Morning Report

September, 1th 2015

Supervisor:
dr. Gede made punarbawa, Sp.OG
DM Jaga:
rian

Morning Report
th
september 1 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G1P0A0L0 27-28 weeks S/L/IU head

presentation + PPI
LABOR

Case 1
Name : Mrs. N I
Age : 23 years old
Address : Batu Layar
Admitted : 31-08-2015
No. RM : 56-60-92
G1P0A0L0 27-28 weeks S/L/IU head
presentation + PPI

TIME

SUBJECTIVE

31/08/201
5
11.15 wita

Patient reffered from Meninting

PHC to NTB GH with G1P0A0
33 weeks S/L/IU head
presentation mother and fetal
well being with plasenta previa
totalis. Patient confessed
vaginal bleeding along with
abdominal pain spread to the
flank (+) since 06.00
(31/08/2015), water leaked out
from her womb (-) bloody
slim(+), FM (+).
History of DM (-), HT (-),
asthma (-) and allergy (-).
LMP : 17/2/2015
EDD : 24/11/2015
History of ANC : 7x at Posyandu
Last result: (29/08/2015)
BP 100/70 mmHg, GW: 33
weeks, UFH 22 cm, transverse
presentation, FHB (+), BW: 49
kg

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,5C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm acral
(+/+).
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 5/5
UFH: 22 cm
EFW : 1550 gr
UC : 1x10 ~15
FHB : 12-12-12
Inspekulo : OUE (-), tissue
(-) active bleeding (-), fluxus
(+), erosion (-), livide (+).

ASSESSMENT
G1P0A0L0 27-28
weeks S/L/IU head
presentation with
suspect placenta
previa totalis

PLANNING
DM planning:
Diagnostic : USG
Therapy : conservative
Nifedipine 3x10 mg
Dexamethasone
6mg/12 hours for 2
days
Monitoring : VS mother,
UC, FHB, observation
for bleeding
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
Suggest mother to
laydown to the left
side.
DM co to GP co to SPV
Conservative,
dexamethasone
12mg/12hours
Nifedipine 3 x 10 mg
USG tomorrow
Observation for
bleeding

TIME

SUBJECTIVE

OBJECTIVE

History of USG : 1x, at SpOG

Last : 05/08/2015
Result : S/L/IU, transverse
presentation GW: 27-28 weeks,
EFW: 1182 gr, sex male, amnion
clear, enough, placenta previa
totalis, EDD 29/10/2015

Laboratory (31/08/2015 10.11):

HB: 9.9 g/dl
RBC: 3.63
HCT: 30.2 %
WBC: 20.84
PLT: 358
HbsAg: non reactive
BT : 230
CT : 600

History of family planning: Next family planning : injection 3

month
Obstetric History:
I. This

Chronologist : at
Meninting PHC (31-082015)
10.25 WITA
S : Patient referred from
midwife confessed about
abdominal pain to the
flank since 30/08/2015
blood come from her
womb since 07.00 wita.
O:
GC : well
Cons : CM
BP : 110/70mmHg
HR : 84x/m
RR : 24x/m
T : 36.5oC

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Obstetric status
Transverse presentation
UFH: 22 cm
EFW : 1550 gr
UC : 2x10~20
FHB : 11-12-11
VT : not do
A : G1P0A0L0 33 weeks S/L/IU
transverse presentation with
placenta previa totalis

P:
Explanation about result of
examination
Informed consent
Consult to GP
Advice infusion RL 28 tpm
Reffered to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME
14.00

SUBJECTIVE
Mother confessed about
abdominal pain

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 90/60 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,6C
UC : 3x10 ~20
FHB : 13-13-13
VT : not do

ASSESSMENT

PLANNING

G1P0A0L0 27-28
weeks S/L/IU head
presentation with
suspect placenta
previa totalis

DM planning:
Diagnostic :
Therapy : Monitoring : VS mother,
UC, FHB, observation
for bleeding
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
Suggest mother to
laydown to the left
side.
DM co to GP :
Inj ceftriaxon 2 gr/IV

TIME
17.15

SUBJECTIVE
Mother confessed about
abdominal pain and water
leaked out from her womb since
17.00 wita

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 96 bpm
RR: 20 bpm
T: 37C
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UC : 3x10 ~30
FHB : 12-13-12
VT : 3 cm, eff 25%, amnion (-)
clear, head presentation, HI,
denominator unclear, sagital
suture transversal, not palpable
small part & umbilical cord
Active bleeding (-)

ASSESSMENT

PLANNING

G1P0A0L0 27-28
weeks S/L/IU head
presentation + PPI
with latent phase
of labor

DM planning:
Diagnostic : Therapy :
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : suggest mother
to laydown at the left
side

TIME
21.35

SUBJECTIVE
Mother wants to bearing down

OBJECTIVE
General status
GC : well
consciousness: CM
UC : 4x10 ~40
FHB : 12-12-12
Inspection : crowning (+)
Vulva opening, pressure of
anus, bulging of perineum

ASSESSMENT

PLANNING

G1P0A0L0 27-28
weeks S/L/IU head
presentation + PPI
with 2nd stage of
labor

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, FHB,
CIE : suggest mother
to squatting
Conduct mother to
bearing down
Episiotomy was done
At 21.45 Baby was
born, male, A-S 3-5,
1400 g, BL 38 cm, HC
24 cm, anus (+)
congenital anomaly (-),
baby in NICU
Placenta was born
uncomplete at 21.55
pro USG
Hecting the episiotomy
Do the management of
4th stage of labor

TIME
23.45

SUBJECTIVE

OBJECTIVE
GC : well
consciousness: CM
BP : 100/60 mmHg
PR: 96 bpm
RR: 20 bpm
T: 37.4C

ASSESSMENT

PLANNING

2 hours post
partum

DM planning:
Diagnostic : USG
Therapy : Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink

1 day post partum

DM planning:
Diagnostic : USG
Therapy : Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink

UC : well
UFH : 2 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU
HR : 158x/minute
RR : 52x/minute
T : 36,1oC
01/09/201
5
07.00

GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 84 bpm
RR: 18 bpm
T: 37.2C
UC : well
UFH : 2 fingers below umbilical
UO : not measured
Active bleeding (-)
Baby in NICU
HR : 154x/minute
RR : 50x/minute
T : 36,3oC

BALLAD SCORE

BALLARD SCORE

KURVA LUBCHENCO ()
11

28-30 weeks, sesuai masa kehamilan

.. Thank
You ..