Morning Report

24 April 2016
Supervisor : dr. Juliawan,
SpOG
DM : Brian, Nanda, Shinta,
Tyas, Vita

Case 1

Name : Mrs. NH
Age : 32 years old
RM : 57-73-17
Address : Penimbung
Admitted : 24th April 2016

Time
24th
April
2016
05.00

Subject
Patient referred from Penimbung
PHC with G2P1A0L1 aterm S/L/IU
head presentation with inpartu
latent phase first stage of labor +
history of C-section. Patient
confessed abdominal pain (+)
since 21.00 (23/04/2016), water
leaked from her womb (+) since
22.00 (23/04/2016), bloody slime
(+), FM (+).
History of DM (-), HT (-), asthma
(-), allergy (-).
Family History (-)
LMP : 05 / 07 / 2015
EDD : 12 / 04 / 2016
GW : 41-42 week
History ANC : 9x at PHC
Last ANC: 22-04-2016,
Result GW 40 weeks, BP : 90/70
mmHg, head presentation, UFH:
27cm, FHB (+) 136x.
History of USG : 1x at Sp.OG
Last USG: 02/02/2016
Result: S/L/IU, head presentation
GW 26-28 weeks, placenta at
fundus, amnion enough, EFW 913
gr, AFI clear.
History of family planning:
Inj. 3 month
Next family planning: Inj. 3 month

Object
General status
GC : well
Consciousness: CM
BP : 100/60 mmHg
PR: 89 tpm
RR: 18 tpm
T: 36,3C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), rhonchi (-/-).
Abdomen : striae (+), linea
nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on left side
L3 : head
L4 : 4/5
UFH : 29 cm
EFW : 2750 gr
FHB: 11-11-12
UC : 3 x 10 ~ 35
VT : 4cm, eff 50%, amnion (-)
clear, head presentation,
denom LOA, HI, small part or
umbilical cord unpalpable.

Assessment
G2P1A0L1 41-42
week S/L/IU head
presentation with
inpartu active phase
first stage of labor +
history of C-section
1x.

Planning
DM Planning:
Diagnostic:
CBC, HbsAg
CTG
Monitoring:
Obs. Mother and fetal
well being
Obs. Progress of
labor with WHO
partograph
Inj. Ceftriaxone 2
gr/IV.
DM co to GP, GP co to
SPV, SPV advice:
Inj. Ceftriaxone 2
gr/IV.

Time

Subject
Obstetric history:
1. Male/ aterm/ SC/ PROM/
Bhayangkara Hospital/ 3910 gr/
5y.o./ Alive.
2. This

Object
Lab:
HB: 12,7
RBC: 4,31
HCT: 36,7
WBC: 20,02
PLT: 239
HbsAg: (-)

Assessment

Planning

Time
24/04/
2016
03.15

Subject
Chronology at Penimbung PHC:
S:
Patient confessed abdominal pain (+)
since 22.00 (23/04/2016)
O:
General status
GC : well
Consciousness: CM
BP : 100/70 mmHg,
PR : 80 ppm,
RR : 20 rpm,
T : 36, 5 C.
L1 : breech
L2 : back on left side
L3 : head
L4 : UFH : 27 cm
UC: 2x10~30
FHB: (+) 136 tpm
EFW: 2480 gr
VT: 1 cm eff 25%, amnion (+),
head palpable, HI, denom
unclear, small part or umbilical
cord unpalpable.
A:
G2P1A0L1 aterm S/L/IU head
presentation, mother and fetal in
good condition with inpartu latent
phase first stage of labor with history
of SC.
P:
- IVFD: RL 28 dpm

Object

Assessment

Planning

Time

Subject

Object

Assessment

Planning

08.30

Abdominal pain (++), mother

wants to bear down.

General status
GC : well
Consciousness: CM
BP : 100/70 mmHg
PR: 78 tpm
RR: 20 tpm
T: 36C
FHB: 12-12-12
UC : 4 x 10 ~ 40
VT: complete eff 100%,
amnion (-), head palpable,
HIII, small part or umbilical
cord unpalpable.

2nd stage of labor

Obs. Mother and fetal

well being
Obs. sign of labor

09.00

Abdominal pain (+++), mother

wants to bear down, mother
feels tired.

