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    Morning Report: Case Resume Normal Labor - Pathology Labor

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    melatiigd
    A 38-year-old woman (G2P0A1) at 38 weeks gestation was referred from a primary health center in her second stage of labor. She had ruptured membranes, bloody show, and fetal movements. Her labor progressed over several hours with abdominal pain, and she was given IV fluids and antibiotics. Due to failure to progress with vaginal exams showing full dilation, she underwent an emergency cesarean section and delivered a healthy baby boy.

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    Morning Report: Case Resume Normal Labor - Pathology Labor

    Uploaded by

    melatiigd
    17 views7 pages
    A 38-year-old woman (G2P0A1) at 38 weeks gestation was referred from a primary health center in her second stage of labor. She had ruptured membranes, bloody show, and fetal movements. Her labor progressed over several hours with abdominal pain, and she was given IV fluids and antibiotics. Due to failure to progress with vaginal exams showing full dilation, she underwent an emergency cesarean section and delivered a healthy baby boy.

    Original Description:

    Morning Report Obstetri

    Original Title

    Morning Report Obstetri 17

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    A 38-year-old woman (G2P0A1) at 38 weeks gestation was referred from a primary health center in her second stage of labor. She had ruptured membranes, bloody show, and fetal movements. Her labor progressed over several hours with abdominal pain, and she was given IV fluids and antibiotics. Due to failure to progress with vaginal exams showing full dilation, she underwent an emergency cesarean section and delivered a healthy baby boy.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    17 views7 pages

    Morning Report: Case Resume Normal Labor - Pathology Labor

    Uploaded by

    melatiigd
    A 38-year-old woman (G2P0A1) at 38 weeks gestation was referred from a primary health center in her second stage of labor. She had ruptured membranes, bloody show, and fetal movements. Her labor progressed over several hours with abdominal pain, and she was given IV fluids and antibiotics. Due to failure to progress with vaginal exams showing full dilation, she underwent an emergency cesarean section and delivered a healthy baby boy.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 7

    Morning Report

    CASE RESUME
    NORMAL LABOR

    PATHOLOGY
    LABOR

    1.G2P0A1H0 38 mg T/H/IU, Preskep K/U In


    Partu 2nd Stage

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT

    PLANNING

    02/07
    /2012

    Patient
    referred
    from
    Cakranegara
    PHC
    with
    G2P0A1L0 38 weeks S/L/IU
    head presentation with 2nd
    stage of labor.
    Patient confessed abdominal
    pain that spread to frank.
    History rupture of membrane
    (+), bloody slim (+), FM (+).
    No history of DM, HT,
    asthma.

    General Status :
    GC : well
    BP : 120/80 mmHg
    PR : 80 bpm
    RR :20 bpm
    T : 37,5 OC
    Eye : anemis (-), icteric (-)
    Cor : S1S2 single regular,
    murmur (-), gallop (-).
    Pulmo
    :
    vesicular
    (+/+),
    wheezing (-/-),
    ronkhi (-/-).
    Abdomen : scar (-), striae
    gravidarum (+), linea nigra (+).
    Extremity : edema (-/-), warm
    acral (+/+).

    G2P0A1L0 38
    weeks S/L/IU
    head
    presentation with
    2nd stage of
    labor

    Check CBC and


    HbSAg
    Tell patient result
    of Examination
    Skin test, result
    (-), inj Ceftriaxon
    IV 1 gr
    Metronidazole
    1
    flash IV
    DM co to SPV,
    advice : VE

    20.45

    LMP : 27/01/2012
    EDD : 3/11/2012
    History of ANC :
    Last ANC :
    History of USG :
    History of family planning :
    (-)
    Next family planning :
    Obstetrical History :
    I.Abortus
    II.This

    Obstetrical Status :
    L1 : breech
    L2 : back on the left side
    L3 : head
    L4 : 3/5
    UFH : 31 cm
    EFW : 3100 gram
    UC : 4x/10~35
    FHB : 12-12-12 (144 bpm)
    VT : 10 cm, effacement
    100%,
    amnion
    (-),
    head
    palpable HIII, denominator
    LIUK Kadep, impalpable small
    part and umbilical cord.

