mr 13agustus13 - kpd preterm drip mr

8/10/2019 MR 13Agustus13 - KPD Preterm Drip mr

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MORNING REPORT

August 13th 2013

Supervisor : dr. Dody Aryo Kumboyo, Sp.OG

DM :

Ika, Dyan, Linda, Dian

Case Resumes

Normal labor: 1

Pathologic labor: 1



Case Report

Mrs. S, 19 years old, from Ampenan,

Hospitalization on 15.22, 12/08/2013.

G2P0A1H0 33-34 wk S/L/IU head presentation with PROM > 12 hours.



Time Subject Object Assessment Planning

12/08/13

15.30

WITA

Patient reffered from Tanjung

Karang PHC with G2P0A1L0 36

weeks S/L/IU head presentation,

with PROM. Patient confessed

abdominal pain since 03.00

(11/08/20132). History rupture of

membrane (+ ) since 11.30(11/82013) clear, Bloody slim (-) ,

FM (+). History of DM (-), HT (-),

asthma (+).

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

), asthma (-)

LMP : 24-12-2012

EDD : 1- 10-2013

History ANC : 3x PHCHistory of USG : +, 13/8/2013

Fetus S/L/IU head presentation

BPD : 31W 2D

AC : 30W 6D

FL : 32W 6D

EFW : 1600 g

EDD : 10 – 10- 2013

Placenta at fundus, amnion fluid less

History of family planning: -

Next family planning: -

Obstetric History:

1. Abortion

2. This

General status

GC : well

GCS: E4V5M6

BP : 110/70 mmHg

PR: 82 tpm

RR: 20 tpm

T: 36,3°C

Local status

Eye : an (-/-), ict (-/-)

Pulmo: ves (+/+), rh (-/-), wh (-/-)

Cor /S1S2 single reg. M(-), G(-)

Abd : striae gravidarum (+), linea

nigra (+), scar (-)

Ext : edema (-/-), warm (+/+)

Obstetric statusL1 : breech UFH: 28 cm

L2 : back on the right side

L3 : head

L4 : 4/5

UC : -

FHB : 12.12.12 (144bpm)

EFW :2635 gram

VT : CD 1 cm, eff 10%, amnion

(+), head presentation, denom

unclear, H I, small part of fetus

or umbilical cord unpalpabled.

PE:

Promontorium unpalpable

Spina ischiadica not prominent

Os coccygeous mobile

Pubic arch > 90’

G2P0A1L0 33-34

weeks S/L/IU head

presentation with

PROM > 12 hours

-Obs. Mother and fetal

well being.

- Ceck CBC and HBsAg

- DM co. to GP, advice :

pro CTG

- GP co. CTG result to

SPV, advice:- Obs. and move to VK

Teratai.

-Inj. Dexamethason 1

ampul/ 6 hours

-Inj. Ampicillin 1 g/24 h

-Pro USG




Cronologist :

10.19 (11/8/2013) at PHC

Patient came to Tanjung Karang

PHC confessed abdominal pain since

03.00 (11/8/2013), history of water

leakage 9-), bloody slim (-), FM (+).

General status : well

BP : 100/80 mm Hg

P :84 x/m

RR :20 xm

Temp : 36,7C

UFH : 27 cm , palpable breech on

fundus, back on right side, head on

pelvic inlet 4/5 part.

EFW : 2480 gUC: 1x 10’ 20“

FHB : 12-11-11 (136 bpm)

VT : CD icm, eff 25%, amnion (+),

head presentation, denom unclear,

H I, small part of fetus or umbilical

cord unpalpabled.

A : G1P0A0L0 36 weeks S/L/IU

head presentation, mother and fetal

are well being, inpartu observation.

11.30

Ruptur of amnion membran

spontaniously, clear, 100 cc.

VT : CD icm, eff 25%, amnion (+),



cord unpalpabled.T : Skin test (-),

Lab:

Hgb : 9,9

Rbc : 3,77

Hct : 29,1

Wbc : 16,47

Plt : 394

HBsAg : -




11.45

Inj. Vicillin 1 g/IV/6 hours

FHB : 146 bpm

UC : 1x 10’ 25”

15.30

UC : 3x10’ 30” FHB : 12-11-12 (140 bpm)

VT : CD 1 cm, eff 25%, amnion (-),



cord unpalpabled.

17.45

Inj. Vicillin 1 g/IV/ 6 hours

19.30

UC : : 3x10’ 30”

FHB : 12-12-12 (144 bpm)

VT : : CD icm, eff 25%, amnion (-),



cord unpalpabled.

