Morning Report

August, 4th 2014

Supervisor:
dr. Agus Thoriq, Sp.OG
dr. I Made Putra Juliawan, Sp.OG
DM Jaga:
Zia, Yid, Santi, Ayu, Ria

Morning Report
nd
August 2 2014
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G1P0A0L0 39-40 wks/S/L/IU with

LABOR
breech presentation + protracted
active phase

Case 1
Name : Mrs. LS
Age : 26 years old
Address : Moyo Hulu, SBW
Admitted : 02-08-2014
No. RM : -G1P0A0L0 39-40 wks/S/L/IU with
breech presentation + protracted
active phase

Time

Subject

02-082014
09.40

Patient come to NTB GH,

referred from Sumbawa
GH with G1P0A0L0 3940 wks/S/L/IU with
breech presentation.
Patient confessed
abdominal pain since 0108-2014 (18.00) water
come out from her
womb since 31-07-2014
(15.00), bloody slim (+),
and FM (+).
No history of DM, HT,
asthma.
LMP : 28 10 2013
EDD : 04 08 2014
History ANC : 7x at PHC
Last ANC : 14-05-2014
result: BP : BP: 120/80
mmHg, UFH 25 cm, head
presentation, FHB (+)
History of USG: -

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 84 x/m
RR: 20 x/m
T: 36,6 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
M(-), G(-)
Abd : striae gravidarum
(+), linea nigra (+), scar
(-)
Ext : edema (-/-), warm
(+/+)
Obstetric status
L1 : head
L2 : back on the right
side
L3 : breech
L4 : 4/5
UFH: 31 cm
EFW : 3100 gram
UC : 2x/10 ~ 30
FHB : 13-12-12

Assessment

Planning

G1P0A0L0 39-40
wks/S/L/IU with
breech
presentation +
active phase

Obs. Mother and

fetal well being
Observation
progress of
labor
Partograf

Time

Subject

Object

History of family
planning : Next family planning :
IUD

VT: 6 cm, eff. 25%, amnion

(-) meconeal, breech
palpable, denom sacrum,
H1, unpalpable small
part/umbilical cord

History of obstetric :
I. This
Chronologist:
Sumbawa GH
(31/07/2014 19.30)

Lab:
HGB = 10.7 g/dl
RBC = 3.86 K/ul
WBC = 8.81 M/ul
HCT : 32.7 %
PLT = 196 M/ul
HBsAg = (-)

Assessment

Planning

Time
10.30

Subject
Abdominal
wound pain

Object

Assessmen
t

Planning

UC: 2x/10 ~ 30
FHB: 12-12-12

11.00

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

11.30

UC: 2x/10 ~ 30
FHB: 12-12-12

12.00

UC: 3x/10 ~ 30
FHB: 12-13-12

12.30

UC: 3x/10 ~ 30
FHB: 12-13-12

13.00

UC: 3x/10 ~ 30
FHB: 12-12-13

13.40

GC: well
BP: 120/80 mmHg
HR: 82 bpm
T 36,70C
RR 20 x/m
UC: 3x/10 ~ 40
FHB: 12-12-12
VT: 9 cm, eff. 25%,
amnion (-) meconeal,
breech palpable, denom
sacrum, H1, unpalpable
small part/umbilical cord

Protracted
active phase

Co to SPV, adv: CS at
15.00
Preop

Time

Subject

Object

Assessme
nt

15.30

Planning
CS began
Baby was born , female
with body weight 3000
gr, AS 7-9, BL 49 cm.
Placenta was born ,,
complete.
Bleeding 300 cc.

18.00

Patient
confessed
asbdominal
wound pain

BP: 120/70 mmHg

HR: 88 pm
RR: 20 tpm
T: 37,5 0C
TFU; 1 finger bellow
umbilicus
UC: +
Active bleeding: (-)
UO: 100cc/2 hours

2 hours post
CS

Observation VS of mother
and baby
Observation of bleeding
Drip oxytocin + Ketorolac
20 tpm

03-082014
7.00
am

Abdominal
wound pain

GC: well cons:E4V5M6

BP: 100/60 mmHg
PR: 80x/m
RR: 20x/m
T: 36,8 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 500cc/8 hour
Lokea rubra (+)

