Morning Report

December 28th 2012

CASE RESUME
NORMAL LABOR

PATHOLOGY LABOR

1. G1P0A0L0, A/S/L/IU with neglected 2nd stage of

labour
2. G2P1A0L1 42-43 Wk S/L/IU with prolonged 2nd
stage of labour

Time

Subject

Object

Chronology in Gerung GH:

28/12/2012,
14.30
S: Patient referred from PHC
jembatan kembar with
rupture of membrane since,
morning with green color
and serotinus..
O: General status : GC well, BP
120/80 mmHg, HR
80x/minute, RR 18x/minute,
T 36,5C.
Obstetric status:
L1 : breech TFU: 31cm
EFW:3100 gr
L2 : back on the left side
L3 : head
L4 : 3/5
UC : 2x/10 20
FHR : 184x/minutes( 15-15-15 )
VT : 3cm, amnion (-), eff.
25%, head palpable, HI
denom unclear, impalpable
small part of fetal & umbilical
cord,

Pelvic Evaluation :
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 90

A: G1P0A0 A/S/L head

palpable GC mother well,
fetus GC is bad laten phase
1st stage of labor with fetal
distress.

Lab result in 28/12/2012,

Hb = 10,9 g/dl
Rbc = 4,60
Leu = 15,56
Plt = 340
Hct = 34,2
HbSAg = (-)

Assessment

Planning

Time

Subject
P:
- Obs. Mother and fetal well
being.
-Obs. Progress of labor.
-Inj. ampicillin1 g/12h (in PHC,
2 times, 10.30).
- rehidration RL : D5 = 2: 1 + O2

Object

Assessment

Planning

Time

Subject

Object

Assessment

16.45

-DM co GP and , GP co
to SPV advice
observation labor .

17.00

DJJ : 11-11-11 ( 132 x/m )

His : 3 x 10 40

G1P0A0H0,
A/S/A/IU with
neglected 2nd stage
of labor .

17.15

DJJ : 11-11-11 ( 132 x/m )

His : 3 x 10 40

G1P0A0H0,
A/S/A/IU with
neglected 2nd stage
of labor .

17.30

DJJ : 11-11-11 ( 132 x/m )

His : 3 x 10 40

G1P0A0H0,
A/S/A/IU with
neglected 2nd stage
of labor .

17.50

Planning

-DM co GP to SC. but

GP co to SPV.
-GP co SPV pro CS,
SPV advice: acc
preparet CS.
-CIE patient and family
to CS, and acc.
-Insert DC.
-Skin test, result (-), Inj.
Ceftriaxon 2g/IV.

Time
18.30

Subject
-

Object
-

Assessment

Planning
CS began
Baby was born (19.00),
Male, BW :3600 gram,
BL: 50 cm, A-S : 7-9,
anus (+), congenital
anomaly (-),
Placenta was born
spontanely, complete.
Bleeding : 300 cc
Intra operative finding:
Caput (+) at LOA,
amnion meconeal.

19.30

CS finished

Time
21.30

29/12/12
07.00

Subject
-

Object

Assessment

Planning

GC : well
BP : 110/60mmHg
PR : 100x/minute
RR : 24x/minute
T : 36,1C
UC: (+)
UFH : 2 finger below umbilicus
UO: 550 cc/6 h
Lochea: (+)

2 hours post CS.

-Obs. Mother and baby

well being.
-CIE mother to eat and
drink.

GC : well
BP : 120/70 mmHg
PR : 84x/minute
RR : 24x/minute
T : 36,6C
UC: +
UFH : 2 finger below umbilicus
UO : 1000 cc
Lochea: (+)

1 day post CS.

-Obs. Mother and baby

well being.
-CIE mother to eat,
drink, and mobilization.

Baby in NICU:
Set ET to give ASI
PR : 136x/minute
RR : 36x/minute
T : 36,5C