23.30

UC : seldom

FHB : 11-12-12 (144 bpm)


03.30 (12/8/2013)

UC : seldom

FHB : 11-12-12 (140 bpm)




13/08/

2013

08.00

05.45


07.30

FHB : 11-12-11 (136 bpm)

UC : seldom

11.30

FHB : 11-11-12

UC : +

14.00

FHB : 12-11-11

UC : -

BP : 110/70 mmHg

P : 80 x/mTax : 37C

Co. dr. advice : Reffered to RSM


GCS : E4V5M6

BP : 110/70 mmHg

P : 84 x/m

RR : 22x/m

Temp : 36,9C

UC : -

FHB : 12-12-11 (140 bpm)

USG Result :

Fetus S/L/IU head presentation

BPD : 31W 2D

AC : 30W 6DFL : 32W 6D

EFW : 1600 g

G2P0A1L0 33-34

weeks S/L/IU head

presentation with

PROM > 12 hours

- SPV advice :

Termination with

oxytocin drip.

-CIE patient and family


well being

- Suggest mother to drink

and eat




20.00

13/08/

2013

06.00

-

-


BP : 120/80 mmHg

P : 86x/m

RR: 20 x/m

Temp: 36,8C

UC : -

FHB : 12-12-13

BP : 110/70 mmHg

P : 80x/m

RR: 20 x/m

Temp: 36,5C

UC : -

FHB : 12-12-12”

G2P0A1L0 33-34

weeks S/L/IU head

presentation with

PROM > 12 hours


well being

-Inj. Dexamethasone

1ampul/6 hours

-Suggest mother to eat

and drink

-Pro USG




09.45

10.15

10.45

11.15

11.45

12.15

12.45

13.15

13.45

14.15

14.45

-

-

-

-

-

-

-

-

-

Abdominal pain increase

-

UC : -

FHB : 12-11-12

UC : 1 x 10’ 10”

FHB : 13-13-12

UC : -FHB : 13-13-12

UC : -

FHB : 13-12-13

UC : -

FHB : 12-12-12

UC : 1 x 10’ 20” FHB : 13-12-13

UC : 1 x 10’ 20”

FHB : 12-13-12

UC : 1 x 10’ 20”

FHB : 12-13-12

UC : 2 x 10’ 20”

FHB : 12-11-12

UC : 2 x 10’ 25”

FHB : 12-13-12

UC : 2 x 10’ 25”

FHB : 12-12-12

-Drip Oxytocin 8 dpm

first flash














15.15

15.45

16.00

16.15

16.45

16.50

-

-

Abdominal pain increase and morefrequently

-

Mother wants to bearing down

UC : 3 x 10’ 30”

FHB : 11-12-12

UC : 3x 10’ 35”

FHB : 11-11-12

General status : wellBP : 100/70 mmHg

RR : 20 x/m

P : 82 x/m

Temp : 36, 6C

UC : 43x 10’ 35”

FHB : 13-12-12 (148 bpm)

VT : CD 6 cm, eff 75%, amnion

(-), head presentation, fontanela

minor anterior, H II, small partof fetus or umbilical cord

unpalpable.

UC : 4 x 10’ 40”

FHB : 11-12-12


FHB : 12-12-12 (144 bpm)

UC : UC : 4 x 10’ 40”-45”

Doran, teknus, perjol, vulka

G2P0A1L0 33-34weeks S/L/IU head

presentation with 1st

stage of labor active

phase with history of

water leakage

G2P0A1L0 33-34

weeks S/L/IU head

presentation with 2nd

stage of labor



-Obs. Progress of labor-Obs. Mother and fetal

well being

-Suggest mother to drink

and eat

- Suggest mother lie

down to left

-Drip Oxcytocin 40 dpm

second flash

-Conduct mother to

delivery the baby

-Baby was born, spt.B,

female, A-S:7-9,

bw:1900 g, bl : 49 cm,

anus (+), anomaly

congenital (-), the baby

room in NICU




17.00

18.50

07.00

-

-

-

-

General status: wellGCS:E4V5M6

BP: 110/70 mmHg

P: 80 x/m

RR: 20 x/m

Tax: 36,4C

UC: +,

UFH: 2 finger below umbilicus


GCS : E4V5M6

BP : 110/80 mmHg

P : 82x/m

RR : 20 x/m

Tax : 36,7C

UC : +

UFH : 2 finger below umbilicus

Lochea rubra : +

3rd stage of labor

P1A1L1 2 hours post partum

1 day post partum

-Placenta was born

spontaniously,

completetly, weight:500 g

bleeding : 150 cc

-Obs. mother condition-Obs. bleeding

- Suggest mother to eat

and drink

- Obs.mother condition

-Mobilitation

-Suggest mother to eat

and drink.

mr 13agustus13 - kpd preterm drip mr

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