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MORNING REPORTAUGUST,11TH 2014

CASE RESUME

NORMAL LABOR 0

PATHOLOGIES

LABOR1. G1P0A0L0 39-40 weeks/S/L/IU head presentation w

Oligohidramnion

2. Dgsg

3. Gf4. Dsg

5. Hdjfh

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Name : Mrs.N

Age : 30 years oldAddress : Taliwang, Sumbawa

Admitted : 12-07-2014

No. RM : 11-26-40

G1P0A0L0 41-42 weeks/S/L/IU head

presentation with history of C.S

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Time Subject Object Assessment Plan

12-07-

2014

12.30

Patient come to NTB GH

with G4P2A1L2 41-42

weeks/S/L/IU head

prsentation.

Patient confessed

abdominal pain since 04.00

(08-07-2014) with water

come out from her vaginasince 11 (08-07-2014) ,

bloody slim (-), and FM (+).

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

asthma (-).

LMP : 26-09-2013EDD : 03-07-2014

History ANC : 11x at PHCLast ANC : 09-06-2014

result: BP : 90/60, 37

weeks, FHB (+) 136 x/min,

mothers and fetals

condition is well

General status

GC : well

GCS: CM (E4V5M6)

BP : 120/80 mmHg

HR: 84 x/m

RR: 22 x/m

T: 36,7 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

L2 : back on the right side

L3 : head

L4 : 4/5

UFH: 33 cm

EFW : 3410 gram

UC : -

FHB : 12-11-11 (136x/min)

G4P2A1L2 41-

42 weeks

A/S/L/IU head

presentation

with faild

inductiction

Obs. Mot

fetal well

DM co to

CTG and

inj.accele

GP co to

acc and a

Accelera

Inj. Ampi

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History of USG : 2 times

Last USG: 12 July 2014

Result: G4P2A1L2 S/L/IU

EFW : 3600 grams.

Amnion (+)

History of family planning

: inj. Three month

Next family planning : -

History of obstetric :

I . Aterm/ 3000 grams /

normal / midwife/ life

II. Aterm / 3600 grams /

C.S / GH Saudi

Arabia / LifeIII. Abortus / 19 weeks

IV. This

VT : 1 cm, eff. 15 % amnion

(+), head palpable, HI, denom

unclear, unpalpable small part of

fetus/ umbilikal cord

PS :Cervic dilatation 1 cm : 1

Cerviks length 2 cm: 2

cerviks consistency soft: 1Cerviks position mid: 1

Station H I: 1

Total: 6

Lab:

HGB = 12.3 g/dl

RBC = 4.10 K/ulWBC = 12.37 M/ul

HCT : 34.0 %

PLT = 276 M/ulHBsAg = (-)

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Time Subject Object Assessment Planni

14.30 UC : -

FHB : 12-12-11 (140x/min)

Start drip oxyt

dpm

15.00 UC : -

FHB : 11-12-11 ( 136x/min)

Oxy drip: 1

15.30 UC : -

FHB : 11-12-12 ( 140x/min)

Oxy drip: 1

16.00 Abdominal pain UC : 2 x 10 ~ 20

FHB : 11-12-11 (136 x/min)

Oxy drip: 2

16.30 UC : 2 x 10 ~ 20

FHB : 11-12-11 (136 x/min)

Oxy drip: 2

17.00 UC : 2 x 10 ~ 30

FHB : 11-12-11 (136 x/min)

Oxy drip: 2

17.30 UC : 3 x 10 ~ 30

FHB : 11-12-12 (140 x/min)

Oxy drip: 3

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18.00 UC : 3 x 10 ~ 20

FHB : 12-12-11 (140x/min)

Oxy drip: 3

18.30 UC : 2 x 10 ~ 30

FHB : 11-12-12 ( 140x/min)

Oxy drip: 4

19.00 UC : 2 x 10 x 20

FHB : 11-12-12 ( 140x/min)

Start drip oxyt

dpm flas

19.35 Baby was bo

2500 gram. 4

7-9. Anus

Congenital an19.50 UC : well

UFH : 2 finger bellow

umbilicus

3rd of labor Placenta wa

spontan. Com

300gra

Leukia 15

episiostomy (

rupture gr

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Time Subject Object Assessment Plannin

18.30 Mother wont to

bearing down

UC : 4 x 10 ~ 45

FHB : 12-13-12 ( 148x/min)