General status
GC : well
Consciousness: CM
BP : 110/70 mmHg
PR: 80 tpm
RR: 22 tpm
T: 36,7C
FHB: 12-11-12
UC : 4 x 10 ~ 40
Head apears at vulva
Bulging of perineum
Open vulva
Pressure of anus

2nd stage of labor

- Conduct labor

Time
09.15

09.30

10.00

Subject
Abdominal pain (+++), mother
feels tired.

Abdominal pain (+) minimal

Abdominal pain (+) minimal

Object

Assessment

General status
GC : well
Consciousness: CM
BP : 100/70 mmHg
PR: 78 tpm
RR: 24 tpm
T: 36,8C
FHB: 13-12-12
UC : 4 x 10 ~ 40

2nd stage of labor

General status
GC : well
Consciousness: CM
BP : 110/70 mmHg
PR: 80 tpm
RR: 24 tpm
T: 36,5C
UFH: as high as umbilicus

Third stage of labor

General status
GC : well
Consciousness: CM
BP : 100/70 mmHg
PR: 90 tpm
RR: 22 tpm
T: 36,6C
UFH: as high as umbilicus
Post partum bleeding: 300 cc

Fourth stage of labor

+ post partum
bleeding

Planning
Suggest to accelerate
second stage of labor
with vacuum extraction
DM co to GP, GP co to
SPV, SPV advice:
- Episiotomy
- Vacuum extraction
- In hour, if the baby
isnt born consul
again for SC
indication.
Baby was born
spontaneously, male,
2750 gr, AS 6-8, BL 49
cm, HC 31 cm, anus
(+), congenital anomaly
(-)
Placenta was born
complete at 09.35
Monitoring:
- Obs. Bleeding
Therapy:
- RL 1 kolf with
oxytocin 2 amp (28
dpm).
CIE:
- Mothers condition
- Mother to eat and
drink
- Mother to continue
her medication

Time
11.30

Subject
Confessed (-)

Object
General status
GC : well
Consciousness: CM
BP : 100/70 mmHg
PR: 92 tpm
RR: 24 tpm
T: 36,7C
UFH: 2 finger below umbilicus

Assessment
2 hours post partum.

Planning
Monitoring:
- Obs. Bleeding
CIE:
- Mothers condition
- Mother to eat and
drink
- Mother to continue
her medication
Moved patient to
Segara Anak

25/04/2016
06.00

Confessed (-)

General status
GC : well
Consciousness: CM
BP : 100/70 mmHg
PR: 92 tpm
RR: 24 tpm
T: 36,7C

1 day post partum.

Suggest:
- Mother to eat and
drink
- Mother to continue
her medication

Case 2

Name : Mrs. P
Age : 18 years old
RM : 57-73-19
Address : Malaka, Pemenang
Admitted : 24th April 2016

Time
24th
April
2016
08.30

Subject
Patient referred from Tanjung GH
with P1A0L1 2 hours post partum
+ rupture perineum grade IV.
Patient confessed bleeding from
her womb (+) after the proses of
labor at Setangi PHC since 05.17
(24/04/2016). History of
episiotomy (+), The babys BW
3500 gr. Patient confessed
headache and weakness, active
bleeding (-).
History of DM (-), HT (-), asthma
(-), allergy (-).
Family History (-)
History of family planning:
Inj. 3 month
Obstetric history:
1. Male/ 9 month/ PHC/
3500 gr/ 1 day/ Alive.

Object
General status
GC : moderate
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 37,5C
Local status
Eye : anemic +/+, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-), rhonchi (-/-).
Abdomen : striae (+), linea
nigra (+).
Extremity : edema (-/-), warm
acral (+/+), pale (+/+).
Tampon was inserted inside
the vagina.
Active bleeding (-)
The rupture was up to the
anus.
Lab:
HB: 10,5
RBC: 3,73
HCT: 29,9
WBC: 22,17
PLT: 375
HbsAg: (-)

Assessment
P1A0L1 post partum
day 1 with rupture
perineum grade IV.

Planning
DM Planning:
Diagnostic:
CBC, HbsAg
Therapy:
IVFD RL
Inj. Antibiotic
Obs. GC and vital
sign.
Perineum repairment.
DM co to GP, GP co to
SPV, SPV advice:
Inj. Ceftriaxone 2 gr
Perineum repairmen
grade IV in the
operating room.

