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    Morning Report: Supervised By: Dr. Edi P.W. Spog

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    Arja' Waas
    1) A morning report from Dr. Edi P.W. SpOG summarized 3 patient cases including a neglected first stage of labor, 42 week pregnancy with oligohidramnion, and a normal labor case. 2) A second patient case involved a 21 year old G1P0A0 woman at 42-43 weeks gestation with head presentation and oligohidramnion who was induced with oxytocin but developed fetal distress. 3) A third case was a 20 year old G1P0A0 woman in neglected active first stage labor who was accelerated with oxytocin and gave birth vaginally to a female infant.

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    Morning Report: Supervised By: Dr. Edi P.W. Spog

    Uploaded by

    Arja' Waas
    30 views10 pages
    1) A morning report from Dr. Edi P.W. SpOG summarized 3 patient cases including a neglected first stage of labor, 42 week pregnancy with oligohidramnion, and a normal labor case. 2) A second patient case involved a 21 year old G1P0A0 woman at 42-43 weeks gestation with head presentation and oligohidramnion who was induced with oxytocin but developed fetal distress. 3) A third case was a 20 year old G1P0A0 woman in neglected active first stage labor who was accelerated with oxytocin and gave birth vaginally to a female infant.

    Original Description:

    18-11-09

    Original Title

    18-11-09

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    1) A morning report from Dr. Edi P.W. SpOG summarized 3 patient cases including a neglected first stage of labor, 42 week pregnancy with oligohidramnion, and a normal labor case. 2) A second patient case involved a 21 year old G1P0A0 woman at 42-43 weeks gestation with head presentation and oligohidramnion who was induced with oxytocin but developed fetal distress. 3) A third case was a 20 year old G1P0A0 woman in neglected active first stage labor who was accelerated with oxytocin and gave birth vaginally to a female infant.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    30 views10 pages

    Morning Report: Supervised By: Dr. Edi P.W. Spog

    Uploaded by

    Arja' Waas
    1) A morning report from Dr. Edi P.W. SpOG summarized 3 patient cases including a neglected first stage of labor, 42 week pregnancy with oligohidramnion, and a normal labor case. 2) A second patient case involved a 21 year old G1P0A0 woman at 42-43 weeks gestation with head presentation and oligohidramnion who was induced with oxytocin but developed fetal distress. 3) A third case was a 20 year old G1P0A0 woman in neglected active first stage labor who was accelerated with oxytocin and gave birth vaginally to a female infant.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 10

    Morning Report

    Nov, 17th 2009

    Supervised by : dr. Edi P.W. SpOG


    Medical Student:
    Syarif
    Winda
    Helmiati
    Halia
    Cases
    resume :

    G1P0A0L0 A/S/L/IU head presentation


    neglected active phase first stage of labor

    G1P0A0L0 42 week/S/L/IU head presentation with


    oligohidramnion

    Normal labor

    with

    Admitted
    to
    Hospital

    Name/adress

    : Mrs. S / Sesaot

    Age

    20 years old

    Address
    Time

    Narmada
    Subject

    Object

    Patient came to Mataram GH


    referred by Sedau PHC with
    G1P0A0L0
    A/S/L/IU
    head
    presentation with neglected active
    phase first stage of labor
    Chronologist :
    Patient came to Sedau PHC at 07.00
    (17/11/09) refered by polindes
    confess abdominal pain since 06.00,
    AM (+) ,fetal movement (+), history of
    hipertension (-), and history of DM (-).
    LMP : forgot
    ANC : 6x at PHC, last 15 nov 2009
    Examination at PHC :
    BP: 120/80 mmHg
    PR: 84 bpm
    RR: 16 bpm
    T: 36 C
    VT : CD 4 cm, AM (+), head palpable,
    descend HI.

