mr 10092015_3.pptx
TRANSCRIPT
Morning ReportSeptember, 10th 2015
Supervisor:Dr. Agus Thoriq, SpOG
DM Jaga:Rian
Morning Reportseptember 10th 2015
Case ResumeNORMAL LABOR
0
PATHOLOGIES LABOR
1. G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest active phase 1st stage of labor
2. G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested active phase 1st stage of labor
Case 1Name : Mrs. IAge : 32 years oldAddress : NarmadaAdmitted : 09-09-2015 No. RM : 56-65-82
G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest active phase 1st stage of labor
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
09/09/2015
21.44 wita
Patient reffered from Narmada PHC with G5P2A2L2 39-40 weeks S/L/IU head presentation mother and fetal well being with inpartu arrest 1st stage active phase of labor. Patient confessed about abdominal pain since 20.00 (08/09/2015) history of water leaked out from her womb (-). History of blood slim (+), FM (+).
History of DM (-), HT in pregnancy (-), asthma (-) and allergy (-).
LMP : 08/12/2014EDD : 15/09/2015
History of ANC : 7x at PHCLast result: (13/08/2015) BP 120/90 mmHg, BW 78 kg, GW 36 w UFH 30 cm, head presentation, FHB (+)History of USG : 1x, at SpOGLast : 25/07/2015S/L/IU head presentation, female, GW 32-34 weeks, placenta at fundus gr II-III, amnion enough, clear, EFW 3200 g
History of family planning: Injection 3 monthNext family planning : Injection 3 month
General statusGC : wellconsciousness: CMBP : 120/80 mmHgPR: 82 bpmRR: 20 bpmT: 37.5°C
Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema of lower extremity(-/-), warm acral (+/+).
Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 35 cmEFW : 3720 gUC : 3x10’~30”FHB : 13-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord
G5P2A2L2 39-40 weeks S/L/IU head presentation with arrest active phase 1st stage of labor
DM planning:Diagnostic : CTGTherapy :Pro amniotomyObservation progress
of laborMonitoring : VS mother,
UC, FHBCIE : CIE mother and
family about diagnostic planning and therapeutic planning
DM co to GP co to SPVAdvice : amniotomyAcceleration if UC
inadequate
Amniotomy was done at 22.30
VT : Ø 5 cm, eff 50%, amnion (-), clear, head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord
UC : 3x10’~30”
Oxytocin Drip starting from 8 dpm (23.30)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Obstetric History:I. Aterm/normal/polindes/
3900 g/female/7 yoII. Aterm/normal/polindes/
3500 g/male/3 yoIII. AbortusIV. AbortusV. This
Pelvic score = 6Dilatation of cervix : 2Length of cervix : 1Station : 1Consistency : 1Position : 1
Laboratory (09/09/2015 21.57):HB: 12.8 g/dl RBC: 4.15HCT: 37.5 %WBC: 15.78PLT: 235HbsAg: non reactiveBT : 2’15”CT : 6’30”
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronology at Narmada PHC (09/09/2015)05.00S :Patient 9 months of pregnancy come to PHC confessed abdominal pain since 20.00 (08/09/2015) bloody slim (+) amnion (-) FM (+)
O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.4°C
Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 37 cmUC : 3x10’~25”FHB : 12-11-12VT : Ø 3 cm, eff 25%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
14.00S :Patient confessed abdominal pain
O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.6°C
UC : 3x10’~30”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
18.00S :Patient confessed abdominal pain
O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.5°C
UC : 3x10’~35”FHB : 12-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord
A :G5P2A2L2 39-40 weeks S/L/IU head presentation with mother and fetal well being + arrest active phase 1st stage of labor
P :CIE mother about examination resultRL : D5 infusion 2:1Observation for mother and fetal well being, progress of labor
