Morning Report (letsu, Oligo, Lilitan Tali Pusat) 413u2p

Time 20 Jan 2012 10.15

S Patient came to Polyclinic with G1P0A0L0 40-41 weeks S/L/IU with breech presentation + oligohydramnion + umbilical cord twisting. History of abdominal pain (-), history of ruptured membrane (-), bloody slime (-), bleeding (-), FM (+) weak LMP: 09 – 04 – 2011 EDD: 18 – 01 – 2012 History of ANC: > 4x, PHC Last ANC: 19/01/2012 USG: 1x at RSUP NTB (19/01/2012)=  Breech presentation, single, alive  Umbilical cord twist on the neck  Amnion ↓, Placenta Gr.III at fundus uteri History of family planning: (-) Next family planning: IUD Chronology: (-)

22 Jan 2012

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O Status generalis: GC : well GCS: E4V5M6 BP : 120/70 mmHg Pulse : 76 x/min T : 36,3’C RR : 18 x/min Eye: anemic (-/-), ict (-/-) Cor: S1S2 single, reg, M (-), G (-) Pul: Ves (+/+), Rh (-/-), Wh (-/-) Extremities: warm (+/ +), edema (-/-)

A G1P0A0L0 40-41 weeks S/L/IU with breech presentation + oligohydramnion + umbilical cord twisting

P  Observe maternal & fetal well being  Observe GC & VS  Suggest mother to consume nutritious foods  Suggest mother to rest well  DM co to GP pro SC, GP co to SPV, SPV: pro Elective SC at Jan 24, 2012

G1P0A0L0 40-41 weeks S/L/IU

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Obstetric status: L1: head L2: fetal back on the left side L3: breech L4: 5/5 UFH: 33 cm, AC: 96 cm EFW: 3168 gr UFH: 24 cm UC: (-) FHB: (+) 12-12-12 (144 x/min) VT: (-) Lab (20/01/2011 – 11.21)  Hb : 13,1  RBC: 4,68  WBC : 12.000  HCT : 42.8%  PLT : 310.000  BT: 2’ 55” ~ CT: 6’ 50”  HbsAg : GC: Well Vital Signs:

Intrauterine rescucitation

07.30

BP: 120/80 mmHg PR: 84 x/min RR: 20 x/min T: 36,9’C UC: (-) FHR: (+), irregular, 104-156 x/min

with breech presentation + oligohydramnion + umbilical cord twisting + fetal distress

08.20

11.15

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DM co to GP pro SC, GP co to SPV, SPV: pro SC at 9.30 (Jan 22, 2012)

SC was begun Baby was born, male, 3750 grams, length : 50 cm, AS : 7-9, amnion: clear, anus (+), congenital anomaly (-) Placenta was born manually (+ 500 gr) - complete, Bleeding ± 250 cc -

GC : well BP : 100/60 Pulse : 76x RR : 20x T : 35,5 UC : (+) good UFH : 1 finger ↓ umbilicus UO : 30 cc/hour Active bleeding : (-)

2 hours post SC

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Observe maternal and fetal well being Suggest mother to eat and drink

PR : 148 x/min T : 36’C RR : 56x/min 22/02/20 12 07.30

GC : well BP : 120/90 Pulse : 96x RR : 18x T : 36,7 UC : (+) good UFH : 2 fingers ↓ umbilicus Active bleeding : (-) Baby

1 day post SC

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Observe maternal and fetal well being Suggest mother to eat and drink

PR : 152 x/min T : 36.5’C RR : 54x/min