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    MR 03-12-2017

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    nitta_
    The document describes the labor and delivery of a 32-year-old woman admitted at 41-42 weeks gestation with breech presentation. Her labor is monitored over several hours, with cervical dilation and fetal heart rate checked regularly. At 9:45 AM, a female infant is delivered weighing 3.1 kg. The placenta is delivered complete at 9:55 AM. Two hours postpartum, both mother and baby are doing well.

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    MR 03-12-2017

    Uploaded by

    nitta_
    17 views15 pages
    The document describes the labor and delivery of a 32-year-old woman admitted at 41-42 weeks gestation with breech presentation. Her labor is monitored over several hours, with cervical dilation and fetal heart rate checked regularly. At 9:45 AM, a female infant is delivered weighing 3.1 kg. The placenta is delivered complete at 9:55 AM. Two hours postpartum, both mother and baby are doing well.

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    Morning report obgyn

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    The document describes the labor and delivery of a 32-year-old woman admitted at 41-42 weeks gestation with breech presentation. Her labor is monitored over several hours, with cervical dilation and fetal heart rate checked regularly. At 9:45 AM, a female infant is delivered weighing 3.1 kg. The placenta is delivered complete at 9:55 AM. Two hours postpartum, both mother and baby are doing well.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    17 views15 pages

    MR 03-12-2017

    Uploaded by

    nitta_
    The document describes the labor and delivery of a 32-year-old woman admitted at 41-42 weeks gestation with breech presentation. Her labor is monitored over several hours, with cervical dilation and fetal heart rate checked regularly. At 9:45 AM, a female infant is delivered weighing 3.1 kg. The placenta is delivered complete at 9:55 AM. Two hours postpartum, both mother and baby are doing well.

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    You are on page 1of 15

    MORNING REPORT

    3 December 2017

    Supervisor: dr, Sp.OG

    Medical Students:
    Ata, Nita, Ratu

    CASE RESUME
    NORMAL LABOR 1. G2P1A0L1 41-42 weeks S/L/IU Breench presentation

    PATHOLOGIES CASE -

    REMAIN CASE -
    Tidak ada
    pertanyaan yang
    salah
    Case I
    Name : Mrs. N
    Age : 32 years old
    Address : Narmada
    Admitted :
    RM : 59-95-01
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
    03/12/2017 Patient referred from Awer Muda Narmada Hospital General Status : G2P1A0L1 41-42 weeks DM Planning:
    03.00 AM with G2P1A0L1 41-42 weeks S/L/IU breech GC : well S/L/IU breech presentation Diagnostic:
    presentation with inpartu 1st stage of labor phase GCS: CM with inpartu 1st stage of labor CTG
    laten. Patient confessed abdominal pain reffered to BP : 120/70 mmHg phase laten Laboratorium
    back since 07.00 AM (02/12/2017), bloody slime PR : 96 bpm
    (+), FM (+). RR : 20 x/min
    Temp : 36.6 oC Observation:
    No history of DM, HT, asthma and heart disease Obs. Mother and fetal well
    Eye : anemic -/-, icteric -/- being.
    LMP : 15 02 2017 Cor : S1S2 single reguler, murmur (-),
    EDD : 22 11 2017 gallop (-). CIE patient to eat and drink
    GW : 41 42 weeks Pulmo : vesikuler (+/+), wheezing (-/-), Inform patient about the
    ronkhi (-/-). diagnostic planning
    History of ANC : 8x at PHC Abdomen : bu (+), linea nigra (+), stria
    Last ANC : 15-11-2017 (-)
    Result: BP 110/70, GW 37-38 weeks, UFH 32cm, Extremity : edema (-/-), warm acral DM co to GP, GP co to SPV,
    head presentation (+/+). advice :
    D5% - 20 tpm
    History of USG : 2x Obstetrical Status : Evaluation 2 hours later
    L1 : head
    History of family planning: patient has a plan to L2 : back on the right side
    have 3 children with 6 or 7 years apart. L3 : breech
    Next family planning : for the contraception patient L4 : 4/5
    chooses to use implant and patient chooses to not UFH : 32 cm
    have a children again. EFW : 3296 gr
    UC : 2x/10 ~ 25
    Obstetrical History : FHB : 11-11-11 (132 bpm)
    VT : 3 cm, eff.25 %, Amnion (+) ,
    1. Female/PCH/normal/midwife/3000gr/6yo HI, breech palpable.
    2. This
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    Pelvic examination
    Spina ischiadica non prominent
    Sacrum convex
    Os coccygeus mobile
    Arcus pubis >90o