1 day post
CS

Observed mother and

baby well being
Suggest mother to
mobilization
Suggest mother to eat
and drink

Time
04-082014
7.00
am

Subject
Abdominal
wound pain

Object
GC: well
cons:E4V5M6
BP: 100/60 mmHg
PR: 80x/m
RR: 20x/m
T: 36,8 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 500cc/8 hour
Lokea rubra (+)

Assessme
nt
2 day post
CS

Planning
Observed mother and
baby well being
Suggest mother to
mobilization
Suggest mother to eat
and drink

Morning Report
th
July 30 2014
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G1P0A0H0 39-40 weeks/ S/L/IU

LABOR
head presentation + prolong 2nd
stage of labor

Case 1
Name : Mrs. I
Age : 23 years old
Address : Montong, Lobar
Admitted : 30-07-2014
No. RM : 54-34-47
G1P0A0H0 39-40 weeks/ S/L/IU
nd
head presentation + prolong 2nd
stage of labor

Time

Subjective

Objective

Assasement

Planing

30072014
12.00

Patien reffered from

Narmada PHC with
G1P0A0H0 38-39 weeks/
S/L/IU head presentation
+ prolonged active
phase. Mother and baby
well.

General Status
GC: weell
GCS: E4V5M6
BP: 130/80 mmHg
HR: 70 bpm
RR: 20 bpm
T: 37 0C

G1P0A0H0 3940 weeks/

S/L/IU head
presentation +
arrested active
phase

Obs. Mother and

baby well being
DM co to GP, GP co
to SPV, adv:
amniotomy
(evaluation 30
minutes, if no
progress, vacum)

Mother confess
abdominal pain since
02.00 (28/07/2014),
water leak out from her
womb (-). Bloody slym
(+), and FM (+).

Local Status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh
(-/),
wh (-/-)
Cor : S1S2 single
regular M(-), G(-)
Abd : striae
gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (-/-)

History of DM (-), HT(-),

asthma (-).
LMP: 25-10-2013
EDD: 01-08-2014
History of ANC; 9x d PHC
Last ANC: BP 110/70
mmHg, UFH 30 cm, BW
52 kg.
USG: Obstetrical history
I. This

Obstetric status
UFH: 36 cm
EFW 3875 gram
UC: 2x10-30
FHB : 11-12.12
L1 : breech
L2 : back on the right
side
L3 : head presentation
L4 : 3/5

Do amniotomy

Tim
e

Subjective

Objective

Chronologist
At Narmada PHC 06.00 (30/07/14)

VT : 8 cm, eff 90%,

Amnion (+), head
palpable HII,
denominator ROA,
impalpable small part
of fetal & umbilical
cord.

S: mother 9 month of 1st pregnancy

come and confess abdominal pain
since 04.00 (30/07/14) , bloody slim
(+), water came out (-), FM (+), LMP
25-10-2013.
O: GC: well, GCS: CM
BP: 110/80 mmHg
HR: 76 bpm
RR: 19 bpm
T: 36,7 0C
Obstetrical status:
UFH: 31 cm
Back on the left side, head presentation
4/5
UC: 3x10-40
FHB: 11-11-12 (136 bpm)
VT: 6 cm, eff 75%, amnion (+), head
palpable, HI, denom unclear,
impalpable small part of fetus ar
umbilical cord.
A: G1P0A0H0 38-39 weeks S/L/IU with
active phase
P: obs. Mother and fetal well being and
progress of labor, suggest to eat and

Lab Examination
Hb: 10,3 g/dl
RBC: 3,84 10 /ul
Hct: 31,1 %
WBC: 19,25 10/ul
Plt: 366 10/ul

Assessme
nt

Planing

Time

Subjective
10.00
S: O:
GC: well Conc: CM
BP: 110/70
HR: 80 bpm
RR: 20 bpm
T: 36,6 0C
UC: 4x/10 ~ 40
FHB: 11-12-12 (140x/m)
VT: 8 cm, eff 75%, amnion (+) , head
palpable, HI+ , denom ROA, impalpable small
part of fetus ar umbilical cord.
A: P:
Co to GP
Rehydration, inj. Ampicillin 1 gr/IV, evaluation
progress of labor, if no progress, refer to NTB GH
11.00
VT: 8 cm, eff 75%, amnion (+) , head
palpable, HI+ , denom ROA, impalpable small
part of fetus ar umbilical cord.
A: P: referred to NTB GH

Objective

Assasemen
t

Planing

Time

Subjective

Objective

13.1
5

Patient
confessed
abdominal pain

Amniotomy (amnion 30 cc)

VT : 8 cm, eff 90%, Amnion (-)
clear, head palpable HII,
denominator ROA, impalpable
small part of fetal & umbilical cord.

