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    Morning Report: Case Resume Normal Labor - Pathology Labor

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    melatiigd
    This document summarizes the labor and delivery of a patient. The patient is a 40-41 week pregnant woman presenting with her first pregnancy. Over 24 hours, the patient's cervical dilation progressed slowly with oxytocin augmentation. Contractions increased in strength and frequency with rising oxytocin doses but dilation failed to progress beyond 3 centimeters. The fetal heart rate remained normal throughout labor.

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    Morning Report: Case Resume Normal Labor - Pathology Labor

    Uploaded by

    melatiigd
    7 views8 pages
    This document summarizes the labor and delivery of a patient. The patient is a 40-41 week pregnant woman presenting with her first pregnancy. Over 24 hours, the patient's cervical dilation progressed slowly with oxytocin augmentation. Contractions increased in strength and frequency with rising oxytocin doses but dilation failed to progress beyond 3 centimeters. The fetal heart rate remained normal throughout labor.

    Original Description:

    Morning Report Obstetri

    Original Title

    Morning Report Obstetri 16

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    This document summarizes the labor and delivery of a patient. The patient is a 40-41 week pregnant woman presenting with her first pregnancy. Over 24 hours, the patient's cervical dilation progressed slowly with oxytocin augmentation. Contractions increased in strength and frequency with rising oxytocin doses but dilation failed to progress beyond 3 centimeters. The fetal heart rate remained normal throughout labor.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    7 views8 pages

    Morning Report: Case Resume Normal Labor - Pathology Labor

    Uploaded by

    melatiigd
    This document summarizes the labor and delivery of a patient. The patient is a 40-41 week pregnant woman presenting with her first pregnancy. Over 24 hours, the patient's cervical dilation progressed slowly with oxytocin augmentation. Contractions increased in strength and frequency with rising oxytocin doses but dilation failed to progress beyond 3 centimeters. The fetal heart rate remained normal throughout labor.

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    You are on page 1of 8

    Morning Report

    CASE RESUME
    NORMAL LABOR

    PATHOLOGY
    LABOR

    1. G1P0A0L0 A/S/L/IU head presentation, stage I


    latent phase with drip failure at second serial

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT

    PLANNING

    30/10
    /2012
    14.00

    Patient
    reffered
    from
    policlinic
    NTB GH with
    G1P0A0L0
    40-41
    weeks
    S/L/IU head presentation with
    mother & fetal well being.
    Patient confessed abdominal
    pain that spread to waist
    since 10.00 (30/10/2012).
    History rupture of membrane
    (-), bloody slim (+) since
    10.00 (30/10/2012), FM (+).
    No history of DM, HT,
    asthma.

    General Status :
    GC : well
    BP : 120/80 mmHg
    PR : 88bpm
    RR : 20 bpm
    T : 36,5OC
    Eye : anemis (-), icteric (-)
    Cor : S1S2 single regular,
    murmur (-), gallop (-).
    Pulmo
    :
    vesicular
    (+/+),
    wheezing (-/-),
    ronkhi (-/-).
    Abdomen : scar (-), striae
    gravidarum (+), linea nigra (+).
    Extremity : edema (-/-), warm
    acral (+/+).

    G1P0A0L0 40-41
    weeks S/L/IU
    head
    presentation with
    mother & fetal
    well being

    Observation
    mother & fetal
    well being.
    Observation
    progress of labor.

    LMP : EDD : History of ANC : > 4x at


    Posyandu
    Last ANC : 01/07/2012
    History of USG : 1 x
    History of family planning :
    (-)
    Next family planning : IUD
    Obstetrical History :
    I. This

    Obstetrical Status :
    L1 : breech
    L2 : back on the right side
    L3 : head
    L4 : 4/5
    UFH : 32 cm
    EFW : 3255 gram
    UC : FHB : 12-11-12 (140 bpm)
    VT : 1 cm, effacement 10%,
    amnion (+), head palpable HI,
    denominator
    unclear,
    impalpable small part and
    umbilical cord.

    TIME

    SUBJECTIVE
    Chronologist : (-)

    OBJECTIVE

    ASSESSME
    NT

    PLANNING

    G1P0A0L0 4041 weeks


    S/L/IU head
    presentation
    with mother &

    Observation
    mother & fetal
    well being.
    Observation
    progress of labor.

    Pelvic Evaluation :
    Spina
    ischiadica
    not
    prominent
    Os coccygeus mobile
    Arcus pubis > 90o
    PS : 5
    Cervix dilatation 1 cm : 1
    Cervix length 1 cm : 2
    Cervix consistency
    moderate : 1
    Cervix position posterior :
    0
    Station H I : 1
    Lab Examination
    (30/10/2012) :
    HB : 10,8 g/dl
    RBC : 3,61 x 106/L
    HCT : 32,2 %
    WBC : 16,06 x 103/L
    PLT : 316 x 103/L
    HbSAg : (-)

    16.00

    (-)

    GC : well
    BP : 110/80 mmHg
    PR : 80 bpm
    RR : 20 bpm
    T : 36,5OC

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT

    PLANNING

    30/10/1
    2
    17.00

    UC : FHB : 12-11-12 (140


    bpm)

