MORNING REPORTJuly 23th 2014

Supervisor : dr. Agus Thoriq, Sp.OG

DM :

Sakti, Ita,Nurul, Era, Jatna

CASE RESUME

Case Resume :

No. Case Total

Pathology Delivery 1

1. G2P1A0L1 A/S/L/IU head presentation with prolonged 2nd stage of labor

Case ReportName : Mrs. H

Age : 23 yo

Address : Gn. Sari

Admitted : 22th July 2014

RM : 54 29 06

G2P1A0L1 A/S/L/IU head presentation with prolonged 2nd stage of labor

Time Subject Object Assessment Planning

23/07/ 2014

History of family planning: injection 3 month Next family planning: injection 3 month

Obstetric History:1.Aterm, Female, 2200 g,doctor, NTB GH, 5 yo, life2.This

VT : Ø 8 cm, effacement 75%, amnion (+), head palpable, denom unclear, H II, unpalpable small part of fetus/ umbilikal cord

Lab:HGB = 9,2 g/dlRBC = 4.23 K/ulHCT = 29,2 K/ulWBC = 19,06 M/ulPLT = 311 M/ulHBsAg = (-)

Time Subject Object Assessment Planning

Chronologist at PHC:22/07/14 (10.00 WITA)S: patient come to Gunung sari PHC

confessed abdominal pain and bloody slim (+) since 04.00 WITA (22/07/2014). Water leaked out from her womb (-) bloody slim (+) FM (+).

O: GC : wellBP : 120/80 mmHgPR: 80 bpmRR: 20 bpmT: 36,5°C

VT : Ø Complete, eff 100%, amnion (+), head palpable denom LOA, HI +, unpalpable small part of fetus/umbilical cord

A: G2P1A0L1 A/S/L/IU head presentation with 2nd stage of labor

P:- Observation of labor - Suggest mother to eat and drink- Obs mother and fetal well being

Time Subject Object Assessment Planning

11.00 WITAS/ abdominal pain ↑↑O/ GC : wellBP : 120/80 mmHgHR: 80 bpmRR: 20 bpmT : 36,50C

VT : Ø complete, eff 100%, amnion (+), head palpable denom LOA, HI +, unpalpable small part of fetus/umbilical cord

A: G2P1A0L1 A/S/L/IU head presentation with prolonged 2nd stage of labor.

P:- Obs mother and fetal well being- Suggest mother to eat and drink- Co to GP, Advice Reffered to NTB GH and rehydrasi

Time Subject Object Assessment Planning

22-07-1413.10 WITA

Abdominal pain ↑↑, Water leaked out from her womb (+)

General statusGC : wellGCS: CM (E4V5M6)BP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36,6°CUC : 3x10’ – 40”FHB : 12-12-12 (144 bpm)

VT : Ø 9 cm, eff 100%, amnion (-) clear, head palpable denom unclear, HI +, unpalpable small part of fetus/umbilical cord

Prolonged active phase

• Observation mother and fetal well being

• Suggest mother to eat and drink

13.30 WITA

UC : 3x10’ – 45”FHB : 12-13-12 (148 bpm)

14.00 Wita

UC : 3x10’ – 45”FHB : 12-11-12 (140 bpm)VT : Ø 9 cm, eff 100%, amnion (-) clear, head palpable denom unclear, HI +, unpalpable small part of fetus/umbilical cord

Arrested active phase

• DM Co to GP,GP advice rehydration

• Observation mother and fetal well being

Time Subject Object Assessment Planning

14.30 UC : 4x10’ – 40”FHB : 12-11-12 (140 bpm)

15.00 UC : 4x10’ – 40”FHB : 12-11-12 (140 bpm)

15.30 WITA

• GP co to SPV, SPV can’t reach

16.00 WITA

UC : 4x10’ – 40”FHB : 12-11-12 (140 bpm)VT : Ø complete, eff 100%, amnion (-) clear, head palpable denom unclear, HI +, unpalpable small part of fetus/umbilical cord

2nd stage • Observation mother and fetal well being

• Suggest mother to eatand drink

• Observation progress of labor

17.00 Wita

UC : 4x10’ – 40”FHB : 12-11-12 (140 bpm)

VT : Ø complete, eff 100%, amnion (-) clear, head palpable denom unclear, HI +, unpalpable small part of fetus/umbilical cord

Prolonged 2nd stage of labor

• DM co to GP pro CS, GP co to SPV, SPV advice : acc VE

• CIE family about planning VE

Time Subject Object Assessment Planning

18.40 WITA

• VE began20.05 wita- Baby was born , female, BW : 3250 g, BL : 52 cm, AS :7-9, anus (+), congenital anomaly (-)

- Placenta was born, completetly, weight : 500 g

Bleeding : + 150 ccRuptur Perineum gr. II heacting

20.40 WITA

GC : wellBP : 110/80 mmHgPR: 88 bpmRR: 20 bpmT : 36,50CUC: (+) wellUFH : 2 finger bellow umbilical Active bleeding: (-)

Baby in NICU•General condition : well•FHR : 146 bpm•RR : 42x/minute•T : 36,2 0C

2 hours post VE • Observation mother and baby well being

• Suggest mother to eat and drink

• Suggest mother to mobilitation

• CIE ASI Eksclusif

Time Subject Object Assessment Planning

23-07-201407.00

- • GC: well cons:E4V5M6• BP: 110/90 mmHg • PR: 88x/minute,• RR: 20x/minute, • T: 36,6 0C• UC: (+) well• UFH: 2 fingers below umbilicus

• Active bleeding: (-)

Baby in Melati rooms• General condition : well

1 day post VE Observation mother and baby well being