Morning Report May 28th 2014

Morning ReportMay 31th 2014Supervisor : dr. Agus Thoriq Sp,OGDM:Dandi, Ardi, Yos, Ryan, VendiName: Mrs. SAge: 18 thAddress: Batu layarAdmitted : 30th May 2014RM : 11 16 36Time SubjectiveObjectiveAssessmentPlanning30/5/1411.30Patient come from polyclinic with G1P0A0L0 40-41 weeks S/L/IU head presentation laten phase 1st stage of laborPatient conffessed abdominal pain since 02.00 wita (30/05/14), water leaked out (-), Bloody slime (-), FM (+)History :DM : (-)HT : (-)Asthma : (-)

Family history :DM : (-)HT (-)

LMP : 20/08/13EDD : 27/05/14ANC history : X at PHC Last ANC : BP :BW :UK :UFH :Presentation : USG History : -

General statusGC : wellGCS : CMBP : 110/70 mmHgPR : 80 bpm RR :20 tpmT : 36,4 C

Eye : anemis (-), ikterus (-)Cor : S1S2 single regular, murmur (-), gallop (-)Pulmo : vesicular, rhonki (-), Wheezing (-)Abdomen : scar (-), Striae Gravidarum (+), linea nigra (+)Extremity :Upper : oedem (-/-)Lower : oedem (-/-)

Obstetrical StatusL1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 36cmEFW : 3875 grUC : 2x 10- 20FHR : 12-11-12 G1P0A0L040-41 weeksS/L/IULaten phase 1st stage of laborObs mother and fetal well being

Suggest mother to eat and drink

DM co to GP adv: obs proggres of labor

Time SubjectiveObjectiveAssessmentPlanningFamiliy planning history : (-)Next family planning : injection 3 months

Obstetrical history :I. this

Chronologist at meninting PHC(30/05/14)(09.30) WITAS/Patient conffessed abdominal pain since 02.00 wita (29/05/14), water leaked out (-), bloody slime (-), FM (+)O/GC : wellGCS : CMBP : 110/70 mmHgPR : 80 bpmRR : 36,5 tpmT : 20 CUFH : 35 cmL1 : breechL2 : back on the right and left sideL3 : headL4 : 3/5UC : 2x10-25FHR : 11-12-11 VT : : 2cmEff : 50%Presentation : headHodge : 1Denominator : unclear

Pelvic Examination :Sacrum convexity normalSpina ischiadica not prominentOs coccygeus mobileArcus pubis > 90

Lab result :HB : 9,6HCT : 30,1WBC : 16,78PLT : 401HbsAg :-Time SubjectiveObjectiveAssessmentPlanningVT : -A/G1P0A0L0 40-41 weeks S/L/IU head presentation laten phase 1st stage of labor + susp gemeli

P/Reffered to NTB GH

15.30

-UC : 2x 10- 25FHR : 12-13-12VT : : 3cm, Eff : 50%, Amnion +, head presentation, Hodge : 1, Denominator : unclear, smal part of fetal and umbilical cord not palpableLaten phase 1st stage of labor

-Obs mother and fetal well being

-DM co lab result for WBC 16,78 to GP pro inj ampicillin, GP adv : inj ampicillin

- Skin test (- ), inj. Ampi 1gr19.30UC : 2x 10- 30FHR : 154 tpmVT : : 3cm, Eff : 50%, Amnion +, head presentation, Hodge : 1, Denominator : unclear, small part of fetal and umbilical cord not palpable

Laten phase 1st stage of labor > 8 hours

Obs mother and fetal well being

DM co to GP, GP co to SPV, SPV advise accelleration

CIE family: acc accellerationTime SubjectiveObjectiveAssessmentPlanning20.30Do CTG, CTG reactive, Drip oxy 5 IU

21.00-HIS : 2x 10- 30FHR : 11-12-11Drip oxy begin flash I, 8 dpm 21.30-HIS : 3x10-35FHR :11-11-11Drip oxy 12 dpm22.00-HIS : 3X10-35FHR :12-12-12Drip oxy 16 dpm22.30-HIS : 3X10-40FHR : 11-12-11Drip oxy 20 dpm23.00-HIS : 4X10-45FHR :11-12-12VT : : 5cm, Eff : 75%, Amnion -, head presentation, Hodge : 1, smal part of fetal and umbilical cord not palpableActive phase 1st stage of labor + drip oxyDrip oxy 24 dpm

obs mother and fetal well being

Obs. Progress of labor, evaluation 4 hours again

Maintenance 24 dpm

Time SubjectiveObjectiveAssessmentPlanning23.30-HIS : 4x 10- 40FHR : 11-12-11Drip oxy 24 dpm00.00-HIS : 4x10-45FHR :11-11-11Drip oxy 24 dpm(31-5-2014)00.30-HIS : 4X10-45FHR :12-12-12Drip oxy 24 dpm01.00-HIS : 4X10-50FHR : 11-12-11Drip oxy 24 dpm01.30-HIS : 4X10-50FHR :11-12-13Drip oxy 24 dpm02.00Mother want to bearing downHIS : 4X10-50FHR :11-12-12VT : : 10cm, head presentation, Hodge : II

2nd stage of laborobs mother and fetal well being

Squad position03.00HIS : 4X10-50FHR : 12-13-12VT : : 10cm , head presentation, Hodge : II , molage (+3)

Arrested 2nd stage of labor + suspect CPD obs mother and fetal well being

Do CTG DM co to GP, result CTG and pro SC,CTG reactive, GP co to SPV, SPV adv: prepare SC Time SubjectiveObjectiveAssessmentPlanning04.0005.00SC began Baby was born, male, A-S : 3-5, BW 4100 gr, BL 51 cm, UAC 13cm, HC 36cm, Anus (+), Congenital Anomaly (-).Recusitation baby.Co to NICUActive management 3rd stage of labor.

Placenta was born complete, 500 g, bleeding 150 cc.Perineum rupture grade II, do hecting of perineum.

Time SubjectiveObjectiveAssessmentPlanningDizzy (-), nausea (-), vomit (-) GC : WellGCS : E4V5M6BP : 110/70 mmHgPR : 88 x/mRR : 22x/mTemp : 36,5 C

UC : (+) wellUFH : 1 finger bellow umbilicusLocea rubra : (+)UO: 120cc/hours

BABY in NICUHR : 148 bpmRR : 51 bpmTemp : 36,70C

2 hours post SCObservation general status , vital sign

CIE patient for eat and drink