Morning ReportNovember 10th , 2015Supervisor : dr. Gede Made

Punarbawa, Sp.OG(K)Medical Students :

Dede, Dila, Nita, Dhani, Farid, Sobri

CASES RESUME NORMAL LABOR

(-)

PATHOLOGY LABOR

1.G2P1A0L1 40-41 weeks S/L/IU head presentation with oligohydramnion

2.G3P0A2H0 43 weeks S/L/IU head presentation with BOH

3. G3P0A2H0 25-26 weeks /S/IUFD/IU + BOH

• Name : Mrs. M• RM : 56 95 30• Age : 22 years old• Address : Lingsar• Admitted : 8th November 2015 at 08.53

WITA

Case Report

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

08/11/2015

08.53

Patient referred from Akasia Klinik to VK IGD NTB GH with G3P0A2L0 18-20 weeks S/IUFD/IU. Patient 4 months pregnancy confessed dindn’t fell the fetal movement since 1 weeks ago, abdominal pain that spread to flank (-), water leaked from her womb (-), bloody slim (-). history of DM (-), HT (-), asthma (+), alergi (-)

LMP : 15 – 05 - 2015EDD : 22– 02 – 2016GW : 25-26 weeks

History of ANC : 6x at PHC and posyanduLast ANC : 06/11/2015Result : BP 110/70, BW 63 kg, GW 17-18 weeks, UFH 1 finger below umbilicus, ballotement (+), FHB (+) History of USG : 1x at Sp.OGLast : 05/11/2015Result : Fetal S/IUFD/IU 16-17 weeks FM (-), FHB (-)

History of family planning : -Next family planning : -

Obstetrical History :1.Abortus 3 months curretage2.Abortus 2 months curretage3.This

General Status :GC : wellBP : 120/80 mmHgPR : 82 bpmRR : 20 bpm Temp : 36,5oCEye : palor (-/-), icteric (-/-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).

Obstetrical Status :Leopold : can’t performUFH : as the umbilicusUC : -FHB : - Ballotement (+)

VT : Ø 1 cm, eff 10 %, amnion (+), impapable small part of fetus and umbilical cord

Lab :Hb 12,2WBC 10,45PLT 297BT 1’45’’CT 5’12’’HbsAg (-)

G3P0A2L0 25-26 weeks S/IUFD/IU

with BOH

DM Planning :Diagnostiik• Lab (Dl, BT, CT,

HbsAg)

Therapy• Observation

mother well being.

• Obs. Inpartu sign• Suggest mother

to at and drink• Pro termination

with misoprostol induction

09.00DM co to GP, GP

to SPV advice : Insertion misoprostol by the vagina ½ tablet per 6 hours

At 06.00 before patient had take gastrul

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Pelvic score (total) : 3Dilatation 1cm (1), cervix length 2cm(1), station H0(0), consistency rigid (0), position middle (1)

12.00 Insertion of misoprostol ½ tab

14.00 GC : wellBP : 110/70 mmHgPR : 80 bpmRR : 22 bpm Temp : 36,8oCUC : -VT : not perform

G3P0A2L0 25-26 weeks S/IUFD/IU with BOH

- Obs mother well being suggest mother to eat and drink

- Obs for vaginal delivery

18.00 GC : wellBP : 120/70 mmHgPR : 84 bpmRR : 20 bpm Temp : 36,5oCUC : -VT : not perform

G3P0A2L0 25-26 weeks S/IUFD/IU with BOH

• Obs mother well being

• Insertion of misoprostol ½ tab

00.00 • Insertion of misoprostol ½ tab

9/11/201506.00

GC : wellBP : 110/70 mmHgPR : 88 bpmRR : 19 bpm Temp : 36,4oCUC : -VT : not perform

G3P0A2L0 25-26 weeks S/IUFD/IU with BOH

• Obs mother well being

• Dm co to GP, GP co to SPV, advice increase misoprostol dose be 1 tab/6hours

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

12.00 GC : wellBP : 110/80 mmHgPR : 92 bpmRR : 21 bpm Temp : 36,3oCUC : -VT : dilatation 1cm, eff 10%, amnion (+), palpable part of fetal or tissue

G3P0A2L0 25-26 weeks S/IUFD/IU with BOH

- Obs mother well being suggest mother to rest well, eat and drink- Insertion of misoprostol 1tab/6hours

18.00 Patient confessed abdominal pain still seldom

GC : wellBP : 110/70 mmHgPR : 96 bpmRR : 22 bpm Temp : 36,5oCUC : 2x10’-15”VT : dilatation 1cm, eff 10%, amnion (+), palpable part of fetal or tissue

G3P0A2L0 25-26 weeks S/IUFD/IU with BOH

-Obs mother well being suggest mother to rest well, eat and drink- Insertion of misoprostol 1tab/6hours

19.00 Patient confessed water leaked from her womb

GC : wellBP : 110/70 mmHgPR : 84 bpmRR : 20 bpm Temp : 36,7oCUC : 4x10’-45”VT : dilatation 4cm, eff 50%, amnion (-), hodge II, palpable part of fetal

G3P0A2L0 25-26 weeks S/IUFD/IU with inpartu active phase of labor + BOH

-Obs mother well being suggest mother to eat and drink-Obs progress of labor

19.12 Mother wants to bear down Inspection : bulging perineum, opening vulva, anus pressure

Second stage of labor

Conduct labor

Baby was born at 19.15 death, male, BW 300gr, BL 21cm, Maseration grade III

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

19.20 GC : wellBP : 100/60 mmHgPR : 76 bpmRR : 22 bpm Temp : 36,7oCUC wellUFH 2 fingers above symphisisBleeding about 50ccPerineum intact

3rd phase of labor with IUFD + suspect rest placenta

- Injection oxytocin 1amp IM- placenta was born spontan not complete, doing exploration- UC well- UFH 2 fingers above symphisis- Bleeding about 50cc- Perineum intact- suggest mother to eat and drink

-DM co to GP, GP co to SPV advice : pro USG tomorrow morning

21.00 GC : wellBP : 120/80 mmHgPR : 80 bpmRR : 19 bpm Temp : 36,8oCUC wellUFH 2 fingers above symphisisActive bleeding (-)

2 hours post partum with IUFD + suspect rest placenta

- Obs UC, bleeding, mother well being- Suggest mother to rest well, eat and drink

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

10/11/201506.00

GC : wellBP : 110/70 mmHgPR : 84 bpmRR : 18 bpm Temp : 36,6oCUC wellUFH 2 fingers above symphisisActive bleeding (-)

1 day post partum with IUFD + suspect rest placenta

- Obs mother well being, UC, bleeding- Suggest mother to eat and drink- Pro USG this morning