04-12-13 letak sugsang finish

8/12/2019 04-12-13 Letak Sugsang Finish

1/13

Morning Report4th December 2013

Supervisor : dr. Agus Thoriq, Sp.OG

Medical Students :

Erna, Alpi, Rangga, Rara, Putri


2/13

RESUME

PATOLOGY LABOR:

1. G4P3A0H2 A/S/L/IU breech presentation

with active phase of labor + history of ROM


3/13

Name : Mrs. R

RM : 528046

Age : 37 years old

Address : gunung Sari

Admitted : December 4th2013

Case Report


4/13

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

04/12

/2013

17.10

Patient referred from Gunung

Sari PHC with G4P3A0L2 A/S/L/IU

with active phase of labor &

breech presentation. Patient

confessed abdominal pain that

spread to frank since 09.00

(04/12/13). Bloody slim (-).

History rupture of membrane (+)

09.00 (04/12/13), FM (+).

No history of DM, HT, asthma.

LMP : forgot

EDD : (-)

History of ANC : 5x at Posyandu

Last ANC : 16/11/2013

History of USG : (-)

History of family planning : oral

KB

Next family planning : -

Obstetrical History :

1. Female, 9 month, spontan,

TBA, 15 years old, life.

2. Male, 9 month, spontan, TBA,

1,5 years old, death.

3. Male, 9 month, spontan, TBA,

11 years old, life.4. This

General Status :

GC : well

BP : 120/80 mmHg

PR : 90 bpm

RR : 22 bpm

Temp : 36,5oC

Eye : palor (-/-), icteric (-/-)

Cor : S1S2single regular,

murmur (-), gallop (-).

Pulmo : vesicular (+/+),

wheezing (-/-), ronkhi (-/-).

Abdomen : scar (-), striae (+),

linea nigra (+).Extremity : edema (-/-), warm

acral (+/+).

Obstetrical Status :

L1 : head

L2 : back on the right side

L3 : breech

L4 : WUFH : 30 cm

AC ; 96 CM

EFW : 2880 gram

UC : 2x10 ~ 35

FHB : 12-12-13 (148 bpm)

G4P3A0H2 A/S/L/IU

breech presentation

with active phase of

labor + history of

ROM

Observation

mother & fetal well

being.

Observation

progress of labor

with partograph

- Inj. Ampicilin 1gr/ 6

hour


5/13

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronologist at PHC Gn Sari

15:30

S : Patient confessed

abdominal pain that spread to

frank since 13.00 (4/12/13).

Meconium (+). FM (+).O :

GC : well

BP : 120/80 mmHg

PR : 84 bpm

RR : 24 bpm

T : 36,7oC

UFH : 30

AC : 96

L1 : head

L2 : back on the Right side

L3 : breech

L4 : (-)

EFW : 2880 gr

FHB : 11-11-11 (132 bpm)

UC : 2x/10~30VT : 4 cm, amnion (-), breech

palpable, H1, impalpable

fetal and umbilical cord.

A : G4P3A0L2 A/S/L/IU with

inpartu active phase breech

presentation

P : - explain examination result

- Co to GP adv Refer to NTB GH

VT : 5 cm, effacement 50 %, amnion (-

), breech palpable HI, impalpable

umbilical cord and small part

ZA score : 7

Multigravida (1) Gestation age : < 37 weeks (2)

History of breech presentation : 1x(1)

EFW : 3100 g (1)

5 cm (2)

Station :


6/13

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

18.00 Abdominal pain (+) GC : well

BP : 120/80 mmHg

PR : 88 bpm

RR : 20 bpm

T : 36,7oC

UC : 3x/10 ~ 35

FHB : 11-11-12 (136 bpm)

G4P3A0H2 A/S/L/IU

breech presentation

with active phase of

labor + history of

ROM

- Obs. mother and fetal well

being.

- Obs. progress of labor

19.50 Patient want to bearing

down

Breech seen in vulva 2ndstage of labor Conduct labor with spontan

bracht

19.55 2ndstage of labor Manual aidlouvset &

mauriceau

Baby was born (20.05) :

Male, 3300 gram, BL 50 cm,

AS 3-5

Amnion fluid: clear

Anus (+). Congenital anomaly(-)

Placenta was born spontan,

complete, 300 gram.


7/13

Ny. R

4/ 12 / 2013

23 yo 4 3 0

09.00 (04 / 12/ 2013)09.00 (04 / 12/ 2013)


8/13

X

17.10 18.10 19.10


9/13

36,5 36,7


10/13

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

22.00 GC : well

BP : 110/70 mmHg

PR : 96 bpmRR : 20 bpm

T : 36,5oC

UFH : 2 finger below umbilicus

UC : (+) well

Lochea rubra : (+)

2 hours post partum Observe mother well being

Suggest mother to take a rest,

eat, and drink.

07.00 - GC : well

BP : 110/80 mmHg

PR : 84 bpm

RR : 20 bpm

T : 36,4oC

UFH : 2 finger below umbilicus

UC : (+) well

Baby in NICU :O22 lpm

PR : 108 bpm

RR : 66 bpm

T : 34,3C

One day post partum Observed mother & baby well

being.

Suggest mother to eat & drink,

mobilisation, medication.


11/13


12/13


13/13

04-12-13 letak sugsang finish

Documents