stage of labor (second baby)Conduct mother to bearing down21.30Second baby was born. female. 2600 gram. 48 cm, AS 5-7. Anus (+). Congenital anomaly(-).TimeSubjectObjectAssessmentPlanning21.40UC : wellUFH : 1 finger bellow umbilicus3rd of laborPlacenta was born spontan. Complete. 500gram.Bleeding 400 cc23.30GC: well cons:E4V5M6BP: 100/70 mmHg PR: 92x/m RR: 20x/m T: 36,6 0CUC: (+) wellUFH: 1 fingers below umbilicusBleeding (+)2 hours post partumObservation mother Suggest mother to eat and drinkSuggest mother to mobilitation

30-08-2014 07.00GC: well cons:E4V5M6BP: 110/70 mmHg PR: 84x/m RR: 18x/m T: 36,4 0CUC: (+) wellUFH: 1 fingers below umbilicusActive bleeding: (-)Lokea rubra +1 day post post partu

Observed mother Suggest mother to eat and drinksuggest mother to breast feedingSuggest mother to mobilisation.

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Bayi pertumbuhan janin terhambat dan kecil masa kehamilanCase Report 3Name: Mrs. BSRM: 545572Age: 32 years oldAddress: Sukadana, BayanAdmitted: August, 29th 2014 (23.45 WITA)Diagnose: G2P1A0L0 A/S/L/IU head presentation with history of CS and asthmaTIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING29/08201423.50 witaPatient reffered from KLU GH with G2P1A0L0 37 wks S/L/IU head presentation with latent phase and LMR Patient confessed lower abdominal pain that spread to flank region since 19.30 wita (29/08/2014), history of water leaked out since 23.00 wita (29/08/2014), bloody slim (+). Fetal movement (+).history of DM ( -), HT(-), asthma (+) recurred 2x during pregnancy allergy (-).

LMP : forgottenEDD : unknown

History of ANC : 2 times at Malaysia and PHCLast result: 27/08/2014 BP:130/90, 36 wks, UFH 30 cm, head presentation, FHB (+)History of USG : 1 time at MalaysiaLast result: normal range History of family planning : -Next family planning : IUD

Obstetrical History :Aterm/male/Malaysia/SCTP/ 2600 g/ deadThis General Status :GC : moderate GCS : E4V5M6BP : 140/90 mmHgPR : 84 bpmRR : 20 bpmT : 36,5oCEye : anemis (-), icteric (-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-), rhonchi (-/-).Abdomen : scar (+), stria gravidarum (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).

Obstetrical Status :L1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH : 25 cm EFW : 2480gramUC : 3 x/10~ 35FHB : 12-13-13 (152 bpm)VT : 4cm, eff. 50%, Amnion (-), clear, head palpable, HI, denom unclear, impalpable small part of fetus or umbilical cord . G2P1A0L0 A/S/L/IU Head presentation with active phase + gestasional HT + history of asthma and CS 1,5 years agoObservation mother & fetal well being.Lab exam

DM co to GP pro observation, GP co to SPV pro CS and SPV advice : Observation Progress of labor, if there is asthma exacerbation co to internaDocumentation of partograph

21TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNINGChronologist at RSUD KLU: 21.00 wita (29/08/2014)S/ Patient referred from Bayan PHC confessed lower abdominal pain that spread to flank region since 19.30 wita (29/08/2014), water leaked out (-), bloody slim (+). Fetal movement (+). history of CS 1,5 years agoO/ BP : 140 / 90 mmHgHR: 84 bpmRR: 21 T: 36,5UFH: 27 cm , 4/5FHB : 12-12-12 (144 x/minute)EFW :2480 grUC: (+) 2x10~25 VT : 2 cm, eff. 25%, amnion (+), head palpable, HI, denom unclear, impalpable small part / umbilical cord.A/ G2P1A0L0 37 wks S/L/IU head presentation, with latent phase of labor and LMRP/ IVFD RL flash 1 - 20 dpmCo to SPV advice: Refer to NTB GH with CIE family

PE :Spina ischiadica not prominent,Os coccygeus mobile,Arcus pubis > 900

Lab Examination : HB : 11 g/dl RBC : 4.62 x 106/L HCT : 35.1 % WBC: 14.17 x 103/LPLT : 245 x 103/LHbSAg : (-)Proteinuria (-)22TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING30/08/201403.50 wita

Mother confessed water leaked out GC : wellGCS : E4V5M6BP : 140980 mmHgPR : 84 bpmRR : 20 bpmUC : 3x10~35FHB : 12-13-12 (148 bpm)VT : 6 cm, eff. 60%, Amnion (-), clear, head palpable, caput (+), HII, impalpable small part of fetus or umbilical cord

Prolonged active phaseCo to GP pro observation mother and fetal well beingSuggest mother to eat and drink04.30 witaMother want to bearing downUC: 4x/10 ~ 35FHB: 12-12-12Inspection: opening vulva (+), bulging of perineum (+), pressure of anus (+)2nd stage of laborConduct labor04.55Baby was born, female, BW 2500 gr, BL 51 cm, AS 7-9 , anus (+), congenital anomaly (-)05.003rd stage of laborPlacenta delivered completed, bleeding 150 cc.23TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING07.00 wita

General condition: GoodBP : 120/80 mmHgHR : 84 bpmRR : 22 tpm T : 36,7oCUFH : 1 finger below umbilicalUC : (+) wellLochea rubra +Active bleeding (- )

Baby is rooming inHR : 128 bpmRR : 50 T : 37,02 hours Post partumObservation 4th stage of labor Observation mother and baby well beingSuggest mother to eat and drinkSuggest mother to mobilizationSuggest mother to early breastfeeding

24THANK YOU