Morning reportMarch, 21th 2014SUPERVISOR:Dr. EDY P.W, SpOG

DM:AKBAR, ARIQ, ASRI

Name: Mrs. RAge: 20 yoAddress: LengkotAdmitted: March, 20th 2014 at 04.30 pm PATIENT IDENTITY

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING20/03/2014

04.30 pmPatient referred from Narmada PHC with G1P0A0 39 40 weeks S/L/IU with PROM + preeclampsia. Patient confessed water came out from her vagina since 11.30 pm (19/03/2014). Abdominal pain (-), bloody slim (-), fetal movement (+).

No history of DM, HT, asthma. No history of allergic reaction to medicine or food.

LMP : 15/06/2013EDD: 22/03/2014

History of ANC : 9xLast ANC: 20/02/2014, result: BP: 120/80 mmHg, 40-41 wk, FHB (+), UFH: 30 cmGeneral status:GC: wellGCS: E4V5M6BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 37,80 C

Eye : anemis (-), icteric (-)Thorax :Cor : S1S2 single reguler, murmur (-), gallop (-)Pulmo : vesikuler (+/+), wheezing (-/-), Ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+)Extremity : edema (-/-), warm acral (-/-)

Obstetrical status:L1: breechL2: back on the left sideL3: headL4: 4/5UFH: 31 cm EFW: 3100 gUC: -FHB: 12-12-13(148x/min)G1P0A0 39 40 weeks S/L/IU head presentation with PROM>12h + gestational hypertensionObs mother & fetal well beingDM co to GP pro induction with drip oxy if PROM>12 h, GP advice : Pro CTGContinue Antibiotic Ampicilin inj 1 gr/ 12 hParacetamol tab 3 x 500 mg

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGHistory of USG : -

History of Family Planning: - Next Family Planning: injection

History of obstetry:This

Chronologist : Narmada PHC20/03/2014S/Patient confessed water came out from her vagina since 11,30 pm (19/03/2014). Abdominal pain (-), bloody slim (-), fetal movement (+).O/General status:GC: wellGCS: E4V5M6BP: 140/100 mmHgPR: 90 bpmRR: 24 rpm T: 36,50 CVT : 1 cm, eff 25%, amnion (-), head presentation, denom unclear, HI, smallest part of fetal or umbilical cord unpalpable

PS: 6Servic dilatatiion: 1cm (1) Servic length:1cm (2)Station: mid (1)Consistency: average(1)Potition : -2cm (1)

PE:Promontorium unpalpable, spina ischiadika not prominent, os coccygeous mobile, pubic arch >90

Lab ResultHb : 9,9 x 106/ LWBC : 9,73 x 103/ LPLT : 396 x 103/ LHCT : 30,9%Proteinuria (-)HBsAg : (-) non reactive

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNINGStatus Obstetric L1 : headL2 : back on the left sideL3 : breechL4 : 4/5UFH : 31 cmEFW : 3100 gramFHR : 12-11-12, reguler (140bpm)UC : -VT : 1 cm, eff 25 %, amnion (-) clear, head palpable H1, denominator unclear, impalpable small part and umbilical cord.

Lab examination:Protein in urine : +1

A/G1P0A0 39 40 weeks S/L/IU general condition of mother and fetus well with PROM > 12h + preeclampsia.

P/KIE patient and family to referred to GH NTBIVFD RL 20 tpmInj. Ampicillin 1 gr/ 12hReferred to GH NTB

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING06.00 pmResult of CTG:

DM co to GP result of CTG, GP advice rehidration intrauterineCTG again after RIU06.30Rehidration intrauterine IVFD RL:Dex 5 % 2:1

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING08.00 pm-GC: wellGCS: E4V5M6BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 C

UC: -FHB: 12-12-12 (144x/min)G1P0A0 39 40 weeks S/L/IU head presentation with PROM>12h + gestational hypertentionPro CTGDM co result GP, GP advice observation 4 hours, repeat CTG

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING12.00 pm-GC: wellGCS: E4V5M6BP: 130/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 C

UC: -FHB: 12-12-12 (144x/min)

G1P0A0 39 40 weeks S/L/IU head presentation with PROM>12h + gestational hypertensionPro CTG

Co to GP, CTG normal, observation.

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING21/03/14

05.30 amGC: wellGCS: E4V5M6BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 CUC: -FHB: 12-12-12 (144x/min)G1P0A0 39 40 weeks S/L/IU head presentation with PROM>12h + gestational hypertensionObs. Mother and fetal well beingPro CTG

DM co to GP, GP advice pro co to SPV at morning.

