mr obgyn 14 okt 2012_fase aktif kasep_sc
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Morning ReportOctober 14th, 2012
Supervisor : dr. Edi Prasetyo W, Sp.OG
Medical Students :
Diah, Rani, Dini F, Subi, Indah
CASES RESUME
NORMAL LABOR
1
PATHOLOGY LABOR
1. G1P0A0L0 37-38 weeks /S/L/IU head presentation with severe preeclampsia and impending eclampsia + obs. dyspnea
2. G1P0A0L0 35-36 weeks/S/L/IU head presentation with PROM <12 hours
3. G1P0A0L0 A/S/L/IU head presentation with neglected active phase 1st stage of labor
Name : Mrs. RAge : 24 yoAdress : Bayan, KLUAdmitted : October, 14th 2012 at 17.10
Name : Mrs. RAge : 24 yoAdress : Bayan, KLUAdmitted : October, 14th 2012 at 17.10
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
14/10/2012
17.10
Patient referred from Bayan PHC with G1P0A0L0 A/S/L/IU head presentation with prolonged active phase 1st stage of labor. Patient confessed abdominal pain spread to back since 06.00 wita (13/10/2012). History rupture of membrane (-), bloody slim (+), FM (+). No history of DM, HT, asthma.
LMP : ForgotEDD : (-)
History of ANC : > 4 Last ANC : 29/09/2012History of USG : never
History of family planning : (-)Next family planning : IUD
Obstetrical History :I.This
General Status
GC : wellConsciusness : CMBP : 100/60 mmHgPR : 84 bpmRR : 22 bpmT : 37,8oC
Eye : anemis (-/-), icteric (-/-)Cor : S1S2 single reguler, M (-), G (-)Pulmo : vesikuler (+/+), wheezing (-/-), ronkhi (-/-).Abdomen : scar (-), striae (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+)
Obstetrical Status
L1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 28 cm EFW : 2635 gUC :2x/10’ ~ 25’’FHB : 12-12-11VT : Ø 6 cm, eff 75%, amnion (+), head palpable ↓H I +, denominator unclear, impalpable small part / umbilical cord.
G1P0A0L0 A/S/L/IU with
head presentation
with neglected active phase 1st stage of labor.
• Obs mother and fetal well being
• DM announce to SPV:
Pro Rehidration and amniotomi
• SPV advice:Rehidration and CS
at 20.00 WITA
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist
At Bayan PHC :
23.00 (13/10/2012)
S : Patient refered abdominal pain since 06.00 (13/10/2012). History rupture of membrane (-)
O : GC : wellBP : 100/70 mmHgPR : 80 bpmRR : 18 bpmT : 36,5oCUFH: 31 cmback on the right sideHead palpable, 2/5UC : (+) 2x10’ ~ 10”FHB : (+) 138 bpmVT : Ø 6 cm, aff 50%, amnion (-)
head palpable, LOA, ↓ H II, impalpable small part of fetal and umbilical cord
A:G1P0A0L0 38-39 weeks /S/L/IU
with latent phase 1st stage of labor .
P:Obs mother and fetal well being- Refer patient to NTB GH
Pelvic Evaluation :•Spina ischiadica not prominent•Os coccigeous mobile•Arcus pubis > 90o
Lab Evaluation :Hb : 12,6 gr/dlHCT : 37,5%RBC : 4,11 M/uLPLT : 249 K/uLWBC : 25,60 K/uLHBsAg : (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
21.00 Mother confessed abdominal pain (+++)
GC : wellBP : 110/90 mmHgPR : 80 bpmRR : 20 bpmT : 37,8oCUC : 2x/10’~25”FHB : 12-12-12 (148 bpm)VT : Ø 8 cm, eff 75%, amnion (+), head palpable ↓H I +, denominator unclear, impalpable small part / umbilical cord.
• Skin test Ampicillin (Inj. 2 gram Amicillin)
• Prepare to CS.
22.00 CS began
Amnion fluid: Meconeal
Baby was born. Male. 3000 g. AS 7-9. Anus (+). Congenital anomaly (-).
Placenta was born. Manually. Complete ± 300 gram.
Bleeding ± 300 cc
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
00.00
GC : wellBP : 130/80 mmHg PR : 88 bpm RR : 20 bpm T : 37oCUC : (+) wellUFH : 2 finger below umbilicusActive bleeding : (-)
2 hours post partum
• Observed mother and baby well being.
• Suggest mother to mobilisation.
15/10/2012
07.00
Delivery wound pain GC : wellBP : 110/80 mmHg PR : 88 bpm RR : 20 bpm T : 36,40CUFH : 3 finger below umbilicusUC : (+) wellLochea rubra : (+)
Baby rooming in :PR :144 bpmRR : 46 bpmT : 36,40C
One day post partum
• Observed mother and baby well being
• Suggest mother to mobilisation, eat, and drink, medication.
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