Oxy drip: 40


bearing down

UC : 4 x 10 ~ 45

FHB : 12-13-12 ( 148x/min)

Inspection : opening of vulva,bulging of perineum, pressure of

anus

2nd stage of labor Conduct mother

down

18.50 Baby was born. fe

gram. 44 cm, AS

(+). Congenital an

18.55 UC : well

UFH : 2 finger bellow umbilicus

3rd of labor Placenta was bor

Complete. 50

Bleeding 2

Time Subject Object Assessment

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21.15 GC: well cons:E4V5M6

BP: 120/80 mmHg

PR: 92x/m

RR: 20x/m

T: 38 0C

UC: (+) well

UFH: 2 fingers below umbilicus

Lab:

Hb : 9,4WBC: 19,53

2 hours post partum Observatio

being

Suggest m

Suggest m

Paracetam

Inj ampi 1

03-08-

2014

07.00

GC: well cons:E4V5M6

BP: 110/70 mmHg

PR: 84x/m

RR: 20x/m

T: 36,4 0C

UC: (+) well


Active bleeding: (-)

Lokea rubra + Baby rooming

1 day post post partu Observed

Suggest m

suggest m

Suggest m

04-08-

2014

07.00


BP: 110/70 mmHg

PR: 84x/m

RR: 20x/m

T: 36,4 0C

UC: (+) well

UFH: 3 fingers below umbilicus Active bleeding: (-)

Bab roomin

2 day post partum Observed

Suggest m

suggest m

Suggest m

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Name : Mrs.N

Age : 30 years oldAddress : Taliwang, Sumbawa

Admitted : 12-07-2014

No. RM : 11-26-40


presentation with history of C.S


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12-07-

2014

12.30


with G4P2A1L2 41-42

weeks/S/L/IU head

prsentation.

Patient confessed

abdominal pain since 04.00

(08-07-2014) with water

come out from her vaginasince 11 (08-07-2014) ,

bloody slim (-), and FM (+).


asthma (-).

LMP : 26-09-2013EDD : 03-07-2014

History ANC : 11x at PHCLast ANC : 09-06-2014

result: BP : 90/60, 37

weeks, FHB (+) 136 x/min,

mothers and fetals

condition is well

General status

GC : well

GCS: CM (E4V5M6)

BP : 120/80 mmHg

HR: 84 x/m

RR: 22 x/m

T: 36,7 C


Pulmo: ves (+/+), rh (-/-), wh (-/-

)


G(-)





L3 : head

L4 : 4/5

UFH: 33 cm

EFW : 3410 gram

UC : -

FHB : 12-11-11 (136x/min)

G4P2A1L2 41-

42 weeks

A/S/L/IU head

presentation

with faild

inductiction

Obs. Mot

fetal well

DM co to

CTG and

inj.accele

GP co to

acc and a

Accelera

Inj. Ampi


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Last USG: 12 July 2014

Result: G4P2A1L2 S/L/IU

EFW : 3600 grams.

Amnion (+)


: inj. Three month

Next family planning : -


I . Aterm/ 3000 grams /

normal / midwife/ life

II. Aterm / 3600 grams /

C.S / GH Saudi

Arabia / LifeIII. Abortus / 19 weeks

IV. This






Cerviks length 2 cm: 2

cerviks consistency soft: 1Cerviks position mid: 1

Station H I: 1

Total: 6

Lab:

HGB = 12.3 g/dl

RBC = 4.10 K/ulWBC = 12.37 M/ul

HCT : 34.0 %

PLT = 276 M/ulHBsAg = (-)

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14.30 UC : -

FHB : 12-12-11 (140x/min)

Start drip oxyt

dpm

15.00 UC : -

FHB : 11-12-11 ( 136x/min)

Oxy drip: 1

15.30 UC : -

FHB : 11-12-12 ( 140x/min)

Oxy drip: 1

16.00 Abdominal pain UC : 2 x 10 ~ 20

FHB : 11-12-11 (136 x/min)

Oxy drip: 2

16.30 UC : 2 x 10 ~ 20

FHB : 11-12-11 (136 x/min)

Oxy drip: 2

17.00 UC : 2 x 10 ~ 30

FHB : 11-12-11 (136 x/min)

Oxy drip: 2

17.30 UC : 3 x 10 ~ 30

FHB : 11-12-12 (140 x/min)

Oxy drip: 3

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18.00 UC : 3 x 10 ~ 20

FHB : 12-12-11 (140x/min)