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
21.00S :Patient confessed abdominal pain
O :GC : wellconsciousness: CM
UC : 3x10’~35”FHB : 11-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord
A :G5P2A2L2 39-40 weeks S/L/IU head presentation with mother and fetal well being + arrest active phase 1st stage of labor
P :CIE mother about examination resultCo to GP adviceRefer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
23.30 UC : 3x10’~30”FHB : 12-11-12
Drip Oxytocin 8 dpm
10/09/201500.00
UC : 3x10’~30”FHB : 12-12-13
Drip Oxytocin 12 dpm
00.30 UC : 4x10’~40”FHB : 12-12-13
VT : Ø 9 cm, eff 80%, amnion (-), not clear, head presentation, ↓HII, denominator transverse sagitalis suture, not palpable small part & umbilical cord
2 hours post amniotomy
Drip Oxytocin 12 dpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
00.55 Mother want to bearing down General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 92 bpmRR: 20 bpmT: 36,7°C
UC : 4x10’ ~40”FHB : 12-12-13
Sign of 2nd stage of labor (+) : crowning, anus pressure, opening of vulva, bulging of perineum
VT : not perform
G5P2A2L2 39-40 weeks S/L/IU head presentation with 2nd stage of labor
DM planning:Diagnostic : -Therapy : -Monitoring : VS mother,
UC, FHBCIE : suggest mother
to bearing down
Conduct mother to bearing down
At 01.00 Baby was born, male, A-S 3-5, 3900 g, BL 52 cm, HC 34 cm, anus (+) congenital anomaly (-)Baby rooming in NICU
Placenta was born uncompletely at 01.10 pro USG
Do the management of 4th stage of labor
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
03.00 GC : wellconsciousness: CMBP : 110/70 mmHgPR: 88 bpmRR: 20 bpmT: 36.4°C
UC : wellUFH : 1 fingers below umbilicalUO : not measuredActive bleeding (-)
Baby in NICU :HR : 142x/minuteRR : 44x/minuteT : 35,8oC
2 hours post partum + rest placenta
DM planning:Diagnostic : USGTherapy : Amoxicillin 3x500 mgMefenamic Acid 3 x
500 mgMonitoring : VS mother,
UC, UFH CIE : suggest mother
to eat and drink
07.00 Patient confessed about abdominal wound pain
GC : wellconsciousness: CMBP : 110/70 mmHgPR: 80 bpmRR: 20 bpmT: 36.4°C
UC : wellUFH : 1 fingers below umbilicalUO : not measuredActive bleeding (-)
Baby in NICU :HR : 144x/minuteRR : 46x/minuteT : 36,1oC
1 day post partum + rest placenta
DM planning:Diagnostic : USGTherapy : -Monitoring : VS mother,
UC, UFH, UOCIE : suggest mother
to eat and drink
Case 2Name : Mrs. SAge : 34 years oldAddress : Gunung SariAdmitted : 09-09-2015 No. RM : 12-27-02
G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
09/09/2015
16.21 wita
Patient reffered from Gunung Sari PHC with G1P0AL0 41-42 weeks S/L/IU head presentation mother and fetal well being with post term. Patient confessed about abdominal pain since 09.00 (08/09/2015) history of water leaked out from her womb (+) since 10.00 (09/09/2015) History of bloody slim (+), FM (+).
History of DM (-), HT in pregnancy (-), asthma (-) and allergy (-).
LMP : 08/12/2014EDD : 15/09/2015
History of ANC : 7x at SpOG Last result: (08/09/2015) BP 100/80 mmHg, BW 45 kg, GW 39 w UFH 29 cm, head presentation, FHB (+)History of USG : 7x, at SpOGLast : 09/09/2015S/L/IU head presentation, male, GW 39-40 weeks, placenta at corpus posterior, amnion enough, not clear, EFW 3200 g
History of family planning: -Next family planning : -
General statusGC : wellconsciousness: CMBP : 100/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C
Local statusEye : an (-/-), ict (-/-)Pulmo : ves (+/+), rh (-/-), wh (-/-)Cor : S1S2 single regular, m (-), g (-)Abd : striae gravidarum (+), linea nigra (+), scar (-)Ext : edema of lower extremity(-/-), warm acral (+/+).
Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 31 cmEFW : 3100 gUC : 2x10’~25”FHB : 12-11-12VT : Ø 3 cm, eff 25%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord
G1P0A0L0 39-40 weeks S/L/IU head presentation latent phase 1st stage of labor
DM planning:Diagnostic : CTGTherapy :Observation progress
of laborMonitoring : VS mother,
UC, FHBCIE : CIE mother and
family about diagnostic planning and therapeutic planning
DM co to GP advice :Observation progress
of labor
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Obstetric History:I. This
Pelvic ExaminationPromontorium unpalpableSpina ishiadica non prominemArcus pubis >90o
Os coccygeus mobile
Laboratory (09/09/2015 16.34):HB: 10.4 g/dl RBC: 3.92HCT: 32.2 %WBC: 10.31PLT: 252HbsAg: non reactiveBT : 2’00”CT : 5’10”
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronology at Gunung Sari PHC (09/09/2015)10.00S :Patient 9 months of pregnancy come to PHC confessed abdominal pain since 09.00 (09/09/2015) bloody slim (+)
O :GC : wellconsciousness: CMBP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C
Obstetric statusL1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH: 30 cmEFW : 2945 gUC : 1x10’~20”
VT : Ø 1 cm, eff 25%, amnion (+), head presentation, ↓HI, denominator unclear, not palpable small part & umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
A :G1P0A0L0 39-40 weeks /S/L/IU head presentation mother and fetal well being with postterm
P :CIE mother about examination resultRL infusion 20 dpmRefer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
19.30 Patient confess about abdominal pain
General statusGC : wellconsciousness: CMBP : 120/80 mmHgPR: 86 bpmRR: 22 bpmT: 36.5°C
UC : 3x10’~40”FHB : 11-11-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord
G1P0A0L0 39-40 weeks S/L/IU head presentation active phase 1st stage of labor
DM planning:Diagnostic :Therapy :Observation progress
of labor with partograph
Monitoring : VS mother, UC, FHB
CIE : CIE mother and family about diagnostic planning and therapeutic planning
23.30 Patient confess about abdominal pain
General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C
UC : 3x10’~40”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator unclear, not palpable small part & umbilical cord
G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase
DM planning:Diagnostic :Therapy :Observation progress
of labor with partograph
Pro amniotomyMonitoring : VS mother,
UC, FHBCIE : CIE mother and
family about diagnostic planning and therapeutic planning
DM co to GP co to SPV : not answered
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
01.30 Patient confess about abdominal pain
General statusGC : wellconsciousness: CMBP : 110/70 mmHgPR: 84 bpmRR: 20 bpmT: 36.7°C
UC : 3x10’~45”FHB : 13-12-13VT : not perform
G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase
DM planning:Diagnostic :Therapy :Observation progress
of labor with partograph
Pro amniotomyMonitoring : VS mother,
UC, FHBCIE : CIE mother and
family about diagnostic planning and therapeutic planning
DM co to GP co to SPV advice (02.00) : amniotomy
Acceleration
Amniotomy was done at 02.15
VT : Ø 4 cm, eff 50%, amnion (-), not clear, head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord
Oxytocin Drip starting from 8 dpm (02.45)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
02.45 UC : 3x10’~30”FHB : 13-12-13
Drip Oxytocin 8 dpm
03.15 UC : 3x10’~30”FHB : 13-12-12
Drip Oxytocin 12 dpm
03.45 UC : 3x10’~30”FHB : 12-11-12
Drip Oxytocin 16 dpm
04.15 UC : 3x10’~35”FHB : 12-11-12VT : Ø 4 cm, eff 50%, amnion (-), not clear, head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord
2 hours post amniotomy
Drip Oxytocin 20 dpm
04.45 UC : 3x10’~35”FHB : 12-13-13
Drip Oxytocin 24 dpm
05.15 UC : 3x10’~35”FHB : 12-12-12
Drip Oxytocin 28 dpm
05.45 UC : 4x10’~40”FHB : 12-12-12
Drip Oxytocin 32 dpm
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
06.15 Mother confessed about abdominal pain
General statusGC : wellconsciousness: CMBP : 110/60 mmHgPR: 86 bpmRR: 20 bpmT: 36.8°C
UC : 4x10’~40”FHB : 13-12-12VT : Ø 4 cm, eff 50%, amnion (+), head presentation, ↓H1, denominator transverse sagitalis suture, not palpable small part & umbilical cord
G1P0A0L0 39-40 weeks S/L/IU head presentation with arrested 1st stage of labor active phase suspect CPD
DM planning:Diagnostic :Therapy :Pro CSMonitoring : VS mother,
UC, FHBCIE : CIE mother and
family about diagnostic planning and therapeutic planning
DM co to GP co to SPVAdvice : observation
progress of labor for 2 hours if there is no progression C-Section
.. Thank You ..