    TIME

    SUBJECTIVE
    Chronologist at Cakranegara
    PHC (27/10/2012)
    13.30
    S : Patient confessed abdominal pain
    that spread to frank. Patient
    mengedan sendiri
    O : GC : well
    BP : 100/70 mmHg
    PR : 80 bpm
    RR : 20 bpm
    T : 36,5OC
    L1 : breech
    L2 : back on the left side
    L3 : head
    L4 : 3/5
    UFH :
    EFW :
    UC : (+), 4x/10~45
    FHB : (+) 132 x/min
    VT : 6 cm, eff 75%, amnion (-),
    head palpable, UUK di depan, HII,
    impalpable small part / umbilical
    cord.
    A : 1st stage of labor
    P:
    Explain result of examination
    Suggest mother to eat & drink
    Observation 4 hours

    OBJECTIVE

    ASSESSMENT

    PLANNING

    TIME

    SUBJECTIVE

    OBJECTIVE

    17.30
    (at
    PHC)

    Abdominal pain came


    and relieved

    UC : 4 x 10 ~ 40
    FHB : 128 bpm
    VT : 9 cm, eff 75%, amnion
    (-), head palpable, UUK di
    depan, HII+, impalpable
    small part / umbilical cord.

    ASSESSMENT

    PLANNING
    Rehidration

    17.35
    (at
    PHC)

    RL and D5% Given 2:1

    18.00
    (at
    PHC)

    Amp Injection 1 gr IV

    TIME

    SUBJECTIVE

    18.35
    (at
    PHC)

    19.15

    Pasien mengedan
    terus

    19.45

    Suami mengamuk
    marah2 minta di rujuk

    19.50

    Konsul dokter
    dirujuk APS

    OBJECTIVE

    ASSESSMENT

    PLANNING

    UC : 4 x 10 ~ 45
    FHB : 128 bpm
    VT : complete , eff 100%,
    amnion (-), head palpable,
    UUK
    di
    depan,
    HIII,
    impalpable small part /
    umbilical cord.

    Lie on left side

    VT : complete , eff 100%,


    amnion (-), head palpable,
    UUK
    di
    depan,
    HIII+,
    impalpable small part /
    umbilical cord.

    Ephisiotomy

    UC : 4 x 10 ~ 45
    FHB : 136 bpm

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT

    PLANNING

    02/07
    /2012

    Patient
    referred
    from
    Cakranegara
    PHC
    with
    G2P0A1L0 38 weeks S/L/IU
    head presentation with 2nd
    stage of labor.
    Patient confessed abdominal
    pain that spread to frank.
    History rupture of membrane
    (+), bloody slim (+), FM (+).
    No history of DM, HT,
    asthma.

    General Status :
    GC : well
    BP : 120/80 mmHg
    PR : 80 bpm
    RR :20 bpm
    T : 37,5 OC
    Eye : anemis (-), icteric (-)
    Cor : S1S2 single regular,
    murmur (-), gallop (-).
    Pulmo
    :
    vesicular
    (+/+),
    wheezing (-/-),
    ronkhi (-/-).
    Abdomen : scar (-), striae
    gravidarum (+), linea nigra (+).
    Extremity : edema (-/-), warm
    acral (+/+).

    G2P0A1L0 38
    weeks S/L/IU
    head
    presentation with
    2nd stage of
    labor

    Check CBC and


    HbSAg
    Tell patient result
    of Examination
    Skin test, result
    (-), inj Ceftriaxon
    IV 1 gr
    Metronidazole
    1
    flash IV
    DM co to SPV,
    advice : VE

    20.45

    LMP : 27/01/2012
    EDD : 3/11/2012
    History of ANC :
    Last ANC :
    History of USG :
    History of family planning :
    (-)
    Next family planning :
    Obstetrical History :
    I.Abortus
    II.This

    Obstetrical Status :
    L1 : breech
    L2 : back on the left side
    L3 : head
    L4 : 3/5
    UFH : 31 cm
    EFW : 3100 gram
    UC : 4x/10~35
    FHB : 12-12-12 (144 bpm)
    VT : 10 cm, effacement
    100%,
    amnion
    (-),
    head
    palpable HIII, denominator
    LIUK Kadep, impalpable small
    part and umbilical cord.

    TIME

    SUBJECTIVE

    OBJECTIVE

    ASSESSMENT
    FHB : 148 bpm

    PLANNING
    VE Begin :
    Failed 3 times
    DM Co SPV advice :
    SC

    22.55

    Baby
    was
    born,
    male, 3000 gram,
    Body Length : 48
    cm,
    Head
    circumference : 33
    cm,
    Arm
    Circumference : 11
    cm, A-S 5-7 caput
    (+) on occiput, anus
    (+),
    anomaly
    congenital (-).

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