Evaluation 30
minutes after
amniotomy

GC: well
BP: 120/70 mmHg
HR: 88 pm
UC: 3x/10 ~ 30
FHB: 12-13-13
VT : 9 cm, eff 90%, Amnion (-),
head palpable HII, denominator
ROA, impalpable small part of fetal
& umbilical cord.

Co to SPV, adv:
Acceleration
Report progres of
labor at 16.00

UC: 3x/10 ~ 30
FHB: 12-12-13

Drip oxytocin 12 dpm

13.4
5

14.3
0
15.0
0

15.3
0

Patient
confessed
abdominal pain
more
frequently

UC: 3x/10 ~ 45
FHB: 12-13-13
VT : complete, Amnion (-), head
palpable HII, impalpable small
part of fetal & umbilical cord.
UC: 3x/10 ~ 45
FHB: 12-12-13

Assasemen
t

Planing

Drip oxytocin 5IU in

D5% 500 cc (14.00) 8
dpm

2nd stage of
labor

Drip oxytocin 16 dpm

Drip oxytocin 16 dpm

Time

Subjective

Objective

Assaseme
nt

Planing

16.00

Patient confessed
abominal pain

UC: 3x/10 ~ 45
FHB: 12-13-13
VT : complete,
Amnion (-), head
palpable, caput (+)
HII, impalpable
small part of fetal &
umbilical cord.

Neglected
2nd stage of
labor

Drip oxytocin 16 dpm

Co to SPV, adv: CS, stop drip
(RL 20 dpm)

13.45

GC: well
BP: 120/70 mmHg
HR: 88 pm
UC: 3x/10 ~ 30
FHB: 12-13-13
VT : 9 cm, eff 90%,
Amnion (-), head
palpable HII,
denominator ROA,
impalpable small part
of fetal & umbilical
cord.

Co to SPV, adv:
Acceleration
Report progres of labor at
16.00

14.30

UC: 3x/10 ~ 30
FHB: 12-12-13

Drip oxytocin 12 dpm

15.00

UC: 3x/10 ~ 30
FHB: 12-13-13

Drip oxytocin 16 dpm

15.30

UC: 3x/10 ~ 45
FHB: 12-13-12

Drip oxytocin 20 dpm

Drip oxytocin 5IU in D5% 500

cc (14.00) 8 dpm

Time

Subjective

Objective

Assasement

17.00

20.00

Planing
CS began
Baby was born
(17.13), male with
body weight 3700
gr, AS 7-9, BL 51
cm.
Placenta was
born, complete.
Bleeding 450 cc.

Patient confess
abdominal wound
pain

BP: 120/70 mmHg

HR: 88 pm
RR: 20 tpm
T: 37,5 0C
TFU; 1 finger bellow
umbilicus
UC: +
Active bleeding: UO: 70cc/2 hours

2 hours post CS

Observation VS of
motherand baby
Observation of
bleeding
Drip oxytosin+
Cetorolac 28 tpm

Time

Subjective

31-072014
07.00

Objective

Assasement

Planing

BP: 120/70 mmHg

HR: 86 pm
RR: 24 tpm
T: 36,2 0C
TFU; 2 finger bellow
umbilicus
UC: +
Active bleeding: UO: 220 cc/ 3 hours
Baby in NICU

1 day post CS

Observation
mother and baby
Early mobilisation
Early breast
feeding

Baby in NICU:
HR: 120 bpm
RR: 42 bpm
T: 37,2 T

03-082014
07.00

BP: 120/70 mmHg

HR: 86 pm
RR: 24 tpm
T: 36,2 0C
Baby:
HR: 120 bpm
RR: 42 bpm
T: 37,2 T

Patient go home

.. Thank
You ..