    Examinaton at ER :
    BP :120/80 mmHg
    PR : 84 bpm
    RR : 20 tpm
    Temp : 36,3 C
    An -/-, ict -/Cor & pulmo : in normal range
    Abd : normal range
    Ext : oedema -/Obstetric status :
    L1 : breech
    L2 : fetal back on the right side
    L3 : head
    L4 : was in pelvic inlet 4/5
    UFH :30 cm
    EFW : 2945 g
    FHR :136 bpm
    UC :2x10-25
    VT :CD 4 cm, eff 40%, AM (+),
    head palpable, descend HI+,
    denominator fontanella minor
    anterior, small part of fetal and
    umbilical cord unpalpable

    22.20

    Th/: infus RL

    Lab. Examination :
    Hb : 11,7 gr%
    Leko : 16.200 mm3
    Trombo : 224.000 mm3
    Hct : 37,3
    HBsAg : -

    17 Nov 2009

    22.20 wita
    Assesment

    Planning

    G1P0A0L0
    A/S/L/IU head
    presentation with
    neglected active
    phase first stage
    of labor

    Obs. Mother and fetal


    wellbeing
    Report to supervisor:
    Propose: acseleration with
    oxcytocin drip
    CTG
    Advice: acseleration agree

    Time

    Subject

    Object
    Pelvic evaluation:
    Os coccygeus mobile
    Archus pubis >90
    Spina ischiadica not prominent

    0%

    Examinaton at VK :
    General condition: good
    BP :120/80 mmHg
    PR : 80 bpm
    RR : 20 tpm
    Temp : 36 C
    An -/-, ict -/Cor & pulmo : in normal range
    Abd : normal range
    Ext : oedema -/Obstetric status :
    L1 : breech
    L2 : fetal back on the right side
    L3 : head
    L4 : was in pelvic inlet 4/5
    UFH :30 cm
    EFW : 2945 g
    FHR :136 bpm
    UC :2x10-25
    CTG baseline : 145 bpm
    Obstetric status:
    1.This
    Contraception history : inject 3
    month
    Contraception planing : inject 3
    month

    Assesment

    Planning

    Time

    Subject

    Object

    Assesment

    Planning

    G1P0A0L0 A/S/L/IU head


    presentation with neglected
    active phase first stage of
    labor

    Aceleration with
    oxytocin 5 IU in D5%
    500 cc start at 8 dpm
    Observed UC and
    FHR 30 minutes again

    23.30

    Abdominal pain >

    UC: 2x10~25
    DJJ : 11 12 11 bpm

    24.00

    Abdominal pain >>

    UC: 3x10~30
    DJJ : 11 12 11 bpm

    Observed UC and
    FHR 30 minutes again

    00.30

    Abdominal pain >>

    UC: 3x10~30
    DJJ : 11 12 12 bpm

    Observed UC and
    FHR 30 minutes again

    01.00

    Abdominal pain >>

    UC: 3x10~30
    DJJ : 12 12 11 bpm

    Observed UC and
    FHR 30 minutes again

    01.30

    Abdominal pain >>

    UC: 3x10~35
    DJJ : 12 11 11 bpm

    Observed UC and
    FHR 30 minutes again

    01.50

    Watery vaginal discharge

    UC:3x10/40
    FHR:11-12-11 bpm
    VT :CD complete, AM (-),
    green thin, head palpable,
    descend HIII, denominator
    fontanella minor anterior,
    small part of fetal and
    umbilical cord unpalpable

    02.00

    Abdominal pain>>>,
    want to bear down

    FHR: 13-12-12
    Doran teknus perjol vulka

    02.20

    mother

    G1P0A0L0 A/S/L/IU head


    presentation second stage of
    labor

    Educate to prepare for


    delivery of baby

    Conduct mother to
    bear down
    Stage 2 of labor

    Stage 3 of labor

    Baby was born female,


    2600 gram, A-S 6-8
    Amniotic fluid green
    thin
    Rupture Perineum
    grade 2
    Placenta was born 5
    minutes later

    Time

    Subject

    Object

    04.20

    BP :110/70 mmHg
    PR : 88 x/
    RR : 16x/
    Temp : 36,9C
    UC : good
    FUH: 2 finger below umbilicus
    Active vaginal bleeding (-)