Oxy drip: 3

18.30 UC : 2 x 10 ~ 30

FHB : 11-12-12 ( 140x/min)

Oxy drip: 4

19.00 UC : 2 x 10 x 20

FHB : 11-12-12 ( 140x/min)

Start drip oxyt

dpm flas

19.35 Baby was bo

2500 gram. 4

7-9. Anus

Congenital an19.50 UC : well

UFH : 2 finger bellow

umbilicus

3rd of labor Placenta wa

spontan. Com

300gra

Leukia 15

episiostomy (

rupture gr

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Time Subject Object Assessment Plannin


bearing down

UC : 4 x 10 ~ 45

FHB : 12-13-12 ( 148x/min)

Oxy drip: 40


bearing down

UC : 4 x 10 ~ 45

FHB : 12-13-12 ( 148x/min)

Inspection : opening of vulva,bulging of perineum, pressure of

anus

2nd stage of labor Conduct mother

down

18.50 Baby was born. fe

gram. 44 cm, AS

(+). Congenital an

18.55 UC : well

UFH : 2 finger bellow umbilicus

3rd of labor Placenta was bor

Complete. 50

Bleeding 2


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21.15 GC: well cons:E4V5M6

BP: 120/80 mmHg

PR: 92x/m

RR: 20x/m

T: 38 0C

UC: (+) well


Lab:

Hb : 9,4WBC: 19,53

2 hours post partum Observatio

being

Suggest m

Suggest m

Paracetam

Inj ampi 1

03-08-

2014

07.00


BP: 110/70 mmHg

PR: 84x/m

RR: 20x/m

T: 36,4 0C

UC: (+) well



Lokea rubra + Baby rooming

1 day post post partu Observed

Suggest m

suggest m

Suggest m

04-08-

2014

07.00


BP: 110/70 mmHg

PR: 84x/m

RR: 20x/m

T: 36,4 0C

UC: (+) well



Bab roomin

2 day post partum Observed

Suggest m

suggest m

Suggest m

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Name : Mrs. A

Age : 24 years oldAddress : Kayangan, KLU

Admitted : 11-08-2014

No. RM : 54-42-92


presentation with arrested active phase


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11-08-

2014

14.11


reffered KLU GH with

G1P0A0L0 A/S/L/IU head

presentation with arrested

active phase + susp

macrosomia + mild

preeclampsia

Patient confessed

abdominal pain since 11-08-2014 (01.00), bloody slim

(+), water come out from her

vagina (-) and FM (+).


asthma (-).

LMP : 12-11-2013

EDD : 19-08-2014

History ANC : > 5x at PHC

Last ANC : 02-06-2014

result: BP : 110/80, 35-36

weeks, Hb: 9 gr/dl, mothers

and fetalscondition is well

General status

GC : well

GCS: CM (E4V5M6)

BP : 160/90 mmHg

HR: 84 x/m

RR: 20 x/m

T: 36,7 C


Pulmo: ves (+/+), rh (-/-), wh (-/-

)


G(-)





L3 : head

L4 : 4/5

UFH: 34 cm

EFW : 3565 gram

UC : 3 x 10 ~ 35

FHB : 11-12-12 (140x/min)

G2P0A1L0 38-

39

weeks/S/L/IU

head

presentation

with protracted

active phase +

mild

preeclampsia+susp

makrosomia

Obs. Mot

fetal well

DM co to

CTG, inj.

Ceftriaxo

to SPV, S

and advic

Accelera

Inj. Ampi


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History of USG :-


: -

Next family planning : IUD


I . Abortion/ 3 months

II. This





Pelvic examination:

Promontorium unpalpable

Spina ischiadica not prominent

Os coccygeus mobileArcus pubic > 90 degree

Lab:

HGB = 13,5 g/dl

RBC = 4,43 K/ul

WBC = 20,75 M/ul

HCT :38.5 %PLT = 169 M/ul

HBsAg = (-)

Proteinuria +1


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Chronologist : at Kayangan PHC (11-08-

2014, 08.30)S : Patient confessed flank pain and

abdominal pain (-), Bloody slim (+)

Water come out from her vagina (-), FM

(+).

