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

Case Report

IdentityName : Mrs. VAge : 17 years oldAddress : GanggaRM : 061060Hospitalization : October, 14th 2012

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14/10/2012

12.00

Patient referred from Gangga PHC with G1P0A0L0 41-42 weeks/S/L/IU l with severe preeclampsia and dyspnea. Patient confessed abdominal pain since 01.00 (14/10/2012). History rupture of membrane (-), bloody slim (-), FM (+).Nausea (-), vomiting(-), visual disturbance (-), epigastric pain (+), seizure (-). headache (+). Dyspnea since 5 days ago, intermittent.No history of DM, HT, asthma.

LMP : 26-01-12EDD : 02-11-12

History ANC : > 4x at PosyanduLast ANC : 03-10-2012Result : BP 120/90

USG : never Last USG : -

History of family planning :-Next family planning : IUD

Obstetric History :1.This

General StatusGC : wellGCS: E4V5M6BP : 160/120 mmHgPR : 110 bpmRR : 34 bpmT : 36,9oC

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

Obstetric StatusL1 : breechL2 : back on the left side L3 : head L4 : 4/5UFH : 28 cmEFW : 2635 gramUC : -FHB : 11-12-12 (140 bpm)VT : Ø (-)

G1P0A0L0 37-38 weeks /S/L/IU head

presentation with severe preeclampsia

and impending eclampsia + obs.

dyspnea

• Observe mother and fetal well being.• 02 2 lpm

• DM announce to SPV pro management with severe preeklampsia therapy (Bolus MgSO 4 40% 4 gr IV, Continue Drip MgSO 4 40% 6 gram 28 dpm, Nifedipin 3x1) and CS.• SPV acc. Prepare

CS at 20.00 wita.

• CIE patient and family.

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronologist at Gangga PHC (14/10/2012) :

10.00

S : Patient confessed abdominal pain since 01.00 wita, dyspnea since 5 days ago. FM (+). LMP : 26-01-12

O : GC : wellBP : 160/110 mmHg PR : 88 bpmRR : 32 bpmT : 36,7°C

UFH : 34 cm EFW: 3565 gUC :-FHR : 11-12-12 (140 bpm)VT : Ø (-)

Lab :Hb: 11,7 g/dl Proteinuria: +3

A :G1P0A0L0 41-42 mg S/L/IU with severe preeclampsia

and dyspnea.

P : (10.30 wita)• 02 2 lpm• Salbutamol 3x1• GG 3x1• Drip infus RL + MGSO4 20 % (6 gram) 28 dpm• Amoxicillin 3x500 mg• Set DC• Refer to NTB GH

Pelvic evaluation:Spina ischiadica not prominentOs coccygeus mobileArcus pubis >90

Lab :HB: 12,8 g/dlHct: 40,8%PLT: 377 x 103/µLWBC: 10,8 x 103/µLSGOT: 21SGPT:11Kreatinin: 0,6 mgl/dlUreum: 23 mgl/dlHBsAg : (-)Proteinuria: +3

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

13.00 Patient confessed headache, dyspnea (+)

GC: wellGCS: E4V5M6TD: 160/110 mmHgHR: 84 x/mntRR: 30 x/mntT: 36,4 C

UC: -FHB: 12-12-11 (140 x/min)UO: 50 cc/hour

- Observe mother and fetal well being.

14.00 Patient confessed headache, dyspnea (+)

GC: wellGCS: E4V5M6TD: 160/110 mmHgHR: 96 x/mntRR: 28 x/mntT: 36,4 C

UC: -FHB: 12-12-12 (144 x/min)UO: 50 cc/hour

- Observe mother and fetal well being.

- MgSO4 drip flash II

15.00 Patient confessed headache, dyspnea (+)

GC: wellGCS: E4V5M6TD: 160/120 mmHgHR: 94 x/mntRR: 32 x/mntT: 36,4 C

UC: -FHB: 12-12-11 (136 x/min)UO: 50 cc/hour

- Observe mother and fetal well being.

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

16.00 Patient confessed headache ↓, dyspnea (+) ↓

GC: wellGCS: E4V5M6TD: 170/110 mmHgHR: 84 x/mntRR: 26 x/mntT: 36,4 C

UC: -FHB: 12-12-11 (140 x/min)UO: 30 cc/hour

- Observe mother and fetal well being.

17.00 Patient confessed dyspnea (+) ↓ GC: wellGCS: E4V5M6TD: 160/110 mmHgHR: 962x/mntRR: 28 x/mntT: 36,4 C

UC: -FHB: 12-12-12 (144 x/min)UO: 30 cc/hour

- Observe mother and fetal well being.

18.00 - GC: wellGCS: E4V5M6TD: 160/110 mmHgHR: 88 x/mntRR: 26 x/mntT: 36,4 C

UC: -FHB: 12-12-11 (136 x/min)UO: 50 cc/hour

- Observe mother and fetal well being.

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

19.00 - GC: wellGCS: E4V5M6TD: 160/110 mmHgHR: 84 x/mntRR: 30 x/mntT: 36,4 C

UC: -FHB: 12-12-11 (140 x/min)UO: 50 cc/hour

- Observe mother and fetal well being.

- Prepare CS - skin tes ampi (-) Inj

ampi 2 g IV

19.50 GC: wellGCS: E4V5M6TD: 160/110 mmHgHR: 96 x/mntRR: 28 x/mntT: 36,4 C

UC: -FHB: 12-12-12 (144 x/min)UO: 30 cc/hour

-Take patient to operation room

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

21.00 CS beganBaby was born, male, BW : 2600 gram, BL: 49 cm, A-S : 7-9, anus (+), congenital anomaly (-), Placenta was born manually, complete,Bleeding : ±500 cc

CS finished

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23.00 Dyspnea (-) GC: well Cons: CMBP: 140/90 HR : 80 bpm RR : 20 tpm T : 36,0 CUFH : 1 finger below umbilicusUC : +

2 hours post CS • Observed mother and baby well being• Suggest mother to

mobilisation.

15/10/201207.00

Patient confessed delivery wound pain, dyspnea (-)

GC: well Cons: CMBP: 140/80HR : 88 bpm RR : 20 tpm T : 36,6 CUFH : 1 finger below umbilicusUC : +

Baby in NICUPR:140RR: 44T: 36,2

1 day post CS • Observed mother and baby well being• Suggest mother to

mobilisation, eat, and drink, medication.