Morning Report

CASES RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1. G1P0A0H0 A/S/L/IU head presentation Arrested Latent

Phase, 1st stage of labour with history ROM +
polyhidramnion + Drip Failure

TIME

SUBJECTIVE

OBJECTIVE

10/12/
2012
01.30

Patient referred from Kayangan

PHC with G1P0A0H0 A/S/L/IU
with PROM > 12 hours
Patient confessed abdominal
pain that spread to waist since
23.00 (08/12/2012). Histrory
water leaked from her womb (+).
Bloody slim (+), FM (+).
No history of DM, HT, asthma.
LMP : 29-3-2012
EDD : 05-01-2012
History of
Posyandu

ANC

>4x

at

History of USG : never

History of family planning : (-)
Next family planning : Injection 3
months.
Obstetrical History :
I. This

General Status
GC : well
Consciusness : CM
BP : 130/80 mmHg
PR : 80 bpm
RR : 24 bpm
T : 37oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral
(+/+)
Obstetrical Status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 5/5
UFH : 36 cm
EFW : 3565 g
UC :FHB : 10-11-14 (140 bpm)
VT : 1 cm, eff 10%, amnion (+),
head palpable H I, denominator
unclear, impalpable small part /
umbilical cord.

ASSESSMENT
G1P0A0H0 36-37
weeks S/L/IU
head presentation
with PROM> 12
hours

PLANNING
Observe mother and
fetal well being.
Observe progress of
labor.
Inj Ampi (at PHC)
GP consult to SPV:
induction with
oxytosin drip
Observation
proggress of labour
CTG
Rehydration

TIME

SUBJECTIVE
Chronologist at Kayangan PHC :
22.15 (08/12/2012)
S : Abdominal pain spread to frank since
23.00 (8/12/2012). History rupture of
membrane (+), bloody slim (+),FM (+).
O : GC : well
BP : 100/60 mmHg
PR : 86 bpm
RR : 20 bpm
T : 38oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 32 cm
UC : 1x/10~20
FHB : 11-11-12 (136 bpm)
VT : 1 cm, amnion (+) , head
palpable HI , denom unclear,
unpalpable small part / umbilical cord.
A
:
G1P0A0H0
A/S/L/IU
head
presentation with PROM > 12 hours
P:
Tell mother and family about
examination
Consurlt GP: advice

RL 20 tpm
Inj. Ampi

Reffered to GH NTB (22.40 wita)

OBJECTIVE
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 900
Lab Evaluation
HB : 9,4g/dl
RBC : 4,19 M/dl
HCT : 30,9 %
WBC : 20,1 K/dl
PLT : 349 K/dl
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

03.00

PLANNING
Set IVFD D5 with 5 IU
of Oxytosin

03.30

UC: 2x/10~25
FHR: 12-12-12

8 dpm

04.00

UC: 2x/10~25
FHR: 12-11-12

12 dpm

04.30

UC: 2x/10~30
FHR: 12-11-12

16 dpm

05.00

UC: 2x/10~30
FHR: 13-14-13

20 dpm

05.30

UC: 2x/10~30
FHR: 12-14-14

24 dpm

06.00

UC: 2x/10~30
FHR: 12-12-13

28 dpm

06.30

UC: 3x/10~35
FHR: 12-13-14
VT: 2 cm, eff 25%, amnion
(+), head palpable, HI,
inpalpable small part of fetal
and umbilical cord

07.30

Patient confessed intermittent abdominal

pain

Result of USG:
Fetal S/L/IU head
presentation
BPD: 35 w 6 d
AC: 39 w 6 d
FL: 88 mm
Amnion (+), polihydramnion
placenta at posterior fundus

G1P0A0H0
A/S/L/IU head
presentation
Latent Phase,
1st stage of
labour with
history ROM.

32 dpm
- Observation mother
and fetal weel being
- Observe patient 4
hours later

- Consul SPV
- Observation and
continue drip

TIME
10.30

14.00

SUBJECTIVE
Patient confessed intermittent abdominal
pain

OBJECTIVE
UC: 3x/10~40
FHR: 158 bm
VT: 2 cm, eff 50%, amnion
(+), head alpable, HI,
impalpable small part of fetal
and umbilical cord

ASSESTMENT
G1P0A0H0
A/S/L/IU head
presentation
Latent Phase,
1st stage of
labour with
history ROM +
polyhidramnion

PLANNING
Consul SPV: continue
induction
Change to 2nd flash
32 dpm

UC: 3x/10~30
FHR: 12-13-13
VT: 2 cm, eff 50%, amnion
(+), head alpable, HI,
impalpable small part of fetal
and umbilical cord

14.30

2nd flash finished

15.00

Consul SPV
Observation and
change IVFD to RL,
if there is SC, patient
will be followed

16.00

Consul SPV:
SC at 21.00 wita
Pre op Patient:
- Set DC
- Inj Ami 2 gr/IV
- Shave pubic hair
CIE patiern and family

20.30

VT: 2 cm, eff UC:

2x/10~25
FHR: 12-12-12
50%, amnion (+), head

G1P0A0H0
A/S/L/IU head
presentation
Arrested Latent

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

21.10

10.00

PLANNING
CS began
Baby was born
(21.30), Male,
BW:3250 g/50 cm,
anus (+), AS: 7-9
Placenta was born
manually, complete,
bleeding 500 cc

Patient confessed can not move her leg

GC: well
Cons: CM
BP: 110/80 HR: 84 bpm
RR: 24 tpm T: 36,5 C
UC: +
UFH: 2 finger below umbilicus
Urine output: 100 cc

2 hours post SC

Observed mother
and baby well being
Suggest mother to
mobilisation.

1 day post SC

Observed mother
and baby well being
Suggest mother to
mobilisation, eat, and
drink, medication.

Baby in NICU
PR: 120
RR: 50
T: 36,7

11/12/2
012
07.00

GC: well
BP: 110/80
HR: 80 bpm
RR: 20 tpm
T: 36,5 C
UC: +
UFH: 2 finger below umbilicus
Urine output: 100 cc