MORNING REPORT

October 11th, 2012

Supervisor : dr. Agus Rusdhy

Hamid, Sp.OG
Medical Students :
Diah, Rani, Dini F, Subi, Indah
CASES RESUME

NORMAL LABOR

PATHOLOGY LABOR

1. G3P2A0L2 A/S/L/IU with PROM >12 hours (death

case)
2. G2P0A1L0 A/S/L/IU transverse lie + active phase 1st
stage of labor + history rupture of membrane +
prolapse umbilical cord
3. G4P3A0L3 A/S/L/IU head presentation latent phase 1st
stage of labor + history ROM + prolaps umbilical cord
+ fetal distress
4. G1P0A0L0 A/S/L/IU with prolonged 2nd stage of labor
5. G2P1A0L1 Preterm/S/IUFD

Name : Mrs. N (060587)

Age
: 36 yo
Adress : Sandik Atas, Gunung Sari,
LOBAR
Admitted: October, 11th 2012

TIME

SUBJECTIVE

11/10
/2012
12.20

Patient
reffered
from
Meninting
PHC
with
G3P2A0L2
A/S/L/IU
with
PROM <12 hours. Patient
confessed water come out
from her womb since 04.00
(11/10/2012),
clear.
Abdominal pain (-), bloody
slim (-), FM (+).
No history of DM, HT,
asthma, cardiac disease
LMP : forgot
History of ANC : >4x at
Posyandu, PHC
Last ANC : 15-09-2012
History of USG : 2x at PHC
History of family planning :
injection 3 months
Next family planning : IUD
Obstetrical History :
I.Aterm, female, 2400 g, TBA,
15 th
II.Aterm, female, 2600 g,
midwife, 6 th
III.Ini

OBJECTIVE
General Status
GC : well
Consciusness : CM
BP : 110/80 mmHg
PR : 86 bpm
RR : 22 bpm
T : 36,5oC
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 right side
L3 : head
L4 : 4/5
UFH : 31 cm
EFW : 3100 gr
UC :FHB : 12-11-12 (136 bpm)
VT : 1 cm, eff 10%, amnion
(-), head palpable H I,
denominator unclear,
impalpable small part /
umbilical cord.

ASSESSMENT

PLANNING

G3P2A0L2
A/S/L/IU head
presentation
with PROM < 12
hours

Observation
mother & fetal well
being.
Skin test (-)
Inj.Ampicilin
1gr/IV (13.20)
Observation until
12 hours

TIME

SUBJECTIVE
Chronologist : 11.00
(11/10/12)
S : patient 9 month
pregnancy came to
Meninting PHC confessed
water come out from her
womb since 04.00
(11/10/2012)
O:
BP : 120/80 mmHg
PR : 80 bpm
RR : 24 tpm
Temp : 36,5OC
UFH : 33 cm, breech at
fundus, back on the left
side, head presentation,
head was in 4/5 part
FHB : 136 bpm
VT: 1 cm, eff 10%, amnion
(-), clear, head palpable
HI, denom unclear,
unpalpable small part /
umbilical cord.
A : G3P2A0L2 S/L/IU head
presentation with latent
phase 1st stage of labor
and PROM
P: Refrred to NTB GH

OBJECTIVE
Lab Evaluation
HB : 11,9 g/dl
RBC : 3,83 M/dl
HCT : 39,0 %
MCV : 101,7 fL
MCH : 31,1 pg
MCHC: 30,5 g/dL
WBC : 12,4 K/dl
PLT : 343 K/dl
HbSAg : (-)

ASSESSMENT

PLANNING

TIME
14.20

SUBJECTIVE
Abdominal pain (-)

OBJECTIVE

ASSESSMENT

GC : well
UC :FHB : 12-12-12 (140 bpm)
VT : 1 cm, eff 10%, amnion (-),
head palpable H I, denominator
unclear, impalpable small part /
umbilical cord.

16.20

PLANNING
CTG
Result:
reactive

G3P2A0L2
A/S/L/IU head
presentation with
PROM > 12
hours

DM announce
to SPV pro
induction
SPV advice :
acc

16.30

UC :FHB : 12-12-11

Induction began
Oxytocin drip
start 8 dpm

17.00

UC : 1X10-25
FHB : 11-11-11

Oxytocin drip
12 dpm

17.30

UC : 1X10-25
FHB : 12-11-11

Oxytocin drip
16 dpm

18.00

UC : 1X10-30
FHB : 12-12-11

Oxytocin drip
20 dpm

18.30

UC : 2X10-35
FHB : 12-13-12
VT : 1 cm, eff 10%, amnion (-),
head palpable H I, denominator
unclear, impalpable small part /
umbilical cord.

Oxytocin drip
24 dpm

19.00

UC : 2X10-35
FHB : 12-13-13

Oxytocin drip
28 dpm

19.30

UC : 2X10-35

Oxytocin drip

20.00

UC : 2X10-35
FHB : 12-12-12

Oxytocin drip
36 dpm

20.30

UC : 2X10-35
FHB : 12-11-12

Oxytocin drip
40 dpm

21.00

UC : 3X10-35
FHB : 12-12-12

Oxytocin drip
maintenance

21.30

UC : 3X10-35
FHB : 12-12-12

Oxytocin drip
maintenance

22.00

UC : 3X10-35
FHB : 12-12-13

Oxytocin drip
maintenance

22.30

Intermitent abdominal pain

UC : 3X10-35
FHB : 12-12-12
VT : 3 cm, eff 25%, amnion (-),
head palpable H I, denominator
unclear, impalpable small part /
umbilical cord.

Inpartu latent
phase 1st of labor
with history
rupture of
membrane

Oxytocin drip
maintenance

22.40

Patient audible bearing

down

GC : cyanosis
Consciousness : coma
BP : unpalpable
PR : unpalpable
RR : apneu
T : cold

Susp. Amnion
emboli

O2 5 L/m
Change oxy drip
with RL, fast
drip
Trendelenburg
position

DM came to patients bed

FHB : 11-11-11
22.43

DM co to SPV,
SPV advice:
move patient
to ICU
Call ICU, ready

22.45

FHB : 7-6-7

Patient in ICU

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING
In ICU:
DM and ICU
Nurse do:
Bagging
CPR
Inj. Adrenalin
and SA
No respon

23.00

23.30

FHB: (-)

Fetal death

Cont:
Bagging
CPR
Inj. Adrenalin
and SA
DC Shock
No respon

Patient dead

Tell to family