MORNING REPORTMay 5th 2012

Supervisor : dr. A. Rushdy A.H., Sp.OG

Medical Student:

Fahmi, Ira, Nana, Nisia, Hasaniah, Heri, Rani, Fadil, Wiwid

Cases Resume

Normal Labor -

Patologyc 1

G2P1A0L1, 37 – 38 weeks, A/S/L/IU with Prolong 2nd stage of Labor

G2P1A0L1, 37 – 38 weeks, A/S/L/IU with prolong 2nd stage of labor

Patologic Case

Identity

• NAME : Mrs. S• Age :31 yo• Admitted: May 5th 2012, 22.30 WITA• Address : Gangga – KLU

S O A P04/05/201222.30(VK IRD)

Patient referred from Gangga PHC, with G2P1A0H1, A/S/L/IU with prolong 2nd stage of labor. Patient confessed abdominal pain, since 11.00 (4/5/12). History of rupture membrane (+) since 11.00 (04/05/2012). History of HT (-), DM (-), asma (-).

LMP : 20 – 8 - 2011EDD : 27 – 5 – 2012History of ANC : > 4x in midwifeLast ANC : 17 – 4 - 2012History of family planning : pil about 1 yearNext familly planning : implantUSG : (-)

Obstetrical History :1. 9 month/female/2.500grams/

midwife/RSUD KLU/life2. This

General Status :GC : wellBP : 120/80 mmHgPR : 98x/mntRR : 24x/mntT : 37.3°C Eyes : an (-/-), icterus (-/-)Pulmo : ves (+/+), Rh(-/-), Wh(-/-). Cor : S1S2 single/reguler, M(-/-), G(-/-).Abdomen : scar (-), striae (+), linea nigra (+)Extremity : edema (-/-//-/-), warm acral (+/+//+/+).

Obstetrical status :L1 : breechL2 : back on the left sideL3 : headL4 : 3/5UFH : 32 cmEFW : 3.255 gramsUC : 3 x 10’ – 40”FHB : 12-12-12 (144x/mnt)

G2P1A0H1 36-37 weeks with prolong 2nd stage of labor

Intrauterine resusitation

Inj. Ampicillin (in PHC)

Laboratory check (DL, HBsAg)

Co. to GP, advice :

S O A P

Chronologist :Patient came to PHC confessed amenorea for 9 month and confessed abdominal pain since 4/5/2012 (11.00), history of rupture membran (+) on 4/5/2012 (11.00). Bloody slim (+).BP : 120/80 mmHgPR : 88x/mntRR : 20x/mntT : 36.5°UFH : 30 cmL1 : breechL2 : back on the left sideL3 : headL4 : 3/5UFH : 32 cmEFW : 3.255 gramsUC : 3 x 10’ – <40”FHB : 136/mnt

VT : Ø completed, amnion (-) clear, head palpable, ↓HII+, caput (+), unpalpable small part of fetal and umbilical cord

S O A P

15.00VT : Ø 7 cm, eff 75% amnion (-) , head palpable, ↓HII, unpalpable small part of fetal and umbilical cord

17.00RL ( flash I) gerojokInj. Ampicillin 1 gr/IV17.15 RL (flash II)

18.00UC : 3 x 10’ – <40”FHB : 134x/m4ntVT : Ø completed, eff 100% amnion (-) , head palpable, ↓HIII, caput (+), unpalpable small part of fetal and umbilical cordReferred to RSUP NTB

S O A P

20.00 Lab:HB: 9,1RBC : 3,90HCT: 27,3WBC: 15,98PLT: 307Protein urine (+++)

PEB + Susp. CPD - CTG : tacicardy

21.30 - Co to SPV, advice : treat as PEB, pro CS.

22.00 - Drip MgSO4 1st flash, 28 tpm

- Further observation