Time
23/04/
2016
22.30

Subject
Chronology at Nipah PHC:
S:
Patient referred from Stangi
Poskesdes with confessing
abdominal pain (+) since 23.00
(22/04/2016), water leaked from her
womb (+) since 20.30 (23/04/2016),
bloody slime (+), This is the first
pregnancy.
LMP: 08-07-2015
EDD: 15-04-2016
O:
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg,
PR : 82 ppm,
RR : 22 rpm,
T : 36 C.
Local status
Eye : anemic -/-, icteric -/Thorax: symmetries
Extremity : edema (-/-)
Obstetric status
L1 : breech
L2 : back on left side
L3 : head
L4 : 4/5
UFH : 30 cm
UC: 2x10~25
FHB: (+) 11-12-11
EFW: 2945 gr
VT: 2 cm eff 25%, amnion (-), head
palpable, HI, denom unclear,
small part or umbilical cord
unpalpable.
A: G1P0A0H0 41-42 weeks S/L/IU
head presentation, mother and fetal
in good condition with inpartu latent
phase first stage of labor.
P:

Object

Assessment

Planning

Time
24/04/
2016
02.30

Subject
Chronology at Nipah PHC:
S:
Patient confessed abdominal pain
(+).
O:
General status
GC : well
Consciousness: CM
BP : 140/100 mmHg,
PR : 82 ppm,
RR : 22 rpm,
T : 36,5 C.
UC: 2x10~30
FHB: (+) 11-11-12
VT: 8 cm eff 75%, amnion (-), head
palpable, HII, small part or
umbilical cord unpalpable.
A:
G1P0A0H0 41-42 weeks S/L/IU head
presentation, mother and fetal in
good condition with inpartu active
phase first stage of labor.
P:
- CIE the mothers condition
- Mother to eat and drink
- Suggest mother to lay to the left
side.
- Rehydrate with RL II flas
- Obs. UC, if the UC is adequate
stop the rehydration.
- If BP >160 give anti-hypertension
- If BP < 160 continue the
rehydration.

Object

Assessment

Planning

Time
24/04/
2016
04.30

Subject
Chronology at Nipah PHC:
S:
Patient confessed abdominal pain (+
++).
O:
General status
GC : well
Consciousness: CM
BP : 140/100 mmHg,
PR : 82 ppm,
RR : 20 rpm,
T : 36,5 C.
UC: 3x10~45
FHB: (+) 12-12-11
VT: 10 cm eff 100%, amnion (-),
head palpable, HIII, small part or
umbilical cord unpalpable.
A:
P:
- Mother was taught how to
bear down.
- Conduct the labor
- Epiciotomy

Object

Assessment

Planning

Time
24/04/
2016

Subject
Chronology at Nipah PHC:
S:
-

05.15
O:
Rupture perineum grade IV
A:
P:
Baby was born complete, BW: 3500
gr, BL: 53 cm, HC: 35 cm
Therapy:
- RL flas III, and continue with flas
IV 30 dpm.
- Tampon
- Referred to Tanjung PHC.

Object

Assessment

Planning

Time
24/04/
2016
07.15

Subject
Chronology at Tanjung GH:
S:
Patient referred from Nipah PHC with
rupture perineum grade IV.
O:
General status
GC : well
Consciousness: CM
BP : 140/80 mmHg,
PR : 85 ppm,
RR : 20 rpm,
T : 36,9 C.
UFH: 2 finger below umbilicus
Active bleeding (-)
Rupture perineum grade IV.
A:
2 hours Post partum with Rupture
perineum grade IV
P:
- IVFD: RL flash III
- DC
- Inj Cefotaxime 1 gr/IV

Object

Assessment

Planning

Time
09.00

10.00

12.00

Subject
Confessed (-)

Confessed (-)

Confessed (-)

Object

Assessment

Planning

General status
GC : moderate
Consciousness: CM
BP : 120/90 mmHg
PR: 96 tpm
RR: 20 tpm
T: 36,5C

P1A0L1 post partum

day 1 with rupture
perineum grade IV

CIE about the patient

condition.
PRC

General status
GC : moderate
Consciousness: CM
BP : 120/100 mmHg
PR: 92 tpm
RR: 24 tpm
T: 37 C

P1A0L1 post partum

day 1 with rupture
perineum grade IV

Inj. Ceftriaxone 1 gr

General status
GC : well
Consciousness: CM
BP : 120/100 mmHg
PR: 96 tpm
RR: 20 tpm
T: 36,8 C

2 hours post
operation

Obs. Bleeding

DM co to GP, GP co to
SPV, SPV advice:
Rupture perineum
repairment.

Patient moved to
operating room

Moved to Segara anak