    Lab: (03/12/2017)
    HB 11,7 g/dl
    RBC 4,47 x 10^6/uL
    HCT 34,6%
    WBC 11.36 x 10^3/uL
    PLT 190 x 10^3/uL
    HbSAg non reactive
    Time Subject Object Assessment Planning
    Chronologist at Narmada Awat Muda
    Hospital

    S/ Patient confessed abdominal pain reffered


    to back since 07.00 AM (02/12/2017), bloody
    slime (+), FM (+).

    O/ GC : well
    GCS: CM (E4V5M6)
    BP : 120/80mmHg
    PR: 80 tpm
    RR: 20 tpm
    T: 36.5C

    Obstetric status
    L1 : head UFH: 34 cm
    L2 : back on the right side
    L3 : breech
    L4 : 4/5
    UC : 2X10-30
    FHB : 144 bpm
    VT : 3cm, eff. 25 %, Amnion (+) HI, the
    little part (umbilical cord) of fetus is not
    palpable .

    A/ G2P1A0L1 41-42 weeks S/L/IU breech


    presentation with inpartu 1st stage of labor
    phase laten

    P/ CIE patient the result of examination


    Inform consent
    Suggest mother to eat and drink,
    Lay to the left side
    Obs mother and fetal well being
    Reffered to NTB GH
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    05.00 AM Abdominal pain (+), GC : well


    bloody slime (+), FM GCS: CM
    (+). BP : 110/70 mmHg
    PR : 84 bpm
    RR : 20 x/min
    Temp : 36.5oC

    UC : 2x/10 ~ 35
    FHB : 136 bpm
    3 cm, eff.25 %, Amnion membrane(+) ,
    HI, breech palpable.

    05.30 AM Abdominal pain (+), GC : well


    bloody slime (+), FM GCS: CM
    (+). BP : 110/70 mmHg
    PR : 88 bpm
    RR : 20 x/min
    Temp : 36.5oC

    UC : 2x/10 ~ 35
    FHB : 140 bpm

    07.00 Abdominal pain (+), GC : well


    bloody slime (+), FM GCS: CM
    (+), amnion (+) BP : 110/70 mmHg
    PR : 84 bpm
    RR : 20 x/min
    Temp : 36.5oC

    UC : 2x/10 ~ 35
    FHB : 136 bpm
    6 cm, eff.50 %, Amnion (-) meconeal, HI,
    breech palpable, denom sacrum dependent.
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    09.00 AM Abdominal pain (+), GC : well


    bloody slime (+), FM GCS: CM
    (+). BP : 120/70 mmHg
    PR : 90 bpm
    RR : 20 x/min
    Temp : 36.5oC

    UC : 4x/10 ~ 40
    FHB : 136 bpm

    09.40 AM Abdominal pain (+), GC : well


    bloody slime (+), FM GCS: CM
    (+). BP : 110/70 mmHg
    PR : 88 bpm
    RR : 20 x/min
    Temp : 36.5oC

    UC : 4x/10 ~ 45
    FHB : 140 bpm
    complete10 cm, HIII (+), breech
    palpable, denom sacrum dependent.

    09.45 AM GC : well Baby was born female, BW : 3100 gr, BL :


    GCS: CM 52 cm, AS : 6-8, anus (+), anomaly
    BP : 110/70 mmHg congenital (-).
    PR : 84 bpm oksitosin 5 IU IM
    RR : 20 x/min Placenta was born complete at 09.55
    Temp : 36.5oC
    Time Subject Object Assessment Planning

    11.45 Confessed (-) GC : well 2 hours post partum Obs. Mother and baby well
    GCS: CM (E4V5M6) being
    BP : 110/70mmHg
    PR: 80 tpm
    RR: 20 tpm
    T: 36,5 C

    UC : well
    UFH : 1 finger below umbilicus
    Active bleeding (-)
    Lokia rubra (+)
    KIA Book
    Partograf
    USG
    Thank You

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