O : GC : well

Cons : CM

BP : 170/100mmHgHR : 82x/mRR : 20x/m

T : 36,5

UFH : 38cm

L1 : breech

L2 : back on the left side

L3 : head

L4 : 3/5

FHR : 140x/m

UC : 3x10-45VT : 8 cm, eff 75%, amnion (-), head

palpable, HII, unpalpable small part of


Proteinuria +1

A : G1P0A0L0 A/S/L/IU with inpartu active

phase + mild preeclampsia + susp.

macrosomia

P : RL 20 tpm, inj.cefotaxime, nifedipin 10m


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Chronologist : at KLU GH (11-08-2014

09.00)

S : Patient confessed flank pain and

abdominal pain since 11-08-2014

(01.00) . Bloody slim (+) Water come out

from her vagina (-), FM (+).

O:GC : wellCons : CM

BP : 160/90mmHg

HR : 84x/m

RR : 24x/m

T : 36

UFH : 35 cm

FHR : 132x/m

UC : 3x10-35

VT : 7cm, eff 50%, amnion (+) , head

flooting palpable, denom unclear, HI,unpalpable small part of fetus/ umbilikal

cord

A : G1P0A0L0 A/S/L/IU head presentation

with active phase

P: Obs. Mother and fetal well being


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12.00


abdominal pain

O:GC : well

Cons : CM

BP : 160/90mmHg

HR : 82x/mRR : 20x/m

T : 36FHR : 144x/m

UC : 3x10-35

VT : 7cm, eff 75%, amnion (+) , head

flooting palpable, denom unclear, HI,

unpalpable small part of fetus/ umbilikal

cord


with protracted active phase + susp

macrosomnia + mild preeclampsia

P: reffered to NTB GH

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18.10 Abdominal pain UC: 3x10 ~ 45

FHR: 156 bpm

Co CTG to GP

to SPV, advice

15.30 - Co to SPV adpro CS at 18.3

CIE patient anto CS

17.30 - Preoperative:

- Inj. Cefotax(skin test)

- Doing dowe

chatteter fo

18.40 - CS began

Baby was borfemale, AS 7-

gram, 46 cm, congenital an

meconeal (-),

Placenta was b

complete, bleecc

Time Subject Object Assessment Planning

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21.30 Abdominal wound

pain

GC: well

cons:E4V5M6BP: 110/70 mmHg

PR: 68x/m RR: 20x/m

T: 36 0CUC: (+) well

UFH: 2 fingers below

umbilicusActive bleeding: (-)

UO: 70cc/hourLokea rubra +

Baby in NICUPulse : 140 bpm

RR : 56x/mT : 36,5 C

2 hours post

CS

Observation moth

baby well beingSuggest mother to

mobilitation

07-07-2014

07.00

Abdominal woundpain

GC: wellcons:E4V5M6

BP: 120/80 mmHgPR: 88x/m

RR: 20x/m

T: 36,4 0CUC: (+) well

UFH: 2 fingers belowumbilicus

Active bleeding: (-)UO: 60cc/hour

1 day post CS Observed motherwell being

Suggest mother tomobilisation.

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Name : Mrs. A

Age : 18 years oldAddress : Kayangan, KLU

Admitted : 12-07-2014

No. RM : 54-23-13


presentation


12 07 P ti t t NTB GH G l t t G1P0A0L0 39 Ob M t

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12-07-

2014

14.25


reffered KLU GH with

G2P1A0L1 40-41

weeks/S/L/IU head

prsentation with inpartu

latent phase + history C.S3

years ago + Skizoprenia

Patient confessedabdominal pain since 04-07-

2014 (11.00), bloody slim

(+), water come out from her

vagina (-) and FM (+).


asthma (-).

LMP : 02-10-2013

EDD : 09-07-2014

History ANC : > 5x at PHC

Last ANC : 02-06-2014

result: BP : 110/80, 35-36

weeks, Hb: 9 gr/dl, mothers

and fetalscondition is well

General status

GC : well

GCS: CM (E4V5M6)

BP : 110/70 mmHg

HR: 88 x/m

RR: 22 x/m

T: 36,6 C


Pulmo: ves (+/+), rh (-/-), wh (-/-

)


G(-)



Obstetric status

L1 : breech


L3 : head

L4 : 4/5

UFH: 29 cm

EFW : 2790 gram

UC : 1 x 10 ~ 20

FHB : 12-11-11 (136x/min)

G1P0A0L0 39-

40 weeks

A/S/L/IU head

presentation

with PROM

Obs. Mot

fetal well

DM co to

CTG, inj.

accelerat

GP co to

acc and a

Accelera

Inj. Ampi


Hi t f USG 1 ti VT 1 ff 10 % i (+)

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Last USG: 04 Juni 2014

Result: G2P1A0L1 31-42

mg S/L/IU, EFW: 1888 gr.


