DELIIVERY ROOM REPORT

Tuesday, February 16th 2016

SUPERVISOR

dr. Christoffel L. Tobing, Mked(OG), SpOG. K

Residents : 1. dr. Vivi Yovita

2. dr. Paul Alwin Khoman
3. dr. Dian Riani Siregar

Department of Obstetrics and Gynecology

Medical Faculty, University of Sumatera Utara
dr. Pirngadi General Hospital
2016

Reported:
1. Preterm Labor + Ovarian Cyst + PG + IUP ( 2728) wga + Live Fetus

No
1

Income
Mrs. F, 29 yo, G1P0A0
Diagnosis:
Preterm Labor + Ovarian
Cyst + PG + IUP ( 27- 28)
wga + Live Fetus

Outcome
Therapy :
- IVFD RL 20 drips/minute
- Inj Dexamethasone 12 mg Single Dose
- Inj Buscopan 1 amp
Planning
- Monitor vital signs, uterine contractions
and FHR
- Observe progress of labor
- Spontaneus Vaginal Delivery

Follow up 14/2/2016 at
08.00 am
CC : infrequent uterine contraction
SP : Sens : Alert
Anemic
: (-)
BP
: 120/80 mmHg
icteric
HR
: 96 x/I Dyspnoe: (-)
RR
: 18 x/I Sianotic : (-)
T : 36.8C
Oedem : (-)
SL :
Abd
: enlarged symetrically
TFU
: difficult to asses
Tension, head
: diffucult to asses
Movement
: (+)
Uterine contraction
: difficult to asses
Fetal Heart rate : 155x/I

: (-)

 Gynecologic State:
VT
: Cx axial, 3 cm, eff 100 %, H I-II,
blood (+),
amniotic membrane (+),
minor fontanel ?
Hand gloves
: blood (+), amniotic fluid (-)

Dx : Preterm Labor + PG + IUP (27-28) wga + Live Fetus +

Ovarian Cyst
Th :
- IVFD RL 20 gtt/I
- Inj. Dexamethasone 12 mg Single Dose
Planning :
- Monitor vital signs, uterine contractions and FHR
- Observe progress of labor

Follow up 14/2/2016 at
10.00 am
CC : infrequent uterine contraction
SP : Sens : Alert
Anemic
: (-)
BP
: 120/70 mmHg
icteric
HR
: 90 x/I Dyspnoe: (-)
RR
: 20 x/I Sianotic : (-)
T : 36.5C
Oedem : (-)
SL :
Abd
: enlarged symetrically
TFU
: difficult to asses
Tension, head
: diffucult to asses
Movement
: (+)
Uterine contraction
: difficult to asses
Fetal Heart rate : 148 x/I

: (-)

 Gynecologic State:
VT
: Cx axial, 4 cm, eff 100 %, H I-II,
blood (+),
amniotic membrane (+),
minor fontanel ?
Hand gloves
: blood (+), amniotic fluid (-)

Dx : Preterm Labor + PG + IUP (27-28) wga + Live Fetus +

Ovarian Cyst
Th :
- IVFD RL 20 gtt/I
Planning :
- Monitor vital signs, uterine contractions and FHR
- Observe progress of labor

Follow up 14/2/2016 at
02.00 pm
CC : uterine contraction
SP : Sens : Alert
Anemic
: (-)
BP
: 120/85 mmHg
icteric
HR
: 88 x/I Dyspnoe: (-)
RR
: 20 x/I Sianotic : (-)
T : 36.6 C
Oedem : (-)
SL :
Abd
: enlarged symetrically
TFU
: difficult to asses
Tension, head
: diffucult to asses
Movement
: (+)
Uterine contraction
: difficult to asses
Fetal Heart rate : 150 x/I

: (-)

 Gynecologic State:
VT
: Cx axial, 4 cm, eff 100 %, H I-II,
blood (+),
amniotic membrane (-),
minor fontanel ?
Hand gloves
: blood (+), amniotic fluid (+)

Dx : Preterm Labor + PG + IUP (27-28) wga + Live Fetus +

Ovarian Cyst
Th :
- IVFD RL 20 gtt/I
- Inj Ceftriaxone 1 gram/12 jam (skin test)
- Inj buscopan 1 amp IM

Planning :
- Monitor vital signs, uterine contractions and FHR
- Observe progress of labor

FOLLOW UP February 15th 2016

Time

BP
(mmH
g)

Pulse
rate
(time/
i)

RR
(time
/i)

Temp
(0 C)

FHR
(time
/i)

08.00

120/80

96

18

36,8

155

09.00
10.00

Uterine
Contrac
tions

Note

VT : Cx axial, 3 cm,
eff 100 %, H I-II,
blood(+), amniotic
membrane (+),
minor fontanel ?
Hand gloves : blood
(+), amniotic fluid (-)

1st PATIENT
144
148

VT : Cx axial, 4 cm,
eff 100 %, H I-II,
blood (+), amniotic
membrane (+),
minor fontanel?
Hand gloves : blood
(+), amniotic fluid (-)

FOLLOW UP February 15th 2016

Time

BP
(mmHg)

Heart
rate
(x/i)

RR
(x/i)

Temp
(0 C)

FHR
(x/i)

11.00

120/80

88

24

36,5

148

12.00

144

13.00

150

14.00

144

15.00
14.00
15.000

1st PATIENT
148

110/80

78

20

36,6

144
140

UTERINE
CONTRACTIO
NS
(In 10
minutes)

THANK YOU