SUPERVISOR:DR. EDY P.W, SPOG

DM:AKBAR, ARIQ, ASRI

Morning reportFebruary, 28th 2014

Name : Mrs. MAge : 28 yoAddress : SelagalasAdmitted : February, 27th 2014 at 10.39 pm

Name : Mrs. MAge : 28 yoAddress : SelagalasAdmitted : February, 27th 2014 at 10.39 pm

PATIEN IDENTITY

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

27/02/2014

10.39 pm

Patient came to GH NTB confessed abdominal pain since 08.00 pm (27/02/2014), water come out from her vagina (-), bloody slim (-), FM (+).

History of DM (-), HT (-), asthma (-).

LMP : 19-05-2013EDD: 26-02-2014

History of ANC: 14x at doctor, last: 25-02-2014, result: normal.

History of USG:4x, last: 25-02-2014

History of family planning: - Next family planning: IUD

Obstetrical history:

I.4 month, abortus, 1 year agoII.this

General status:GC: wellGCS: E4V5M6BP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 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 right sideL3: headL4: 4/5UFH: 31 cm EFW: 3100 gUC: 2x10’~25”FHB: 12-11-11(132 x/min)

G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor

• Obs mother & fetal well being

• Obs. progression of labor

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.

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

Lab. result:HB : 10,9 g/dl RBC : 3,77 M/dl WBC : 5,44 K/dlPLT : 162 K/dlHbSAg : (-)

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

28/02/2014

02.40 am

Abdominal pain UC : 2x10’ ~25”FHB : 12-12-12 (144 bpm)VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.

- -

06.40 am

Abdominal pain UC : 2x10’ ~20-25”FHB : 12-12-11 (140 bpm)VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.

G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor > 8 h

• Pro CTG

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

08.20am

Abdominal pain UC : 2x10’ ~25”FHB : 12-12-12 (144 bpm)

G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor > 8 h

•DM co to GP result of CTG is reactive, suggest acceleration by drip oxytocin, GP co to SPV result of CTG, advice drip oxytocin

•CIE to family about condition and next planning to drip oxytocin

08.30 am

- BP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 CUC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)

G2P0A1L0 40-41 weeks S/L/IU head presentation with laten phase of labor > 8 h

•Flash 1st Drip oxy began 8 dpm

09.00 am

- UC : 2x10’ ~15”FHB : 12-12-12 (144 bpm)

•Drip oxy 12 dpm

09.30 am

- UC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)

•Drip oxy 16 dpm

10.00 am

- UC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)

•Drip oxy 20 dpm

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

10.30 am

- UC : 2x10’ ~15”FHB : 12-12-13 (148 bpm)VT: Ø 2 cm, eff 25 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.

•Drip oxy 24 dpm

11.00 am

- UC : 2x10’ ~15”FHB : 12-12-12 (144 bpm)

•Drip oxy 28 dpm

11.30 am

- UC : 2x10’ ~15”FHB : 12-11-11 (136 bpm)

•Drip oxy 32 dpm

12.00 am

- UC : 2x10’ ~15”FHB : 12-12-11 (140 bpm)

•Drip oxy 36 dpm

12.30 pm

Abdominal pain UC : 2x10’ ~15”FHB : 13-12-12 (148 bpm)

•Drip oxy 40 dpm

01.00 pm

Abdominal pain UC : 2x10’ ~20”FHB : 12-12-12 (144 bpm)

•Drip oxy 40 dpm

01.30 pm

Abdominal pain UC : 2x10’ ~20”FHB : 12-12-12 (144 bpm)

•Drip oxy 40 dpm

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

02.00 pm

Abdominal pain UC : 2x10’ ~20”FHB : 12-12-12 (144 bpm)

•Drip oxy 40 dpm

02.30 pm

Abdominal pain increased BP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 C

UC : 3x10’ ~35”FHB : 12-12-11 (140 bpm)VT: Ø 4 cm, eff 50 %, amnion (+), head palpable H1, denominator unclear, impalpable small part and umbilical cord.

G2P0A1L0 40-41 weeks S/L/IU head presentation inpartu with active phase of labor

•Obs. Mother and fetal well being

•Suggest mother to eat and drink

•Obs. progress of labor with WHO partograf

•Flash 2nd Drip oxy 40 dpm

•Pro CTG

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

03.40 pm

Patient confessed water come out from her vagina

UC : 4x10’ ~45”FHB : 12-12-12 (144 bpm)VT: Ø 10 cm, eff 100 %, amnion (-), head palpable HII, denominator SS transverse, impalpable small part and umbilical cord.

G2P0A1L0 40-41 weeks S/L/IU head presentation wth second stage of labor

•Obs. Mother and fetal well being

•Suggest mother to eat and drink

•Suggest mother to squat down and lying down to the left.

04.30 pm

Abdominal pain increase, mother want to bearing down

UC : 4x10’ ~45”FHB : 12-12-12 (144 bpm)VT: Ø 10 cm, eff 100 %, Inspection’Bulging of perineum, opening vulva, anus presure

G2P0A1L0 40-41 weeks S/L/IU head presentation wth second stage of labor

•Conduct labor

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

04.40 pm

- - - Baby was born, male, 7-9, BW/BL = 2900/49

Placenta was born with MAK IIIWeight 500 grBleeding 100 cc

06.40pm

- Cons: wellGCS: CMBP: 100/70 mmHgPR: 82 bpmRR: 18 rpm T: 37,00 CUC: (+) goodUFH: 1 finger below umbiliccalBleeding -

2 hours post partum

•Obseation Mother and baby well being

•Suggest mother eat and drink and mobilitation

•Move patient to melati ward

04.30 pm

- Cons: wellGCS: CMBP: 110/70 mmHgPR: 84 bpmRR: 20 rpm T: 37,30 CUC: (+) goodUFH: 2 finger below umbiliccalBleeding –Baby rooming in is normal.HR : 148 bpmRR : 54 bpmTemp : 36,70C

1 day post partum

•Obseation Mother and baby well being

•Suggest mother eat and drink and mobilitation

•Suggest mother to breast feeding.

Thank you…