03-07-12 Fase Aktif Memanjang Drip & Kala II Lama VE

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Morning Report July 3rd 2012

Supervisor : dr. MadeMahayasa, Sp.OG

Medical Students :

an, !i"id, #ovi, Sapto, $%a, $ra,&ani

'(S) R)S*M)

#ORM(& &(+OR 3

(-O&OG&(+OR

1.G10(0&0 /0/1 "ee%s S&$* "ith prolonged2nd stage o laor.

2.G/1(2&1 /2/3 "ee%s S&$* "ith severepreecla4psia

3.G10(00 (S&$* "ith neglected activephase 1st stage o laor 5 ecla4psia.



'ase Report

Name : Mrs. I

RM : 044809

Age : 23 years old

Address : Selagalas, Mataram

Admitted : July 2nd 202



-$M) S*+J)'-$6) O+J)'-$6) (SS)SSM)#-

&(##$#G

02072012

01.30

!atient "ame to #$ IR%"on&essed 'ater "ameout &rom (er 'om) sin"e00.30 *02+0+202-, "lear,odorless. A)dominal ain*/- sin"e 22.00*30+0+202-. 1loody slim*/-, M */-.No (istory o& %M, ,ast(ma.

5M! : 8+09+20

6%% : 27+0+202

istory o& AN : 4 at!olindes5ast AN : 2+0+202istory o& ;S< : , resultnormal

istory o& &amily lanning: *=-Net &amily lanning :in>e"tion 3 mont(s.

Ostetrical istory :I.(is

General Status :< : 'ell1! : 20+80 mmg!R : 84 )mRR : 20 )m : 3,7o6ye : anemis *=+=-, i"teri"*=+=-or : SS2 single regular,

murmur *=-, gallo *=-.!ulmo : ?esi"ular */+/-,'(ee@ing *=+=-, ron(i *=+=-.

A)domen : s"ar *=-, striagra?idarum */-, lineanigra */-.6tremity : edema *=+=-,'arm a"ral */+/-.

Ostetrical Status :5 : )ree"(

52 : )a" on t(e le&t side53 : (ead54 : 4+7; : 34 "m6B : 377 gram; : 2+0C D37CC1 : =2=2 *40 )m-

# : E 2 "m, eFa"ement70G, amnion *=- "lear,(ead ala)le H I/,

<!0A05040=4 'eesS+5+I; latent

(ase st stage o&

la)or 'it((istory o&ruture

mem)rane /mild anemia

• )ser?ationmot(er &etal'ell )eing.

• )ser?ationrogress o& la)or



-$M) S*+J)'-$6) O+J)'-$6) (SS)SSM)#- &(##$#G

) :Sina is"(iadi"a notrominents "o""ygeus mo)ileAr"us u)is 90o

&a )a4ination :) : 8,9 g+dlR1 : 4,2 0+K5 : 30, GB1 : 2,79 03+K5!5 : 288 03+K5)SAg: *=-

0;.30

!atient "on&esseda)dominal ain

; : 3+0C D37CC1 : 2=2=2 *44)m-# : E 4 "m, eFa"ement70G, amnion *=-, (eadala)le H I/,denominator un"lear,

imala)le small artand um)ili"al "ord.

<!0A050 40=4 'ees

S+5+I; a"ti?e(ase st

stage o& la)or'it( (istory o&

ruture


• )ser?ationmot(er &etal 'ell)eing.

• )ser?ationrogress o& la)or'it( artogra(

0<.30

!atient "on&esseda)dominal ain more&reLuently

; : 4+0C D30CC1 : 2==2 *40)m-# : E 8 "m, eFa"ement7G, amnion *=-, (ead

ala)le H II,denominator 5A,im al a)le small art

<!0A050 40=4 'ees

S+5+I; a"ti?e(ase st

stage o& la)or

'it( (istory o&ruturemem)rane /

• )ser?ationmot(er &etal 'ell)eing.

• )ser?ationrogress o& la)or

'it( artogra(



-$M) S*+J)'-$6) O+J)'-$6) (SS)SSM)#-

&(##$#G

11.30


; : 2+0C D27CC1 : 2=2=2 *44)m-# : E 9 "m, eFa"ement

90G, amnion *=-, (eadala)le H II/, "aut*/-, imala)le smallart and um)ili"al "ord.

<!0A050 40=4 'eesS+5+I; 'it(rolonged

a"ti?e (asest stage o&la)or 'it((istory o&ruture


• )ser?ationmot(er &etal'ell )eing.

• < rea"ti?e•

%M "o to <!, <!ad?i"e :a""eleration 'it(dri oyto"in.

12.30 Mot(er 'ants to )earingdo'n ; : 4+0C D30CC1 : 2== *3)m-# : E "omlete, amnion*=-, (ead ala)le H II/,"aut */-, imala)lesmall art and um)ili"al"ord.

2nd

stage o&la)or•

%ri oyto"in)egan 8 tm• Suggest mot(er toeat and drin.

• Suggest mot(er tosLuatting do'n.

13.00


; : 4+0C D30CC1 : 2==2 *40)m-

%ri oyto"in 2tm

13.30


; : 4+0C D30CC1 : 2=2=2 *44)m-

%ri oyto"in tm

1/.00


; : 4+0C D30CC1 : 2== *3

%ri oyto"in 20tm



-$M) S*+J)'-$6) O+J)'-$6) (SS)SSM)#

-

&(##$#G

1;.00

6) egan#6 su""eed in 2 timestra"tion.!erineum eisiotomy*/-1a)y 'as )orn, male,3700 gram, 70 "m, A=S=8, "aut */- ono""iut, anus */-,anomaly "ongenital *=-.!la"enta 'as )ornsontaneous,"omlete.1leeding 70 ""

Ruture erineumgrade II

17.00

!atient "on&esseddeli?ery 'ound

< : 'ell1! : 20+90 mmg!R: 80 )mRR : 20 )m

: 3.

; : 2 Ongers )elo't(e um)ili"us

2 (ours ost#6

• )ser?e mot(er and)a)y 'ell )eing.

• Suggest mot(er totae a rest, eat, anddrin.



-$M) S*+J)'-$6) O+J)'-$6) (SS)SSM)#- &(##$#G

030720

12

07.00

!atient "on&esseddeli?ery 'ound

< : 'ell1! : 0+0 mmg

!R : 2 )mRR : 20 )m

: 3.2; : 2 Ongers)elo' t(e um)ili"us5o"(ea ru)ra : */-

+ay in #$'* :

< : 'ell!R : 20 )mRR : 72 )m

: 3,4o

st day ost artum • )ser?e mot(erand )a)y 'ell

)eing.• Suggest mot(er totae a rest, eat, anddrin.

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03-07-12 Fase Aktif Memanjang Drip & Kala II Lama VE