Morning Report

CASES RESUME
NORMAL LABOR
PATHOLOGY LABOR

1. G2P1A0L1 A/S/L/IU head presentation with

neglected 2nd stage of labour

TIME

SUBJECTIVE

25/12/
2012
15.30

Patient referred from Gangga

PHC with G2P1A0L1 A/S/L/IU
head presentation with
prolonged 2nd stage of
labour. Patient confessed
abdominal pain (+) since
03.00 24/12/2012. Bloody
slim (+). History rupture of
membrane (+) since 10.20
25/12/2012, Fetal Movement
(+). Dizziness (-)
No history of DM, HT,
asthma.
LMP: April 2012 (firs week)
EDD: History of ANC: 7x at
posyandu
Last ANC: 13/12/2012
Result : Normal
History of USG: 1x in SpOG
(6/11/2012)
History of family planning:
Injection 3 month
Next family planning:
Injection 3 month
Obstetrical history :
I.Aterm, Spontan, Polindes,
Midwife, 3900 gr, Female,
Life, 8 YO
II.This

OBJECTIVE
General status :
GC: Well
Cons : Composmentis
BP: 100/70 mmHg
PR: 88 bpm
RR: 22 bpm
T: 37,1, C
Local Status :
Eye : Anemic (-/-), icteric (-/-)
Thorax :
Cor : S1S2 single reguler,
murmur (-), Gallop (-)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae gravid
(+), linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical status:
L1: breech
UFH:
29 cm
L2: back on the right side
EFW: 2635 g
L3: head
L4: 2/5
UC: (3x10~45)
FHB: 12-12-13 (148 x/min)
VT: Complete, Amnion (-),
meconeal, H III, caput (+),
denom LOA, impalpable small
part of fetus or umbilical cord

ASSESTMENT
G2P1A0L1
A/S/L/IU head
presentation
with neglected
2nd stage of
labour

PLANNING
Obs mother & fetal
well being
Check CBC HBsAG.
Rehidration with
RL:D5% 2:1
Give ceftriaxon 1
gr/IV
DM suggest to GP
to VE, GP co to
SPV, SPV advice:
VE

TIME

SUBJECTIVE

OBJECTIVE
Lab:
HB: 12,0 g/dl
RBC: 4,23 x106/l
HCT: 36,2 %
WBC: 23,79 x103/l
PLT: 290 x103/l
HbSAg: (-)

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

Chronologist at Genggelang
Polindes:
07.15(25/12/2012)
S : Patient came Genggeleng
Polindes
confessed
abdominal
pain
that
spread to waist since
03.00 25/12/2012
O : VT : 6 cm, amnion (+),
portio thick and stiff, head
palpable HI +,
UC : 3x10
P : Suggest mother to eat
and drink
Suggest mother to walk,
if no abdominal pain
10.20
S : Mother confessed want to
bearing down
O : VT : 10 cm, portio not
palpable,
amnion
(-),
unclear, head palpable
HIII,
P

UC : 5x10 ~ 40
: Suggest mother
bearing down

to

11.20
O:
FHB : 138x/minutes, head
palpable H III, UC :
5x10~40

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
12.00 (25/12/2012)
S : Mother still bearing down
O : VT : 10 cm, head
palpable HIII, caput (+)
FHB : 140x/minutes
P : Give motivation to patient
to referred to Gangga PHC
IVFD

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
Chronologist at Gangga PHC:
12.50 (25/12/2012)
S :
Patient referred from
Genggeleng
Polindes
confessed abdominal pain
that spread to waist since
03.00 25/12/2012
O : General Status : Mother
and fetal well
Consciousness
:
Composmentis
BP : 110/80 mmHg
PR : 88 bpm
RR : 20 tpm
T : 36,6 C
UFH : 35 cm
EFW : 3720 gr
UC : 4x10~40
FHB : 11-12-11 (136 bpm)
L1 : Breech
L2 : Back on the right side
L3 : Head
L4 : 2/5
VT : 10 cm, eff 100%,
amnion (-), head palpable
HIII , caput (+), denom
LOA, impalpable small
part of fetus/ umbilical
cord.

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
A : G2P1A0L1 A/S/L/IU head
presentation,
with
neglected 2nd stage of
labour
P : IVFD RL 2 flash 28 dpm
(13.30)
Co to GP adv : suggest
mother to eat and drink,
suggest mother to
bearing down, if in 30
minutes no progress,
referred to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

17.10

PLANNING
VE start, with 1
traction, baby was
born male, A-S 6-8
BW:3000 gr, BL:49
cm
Placenta was born
spontaneously,
complete,
Bleeding : 300 cc

19.10

GC: well
Cons: CM
BP: 110/70
HR : 88 bpm
RR : 20
tpm
T : 36,6 C
UFH : 1 finger below umbilicus
UC : +

2 hours post VE

Observed mother
and baby well being
Suggest mother to
mobilisation.

26/12/
2012
07.00

GC: well
Cons: CM BP: 120/80 HR : 72 bpm RR :
16 tpm
T : 36,9 C
UFH : 2 finger below umbilicus UC : +

1 day post VE

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

Baby in NICU:
PR:148 RR: 52 T: 36,4