    07.00

    BP :110/60 mmHg
    PR : 76 x/
    RR : 16x/
    Temp : 36,5C
    UC : good
    FUH: 2 finger below umbilicus
    Active vaginal bleeding (-)
    Baby :
    RR : 36 tpm
    HR: 120 bpm
    T:36,5C

    Assesment
    2 hours post partum

    Planning
    Referred mother
    and baby to melati
    room

    Admitted
    to
    Hospital

    Name/adress

    : Mrs. F/Gunung Sari

    Age

    21 years old

    Address
    Time

    Narmada
    Subject

    Object

    Patient reffered by Gunung Sari PHC


    with G1P0A0 42-43 w/S/L/IU head
    presentation. Patient came to out patien
    care Mataram GH confess pregnant
    more than 9 month. Fetal movement (+),
    history of hipertention (-), DM (-).
    Examination in PHC:
    General condition: good
    BP :110/80 mmHg
    PR : 80bpm
    LMP:25/1/09
    EDD: 2/11/09
    UFH: 35 cm
    Examination in OPC
    BP :130/80 mmHg
    PR : 84bpm
    RR : 16 tpm
    Temp : 36,5 C
    An -/-, ict -/Ext : oedema -/LMP:25/1/09
    EDD: 2/11/09
    ANC 7 x, last 16 nov 2009.
    Obstetric status :
    L1 : breech
    L2 : fetal back on the right side
    L3 : head
    L4 : was in pelvic inlet 4/5

    Examinaton at VK :
    BP :110/80 mmHg
    PR : 84 bpm
    RR : 16 tpm
    Temp : 37 C
    An -/-, ict -/Cor & pulmo : in normal range
    Abd : normal range
    Ext : oedema -/Obstetric status :
    L1 : breech
    L2 : fetal back on the left side
    L3 : head
    L4 : was in pelvic inlet 4/5
    UFH :33 cm
    EFW : 3410 gr
    FHR :12-13-12 bpm
    UC :VT: CD 1 cm, eff 25%, AM (+), head
    palpable,
    denominator
    unclear,
    descend H1 +, unpalpable small
    part of fetal and umbilical cord
    Lab. Examination :
    Hb : 11,3 gr%
    Leko : 11.600 mm3
    Trombo : 179.000 mm3
    Hct : 30,7 gr%
    HBsAg : PS: 5

    12.00

    17 Nov 2009

    12.00 wita
    Assesment

    Planning

    G1P0A0L0 42-43
    week/S/L/IU head
    presentation with
    oligohidramnion

    Obs. Mother and fetal


    wellbeing
    CTG
    Report to supervisor (11.00)
    Induction with oxytocin drip

    Time

    Subject
    UFH :33 cm
    EFW : 3410 gr
    FHR :12-12-12 bpm
    UC : USG:
    Fetal S/L/IU head presentation
    amnion clear and little
    Obstetric status:
    1.Now
    History KB (-)
    Planing KB (-)

    Object
    Pelvic evaluation:
    Os coccygeus mobile
    Archus pubis >90
    Spina ischiadica not prominent

    Assesment

    Planning

    Time

    Subject

    Object

    Assesment

    14.00

    Abdominal pain-

    CTG baseline : 145 bpm


    UC :-

    14.30

    Abdominal pain-

    UC:FHR:11-12-12

    Observed UC and FHR 30


    minutes again

    15.00

    Abdominal pain-

    UC:FHR:12-12-12

    Observed UC and FHR 30


    minutes again

    15.30

    Abdominal pain-

    UC:FHR:11-12-11

    Observed UC and FHR 30


    minutes again

    16.00

    Abdominal pain-

    UC:FHR:13-12-12

    Observed UC and FHR 30


    minutes again

    16.30

    Abdominal pain>

    UC: 1x10/20
    FHR:16-13-16

    17.00

    Abdominal pain>

    UC: 1x10/20
    FHR:14-12-13

    Obs. Mother and fetal


    wellbeing

    17.30

    Abdominal pain>

    UC: 2x10/25
    FHR:12-12-13

    Obs. Mother
    wellbeing

    0%

    G1P0A0L0 42-43
    week/S/L/IU head
    presentation with
    oligohidramnion

    Planning

    G1P0A0L0
    42-43
    week/S/L/IU
    head
    presentation
    with
    oligohidramnion+fetal
    distress

