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Morning report
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1. SUG, 29 yo WAW
Complained labor pain (+) since 10.00 pm (30/08/2014) , watery vaginal discharge (-), FM (+) good. Known breech pres since 08/07/2014 ~ 33 wks GA (USG at O&G).
LMP: 25/11/2013EDD: 02/09/2014 PNC: Midwife, O&G
Obstetric History:1. ♂, 3500 g, SVD, midwife, 11 yo2. ♀, 3500 g, SVD, midwife, 8 yo3. ♂, 3500 g, SVD, midwife, 2 yo4.Current pregnancy
Married: 2x: I~8 yrs II~2 yrsContraception: OCP ~ stop August 2013
W/H: 67/152Present St:BP: 120/70 RR: 20P : 88 Tax: 36,7
General St :Eyes : anemic -/-Thorax cor : S1S2 sgl, reg, m (-) pulmo : ves +/+, rh -/-, wh -/-Ext : warm +/+ Oedem -/- +/+ -/- Obstetric St:Abd: FH 38 cm ω, AC 97 cm UC (+) 3x/10’~40-45’’ FHB (+) 138 bpm
VT (SDW) 08.30 amCD 8 cm, Eff 75%, AM (+)Buttock palp, Sacrum Left Anterior, ↓H IIUnpalp small parts/umb cord
G4P3003 39-40 wks, S/L, Breech Prest, 1st stage of labor
EFW: 3592 g ZA: 4
Pdx:-
Tx:•Exp Vaginal Delivery•IVFD RL 20 dpm
Mx: •C, VS, FHB, UC, Progress of labor
CIE
OBSTETRIC EMERGENCY ROOMLETAK SUNGSANG
1. SUG, 29 yo WAW
at 09.25 amPatient urge to bear down, spontaneously ROM
LAB:WBC: 14,6 PLT: 266HGB: 11,2 BT: 1’00HCT: 40,4 CT: 8’30”
USG:Fetus, S/L, breech prest, FHB (+), FM (+)BPD: 96,0 ~ 39W6D AVE 39W3DAC: 348,2 ~ 39W3D EFW: 3592 gFL: 79,3 ~ 40W3D EDD: 2/09/14Placenta Fundus Corpus Anterior grd IIIAFI 8,2
Obstetric St:Abd: UC (+) 4-5x/10’~40-45’’ FHB (+) 142 bpmVT (WAW) 09.25 am CD complete, AM (-) Buttock palp, Sacrum Transverse, ↓HIII+
2nd stage of labor
Tx: Lovset Mauriceau
At 09.33 amborn baby, ♂, 3900 g,
AS 7-8
OBSTETRIC EMERGENCY ROOMDUTY ON : SUNDAY, AUGUST 31st 2014