Morning Report

july 15th 2009

•Supervise by : dr.Agus Thoriq, SpOG Medical Student:

•Dwi • Retna

• Sumiati•Husni

Cases resume :1 G1P1A0 A/S/L with head presentation + PROM <12

hours + severe PE 1

2 1

Name : Mrs. Zuhaerani Additted : 15.07.09

age : 35 years : 13.00

Address : Cakra-utara

Time Subject Object Assesment Planning

13.00 Patien come to ER General Hospital of Mataram confess abdominal pain and bloody show since at 11.00 (15/7/09). history watery vaginal discharge since at 08.00 (15/7/09).Headache (-),blur vision (-),epigastric pain (-)

LMP : forgotANC : routine at PHC (>7x)History family planning : -Family planning : IUD

General status : •General condition: well•Conciousness: CM•BP: 150/110 mmHg•RR: 20 x/mnt•Pulse :80x/mnt•T: 36.8 ‘C Eyes : an(-), ikt (-)Cor -Pulmo : in normal rangeExt : edema -/-Obstetric status :L1 : breechL2 : Right backL3 : headL4 : descensus 4/5UFH 29 cmEFW : 2790 g UC : 1x/10’ – 20”Fetal Heart Rate : 12-12-12VT : CD 1 cm, eff 25 % AM (-), clear, head palpable, descensus HI, umbilical cord or small part of fetal unpalpable

G1P0A0 A/S/L head presentation with PROM +severe PE

- Observation mother and fetal well being

- Laboratory tes, DL, UL, HbsAg

- Inj ampicillin 1 gr IV

Report to superviser Proposed management

severe PE Advice from

supervisor : management severe PE and evaluation 2 hours if vital sign was good start drip oxytocin.

- Education mother to eat and drink

Bishop score : 6Dilatation cervix : 1Length of servix : 2Station : 1Consistensi : 1Position : 1Pelvic evaluation :Spina ischiadica unpalpable, os coxigeus mobile, distansia tuberum >90’

Lab examination :Hb :11,5 gr %Leukosit :7100 /mm3Trombosit :308.000/mm3Hematocrit :34,1HBsAg : (-)Protein : +3

time Subject Object Assesment Planning

obs. Mother and fetal well being

Educate mother to left lateral position

Educate mother to eat and drink

G1P0A0 A/S/L/Head presentatiion with PROM + severe PE

General status : well

BP : 170/100 mmHg

RR : 20x/mnt

Pulse : 84x/mnt

Temp : 36,5 c

Prod urine : 100 cc/hr

FHR : 150x/mnt

UC : 3-4x/10’-30”

Abdominal pain (++)

Subjective complain (-)

14.30

obs. Mother and fetal well being

Educate mother to left lateral position

Educate mother to eat and drink

G1P0A0 A/S/L/Head presentatiion with PROM + Severe PE

General status : well

BP : 160/110 mmHg

RR : 20x/mnt

Pulse : 80x/mnt

Temp : 36,8 c

FHR : 156x/mnt

UC : 2-3x/10’ -25”

Abdominal pain (+)

Subjective complain (-)

14.00

Management severe PE :

MgSO4 bolus 4 gr IV

MgSO4 6 gr in RL 28dpm

Nifedipine 3x10 mg

DC

Educate mother to eat and drink

G1P0A0 A/S/L/Head presentation with PROM + severe PE

General status : well

BP : 160/110 mmhg

RR : 18x/mnt

Pulse : 84x/mnt

Temp : 37,2 c

prod urine : 100 cc/hr

FHR : 154x/mnt

UC : 2-3x/10’-25”

Abdominal pain (+)

Subjective complain (-)

13.30

time Subject Object Assesment Planning

obs. Mother and fetal well being

Educate mother to left lateral position

Educate mother to eat and drink

G1P0A0 A/S/L/Head presentatiion + PROM + severe PE

General status : well

BP : 160/100 mmHg

RR : 18x/mnt

Pulse : 80x/mnt

Temp : 36,7 c

Prod urine : 120 cc/hr

FHR : 146

UC : 3-4x/10’ ~ 30”

Abdominal pain (++)

Subjective complain (-)

15.30

Observation mother and fetal well being

Educate mother to left lateral position

Educate mother to eat and drink

G1P0A0 A/S/L head presentation + PROM + Severe PE

General status : well

BP : 160/100

Pulse : 84x/mnt

RR : 18x/mnt

Temp : 36,7 ‘c

FHR : 146x/mnt

UC : 3-4x/10’ – 30”

VT : CD 4 cm, eff 45%,AM (-), clear, head palpable decensus H1, umbilical cord and small part of fetal unpalpable.

Abdominal pain (++)

Subjective complain (-)

15.00

time Subject Object Assesment Planning

Aff DC

Report to supervisor : proposed vacuum,

Proposed agree

G1P0A0 A/S/L/Head presentatiion + PROM +severe PE

General status : well

BP : 170/100 mmHg

RR : 18x/mnt

Pulse : 84x/mnt

Temp : 36,5 c

Patient want to bearing down17.00

•Educate mother to left lateral position•Educate mother and fetal well being•Educate mother to eat and drink

G1P0A0 A/S/L/Head presentatiion + PROM + severe PE

General status : well

BP : 170/100 mmHg

RR : 18x/mnt

Pulse : 84x/mnt

Temp : 36,6 c

Prod urine :130 cc/hr

FHR : 146 x/mnt

UC : 3-4x/10’ -40”

Abdominal pain (++)

Subjective complain (-)

16.30

obs. Mother and fetal well being

Educate mother to left lateral position

Educate mother to eat and drink

G1P0A0 A/S/L/Head presentatiion + PROM + severe PE

General status : well

BP : 170/100

Pulse : 84x/mnt

RR : 22x/mnt

Temp : 36,7 c

FHR : 138

UC : 3-4x/10’ ~ 35”

Abdominal pain (++)

Subjective compalain (-)

16.00

PlanningAssesmentObjectSubjecttime

Baby was born, female. Weight 2600 gr ,length 46 cm. AS 7-9

Placenta was born completeHemorarge 150 cc

2nd stage of labor

3nd stage of labor

17.30

Conduct mother to bearing downepisisiotomiObs.mother and fetal well being

G1P0A0 A/S/L/ 2nd

Stage of labor + head presentation

Doran teknus perjol vulkaMother wont to bearing down17.20

VT : CD complete, eff 100%, AM (-),clear, head palpable decensus H111, umbilical cord and small part of fetal unpalpable.

Time Subject Object Assesment Planning

Mother and baby rooming in melati room

1 day of puerpuralis

07.00

Obs. Vital signObs.uterus contractionObs.bleeding

Educate mother to give lactation

4nd stage of labor +Mild PE

General status : wellBP : 150/100 mmHg RR : 18x/mntPulse : 80x/mntTemp : 36,5 ‘cUFH : 2 fingers below the umbilicalUC : good

19.00

Obs.vital sign of motherObs. Uterus contractionObs.bleeding

4nd stage of labor + Mild PE

General status : wellBP : 150/100 mmHgRR : 20x/mntPulse : 88x/mntTemp : 37 cUFH : 2 fingers below the umbilicalUC : good

18.00

Time Subject Object Assesment Planning

General status : wellBP : 150/100 mmHg RR : 20x/mntPulse : 76x/mntTemp : 36,8 ‘cUFH : 2 fingers below the umbilicalUC : good