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING08.00 amGC: wellGCS: E4V5M6BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 CUC: -FHB: 12-12-12 (144x/min)G1P0A0 39 40 weeks S/L/IU head presentation with PROM>12h + gestational hypertension DM co to GP, GP co to SPV, SPV advice pro USG09.30 am--USG result: SPV advice drip oxytocinCIE to family about condition and next planning to drip oxytocin

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING10.00 am-BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 CUC: -FHB: 12-12-12 (144x/min)Flash 1st Drip oxy began 8 dpm

10.30 am-UC : -FHB : 12-12-12 (144 bpm)Drip oxy 12 dpm11.00 am-UC : -FHB : 12-12-11 (140 bpm)Drip oxy 16 dpm11.30 amAbdominal painGC: wellGCS: E4V5M6BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 CUC: 2x10 ~25FHB: 12-12-12 (144x/min)VT : 3 cm, eff 25%, amnion (-), head presentation, denom unclear, head HI, smallest part of fetal or umbilical cord unpalpable.G1P0A0 39 40 weeks S/L/IU head presentation with history ROM + laten phase 1st stage of labor + gestational hypertension Drip oxy 20 dpm

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING12.00 amAbdominal painUC : 3x10 ~25FHB : 12-12-12 (144 bpm)Drip oxy 24 dpm12.30 pmAbdominal painUC : 3x10 ~25FHB : 12-11-12 (144 bpm)Drip oxy 28 dpm01.00 pmAbdominal painUC : 3x10 ~25FHB : 12-12-12 (144 bpm)Drip oxy 32 dpm01.30 pmAbdominal painUC : 3x10 ~25FHB : 12-11-12 (144 bpm)Drip oxy 36 dpm02.00 pmAbdominal painUC : 3x10 ~25FHB : 12-12-12 (144 bpm)Drip oxy 40 dpm

02.30 pm Abdominal painUC : 3x10 ~25FHB : 12-11-12 (144 bpm)Drip oxy 40 dpm

03.00pmAbdominal painUC : 3x10 ~25FHB : 12-12-12 (144 bpm)Drip oxy 40 dpm

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING03.30 pmAbdominal painGC: wellGCS: E4V5M6BP: 140/90 mmHgPR: 88 bpmRR: 22 rpm T: 36,70 CUC: 3x 10~35FHB: 12-12-12 (144x/min)VT : 6 cm, eff 75%, amnion (-), head presentation, HII, denom unclear, smallest part of fetal or umbilical cord unpalpableG1P0A0 39 40 weeks S/L/IU head presentation with history ROM + active phase 1st stage of labor + gestational hypertension Drip oxy 40 dpm04.00 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/min)Stop flash 1st change to flash 2nd 04.30 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/minDrip oxy 40 dpm05.00 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/minDrip oxy 40 dpm05.30 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/minDrip oxy 40 dpm06.00 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/minDrip oxy 40 dpm

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING06.30 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/min)Drip oxy 40 dpm07.00 pmAbdominal painUC: 3x 10~35FHB: 12-12-12 (144x/min)Drip oxy 40 dpm

07.30 pmAbdominal pain increasedUC : 4x10 ~40FHB : 12-12-12 (144 bpm)VT: complete, eff 100%, amnion (-), head presentation, HII, denom unclear, smallest part of fetal or umbilical cord unpalpable.G1P0A0 39 40 weeks S/L/IU head presentation with 2nd stage of labor + gestational hypertension Obs. Sign of labor08.10 pmAbdominal pain increase, mother want to bearing downInspection:Bulging of perineum, opening vulva, anus presureConduct labor08.20 pmBaby was born, male, AS: 7-9, BW/BL = 3350/50, anus +, anomaly kongenital -

08.30 pmMAK III

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING08.45 pmPlacenta wasnt bornUC flacidBleeding activeBP: 110/80 mmHgRetentio uteri Inj oxy 1 ampManual placentaKBI 5 minutesDrip oxy 2 amp in RL 40 tpm08.50 pmUC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 110/80 mmHgPost PartumObs. Mother well beingObs. Bleeding and VS09.05 pmUC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 110/80 mmHg15 minutes PPObs. Mother well beingObs. Bleeding and VS

09.20 pmUC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 110/80 mmHg30 minutes PPObs. Mother well beingObs. Bleeding and VS09.35 pmUC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 110/80 mmHg45 minutes PPObs. Mother well beingObs. Bleeding and VS

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING09.50 pm-UC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 120/80 mmHg1 hour PPObs. Mother well beingObs. Bleeding and VS

10.20 pm-UC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 120/80 mmHg1 hour 30 minutes PPObs. Mother well beingObs. Bleeding and VS10.50 pm-UC wellUFH 2 finger bellow umbilicalActive bleeding +BP: 110/80 mmHg

VT: palpable rest amnion and placenta2 hours PP + HPP ec Rest placentaExploration uteriContinue drip oxy 2 amp11.30 pm-UC wellUFH 2 finger bellow umbilicalActive bleeding -BP: 120/80 mmHg

Lab ResultHb : 9,7 x 106/ LWBC : 26,92x 103/ L30 minutes post HPPObs. Mother well beingObs. Bleeding and VSBreast feedingSuggest mother to eat and drink

TIMESUBJECTIVEOBJECTIVEASSESTMENTPLANNING07.00 pm-Cons: wellGCS: CMBP: 120/80 mmHgPR: 84 bpmRR: 20 rpm T: 37,30 CUC: (+) wellUFH: 2 finger below umbiliccalBleeding Baby rooming in is normal.HR : 148 bpmRR : 54 bpmTemp : 36,70C1 day post partumObseation Mother and baby well beingSuggest mother eat and drink Suggest mother to breast feeding.

Thank you