    Induction with oxytocin 5 IU


    in D5% 500 cc start at 8
    dpm
    Observed UC and FHR 30
    minutes again

    Report to supervisor:
    Propose: stop drip oxytocin,
    resucitation:
    RL:D5=2:1
    O2 5 ltr
    Left lateral position
    Advice: propose aggre and
    SC at morning.

    and

    fetal

    Time

    Subject

    Object

    Assesment

    Planning

    18.00

    Abdominal pain>

    UC: 2x10/30
    FHR:12-12-13

    Obs. Mother and fetal


    wellbeing
    Observed UC and FHR 30
    minutes again

    18.30

    Abdominal pain>

    UC: 3x10/30
    FHR:12-12-12

    Obs. Mother and fetal


    wellbeing
    Observed UC and FHR 30
    minutes again

    19.00

    Abdominal pain>

    UC:3x10/40
    FHR:12-12-12

    Obs. Mother and fetal


    wellbeing
    Observed UC and FHR 30
    minutes again
    Evaluation 2 hours again

    19.30

    Abdominal pain>

    UC:3x10/40
    FHR:11-12-11

    Obs. Mother and fetal


    wellbeing
    Observed UC and FHR 30
    minutes again

    20.00

    Abdominal pain>>

    UC:3x10/40
    FHR:13-12-12

    Observed UC and FHR 30


    minutes again

    20.30

    Abdominal pain>>

    UC:3x10/40
    FHR:11-12-12

    Observed UC and FHR 30


    minutes again

    21.00

    Abdominal pain>>>

    UC:4x10/40
    FHR:11-12-12
    L4:2/5
    VT :CD 8 cm, eff 80%, AM (+), head
    palpable, descend HII, denominator
    fontanella minor anterior, small part of
    fetal and umbilical cord unpalpable

    21.30

    Abdominal pain>>>>

    UC:4x10/40
    FHR:11-12-12

    G1P0A0L0
    42-43
    week/S/L/IU
    head
    presentation
    of
    active
    phase first stage of labor
    with oligohidramnion

    Observed UC and FHR 30


    minutes
    VT 2 hour again
    again

    Observed UC and FHR 30


    minutes again

    Time

    Subject

    Object

    22.00

    Watery vaginal discharge

    UC:4x10/40
    FHR:11-12-11
    VT :CD complete, AM (-), clear, head
    palpable, descend HIII, denominator
    fontanella minor anterior, small part of
    fetal and umbilical cord unpalpable

    22.15

    Abdominal pain>>>>, mother


    want to bear down

    FHR: 13-12-12
    Doran teknus perjol vulka

    22.45

    Assesment
    Stage 2 of labor

    Stage 3 of labor

    BP :100/60 mmHg
    PR : 76 x/
    RR : 16x/
    Temp : 36,8C
    UC : good
    UFH : 2 finger below umbilicus
    Active vaginal bleeding (-)

    06.30

    BP :110/80 mmHg
    PR : 76 x/
    RR : 16x/
    Temp : 36,5
    UC: good
    FUH: 2 finger below umbilicus
    Active vaginal bleeding (-)
    Baby:
    T:36,6 C
    RR: 36 tpm
    HR : 120 bpm

    Educate to prepare for


    delivery of baby

    Conduct mother to bear


    down
    Stage 2 of labor

    00.45

    Planning

    2 hours post partum

    Baby was born female, 3300


    gram, A-S 7-9
    Amniotic fluid clear
    Rupture Perineum grade 2
    Postterm sign:
    Stadium I
    Placenta was born 8 minutes
    later
    Referred mother and baby to
    melati room

    Motivated to breastfeeding

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