    Drip oxytocin 12 dpm

    17.30

    UC : FHB : 12-13-13 (152


    bpm)

    Drip oxytocin 16 dpm

    18.00

    Abdominal pain came and


    relieved

    UC : 2x10~15
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 20 dpm

    18.30

    Abdominal pain came and


    relieved

    UC : 2 x 10 ~ 25
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 24 dpm

    19.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 25
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 28 dpm

    19.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 25
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 32 dpm

    20.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 25
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 36 dpm

    GC : well
    BP : 120/80 mmHg
    PR : 81bpm
    RR : 20 bpm
    T : 36,9OC
    20.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 25
    FHB : 11-12-11 (136
    bpm)

    Drip oxytocin 40 dpm

    21.00

    Abdominal pain came and

    UC : 2x 10 ~ 25

    Drip oxytocin 40 dpm

    TIME

    SUBJECTIVE

    OBJECTIVE

    30/10/1
    2
    22.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 25
    FHB : 12-11-12 (140
    bpm)

    23.00

    Abdominal pain came and


    relieved

    UC : 2x10~15
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 40 dpm

    23.30

    Abdominal pain came and


    relieved

    UC : 2 x 10 ~ 25
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 40 dpm

    24.00

    Abdominal pain came and


    relieved

    UC : 2 x 10 ~ 35
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 40 dpm

    GC : well
    BP : 120/80 mmHg
    PR : 81bpm
    RR : 20 bpm
    T : 36,9OC

    ASSESSMENT

    PLANNING

    G1P0A0L0 40-41 mg
    S/L/IU head
    presentation with
    mother & fetal well
    being.

    Drip oxytocin 1st flash


    end, continue with
    2nd flash

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT

    PLANNING

    31/10/1
    2
    00.30

    Abdominal pain came and


    relieved

    UC : 2 x10~35
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 40 dpm

    01.00

    Abdominal pain came and


    relieved

    UC : 3 x 10 ~ 35
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 40 dpm

    01.30

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 40 dpm

    02.00

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 40 dpm

    02.30

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    03.00

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 11-12-11 (136
    bpm)

    Drip oxytocin 40 dpm

    VT : 1 cm,
    effacement 10%,
    amnion (+), head
    palpable HI,
    denominator unclear,
    impalpable small part
    and umbilical cord.
    03.30

    Abdominal pain came and


    relieved

    UC : 3 x 10 ~ 35
    FHB : 12-11-12 (140
    bpm)

    G1P0A0L0 40-41 weeks


    S/L/IU head
    presentation, mother &
    fetal well being, with
    dirp failure at first serial

    Drip oxytocin 40 dpm


    2nd flash finished,
    change flash with
    Ringer Lactat
    Obs mother and fetal
    well being

    TIME

    SUBJECTIVE

    31/10/1
    2
    10.15

    Abdominal pain came and


    relieved

    1/10/12
    09.30

    OBJECTIVE

    ASSESSMENT

    PLANNING

    UC : FHB : 12-11-12 (140


    bpm)

    G1P0A0L0 40-41 weeks


    S/L/IU head
    presentation, mother &
    fetal well being, with
    dirp failure at first serial

    Patient moved to
    melati

    Abdominal pain came and


    relieved

    UC : FHB : 12-12-12 (144


    bpm)

    G1P0A0L0 40-41 weeks


    S/L/IU head
    presentation, mother &
    fetal well being, with
    dirp failure at first serial

    Patient come to VK
    Teratai

    10.00

    Abdominal pain came and


    relieved

    UC : FHB : 12-12-12 (144


    bpm)

    Drip oxytocin 2nd


    serial start at 8 dpm

    10.30

    Abdominal pain came and


    relieved

    UC : FHB : 12-12-11 (140


    bpm)

    Drip oxytocin 12 dpm

    11.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 10
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 16 dpm

    11.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 15
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 20 dpm

    12.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 15
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 24 dpm

    12.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 10
    FHB : 12-12-11 (140
    bpm)

    Drip oxytocin 28 dpm

    13.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 15
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 32 dpm

    13.30

    Abdominal pain came and

    UC : 2x 10 ~ 15

    Drip oxytocin 36 dpm

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT

    31/10/1
    2
    15.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 15
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    16.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 15
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    16.30

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 15
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    17.00

    Abdominal pain came and


    relieved

    UC : 2x 10 ~ 25
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    17.30

    Abdominal pain came and


    relieved

    UC : 2 x 10 ~ 25
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    18.00

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 25
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    18.30

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    19.00

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-12-12 (144
    bpm)

    Drip oxytocin 40 dpm

    19.30

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-13-12 (148
    bpm)

    Drip oxytocin 40 dpm

    20.00

    Abdominal pain came and


    relieved

    UC : 3x 10 ~ 35
    FHB : 12-11-12 (140
    bpm)

    Drip oxytocin 40 dpm

    20.30

    Abdominal pain came and

    UC : 3x 10 ~ 35

    G1P0A0L0 40-41 weeks

    PLANNING

    Drip oxytocin finished

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