: -

Next family planning :


I. This

VT : 1 cm, eff. 10 % amnion (+)

thin, head palpable, HI, denom



Pelvic examination:

Promontorium unpalpable

Spina ischiadica not prominent

Os coccygeus mobileArcus pubic > 90 degree


Cerviks length 3cm: 1

cerviks consistency soft: 1

Cerviks position mid: 1

Station H I: 1

Total: 5

Lab:

HGB = 9.5 g/dl

RBC = 3.91 K/ul

WBC = 8.80 M/ul

HCT : 30.3 %

PLT = 440 M/ul

HBsAg = (-)


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Chronologist : at (05-07-2014 20.30)




from her vagina (+) since 05-07-2014

(07.00), FM (+).

O : GC : well

Cons : CM

BP : 110/70mmHgHR : 82x/mRR : 22x/m

T : 36,5

UFH : 25cm

L1 : -

L2 : back on the left side

L3 : head

L4 : -

FHR : 140x/m

UC : 1x10-35VT : 7cm, eff 75%, amnion (-), head

palpable, HII, unpalpable small part of



phase 1ststage of labor + ROM > 12

hours + KEK

P : Obs. Mother and etal well being, CIE

patient and familiy


23 30

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23.30

S :Abdominal pain (+)

O: GC : well

Cons : CMBP : 110/70mmHg

HR : 82x/m

RR : 22x/mT : 36,5

UFH : 25cm

FHR : 140x/m

UC : 1x10-35

VT : 7cm, eff 75%, amnion (-) , head

palpable, H1+, unpalpable small part of



phase 1st

stage of labor + ROM > 12hours + KEK

P:Reffered to Tanjung GH


Chronologist : at Tanjung GH (06-07-

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Chronologist : at Tanjung GH (06-07-

2014 01.20)




from her vagina (+) since 05-07-2014(11.00), FM (+).

LMP : forget

EDD : -

O:GC : well

Cons : CM

BP : 120/80mmHg

HR : 80x/m

RR : 20x/m

T : 36.8

UFH : 26 cm

FHR : 140x/m

UC : 2x10-25

VT : 5cm, eff 50%, amnion (-) , head

palpable, denom unclear, HII,

unpalpable small part of fetus/ umbilikal

cord


with ROM > 12 hours

P: infuse RL 1 f lash 28 dpm, inj ampicillin

1gr/iv,


03.00

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03.00

Infus RL flash II 28 dpm

05.30

S : -

O : GC : well, BP : 110/80mmHg, HR :80x/m, T : 37 C, RR 20x/m

UC : 2x10-25. FHR : 140x/m

VT : 5 cm , eff. 50 % amnion (-), denom

unclear, HII, unpalpable small part of



with arrested active phase

P : RL:D5 = 2:1

Adv spOG obs. 1 hour

BELUM SELESAI...!!!

14.00 Abdominal pain UC: (-) Co CTG to SP

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p ( )

FHR: 140 bpm observation

15.30 - Co to SPV adpro CS at 18.3

CIE patient anto CS

17.30 - Preoperative:

- Inj. Cefotax(skin test)

- Doing dowe

chatteter fo

18.40 - CS began

Baby was borfemale, AS 7-

gram, 46 cm, congenital an

meconeal (-),

Placenta was b

complete, bleecc

Time Subject Object Assessment Planning

21 30 Abdominal wound GC: well 2 hours post Observation moth

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21.30 Abdominal wound

pain

GC: well

cons:E4V5M6BP: 110/70 mmHg

PR: 68x/m RR: 20x/m

T: 36 0CUC: (+) well

UFH: 2 fingers below

umbilicusActive bleeding: (-)

UO: 70cc/hourLokea rubra +

Baby in NICUPulse : 140 bpm

RR : 56x/mT : 36,5 C

2 hours post

CS

Observation moth

baby well beingSuggest mother to

mobilitation

07-07-2014

07.00

Abdominal woundpain

GC: wellcons:E4V5M6

BP: 120/80 mmHgPR: 88x/m

RR: 20x/m

T: 36,4 0CUC: (+) well

UFH: 2 fingers belowumbilicus

Active bleeding: (-)UO: 60cc/hour

1 day post CS Observed motherwell being

Suggest mother tomobilisation.

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MR 12 Agustus