Morning Report

DOKTER MUDA FK. UNRAM

BAGIAN SMF OBGYN
RSU MATARAM
4 November 2008

Supervisor : dr. Punarbawa, Sp.OG

Dokter Muda Jaga:
1.Nasrullah
2.Sulistiawati
3.Zikrul Haikal
Resume Kasus :
No.

Jenis Kasus

Jumlah

1.

IUFD

2.

PPROM

3.

Footling preentation 1.

4.

Prolong labor with complication

5.

APB e.c placenta previa totalis

6.

Normal Delivery

Name

: Mrs. Salmiah

CTH

: 13 10 - 2009

Age

: 22 years

Pukul

: 18.15

Address

: Banjar Ampenan

Wakt
u

Subject

18.1
5

Patient refered by Tanjung Karang

Community Health Center with
G2P1A0H1
preterm/single/life/intra
uterine
with transverse liy presentation.
cronologis :
Patient felt intermitten abdominal
pain and bloody shows since 03.00
(12-10-2009), then she went to
Tanjung Karang Community Health
Center at 16.30 (13-10-2009). She
feel rupture of amnion membrane
at 18.00 (13.10.09), and the fetal
movement wasnt active since 1 day
ago. History of The examination in
Tanjung Karang Community Health
Center found :
General status : well
BP : 110/80 mmHg
Pulse = 84 x/mnt
RR: 24 x/mnt
Temp = 36,5C
Fetal heart rate = (+) 140 x/mnt
Uterine fundal length = 24 cm
17.00
VT : 10 cm,eff 100 %,

amnion fluid (+), head was

hight.
EFBW : 2015 gr

Object
General status :
General condition: well,
Conciousness: CM
Blood presure: 110/70
RR: 20 x/mnt
Pulse :88 x/mnt
T: 36,5 C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : L2 : left head
L3 : L4 :
Uterine Fundal Length : 22 cm
EFBW : His : (+), 3x/10~40
Fetal Heart Rate : 18.15
VT : 6 cm, eff 75 %, amniotic fluid
(-), right Hand precentation, descend HI.
Lab. result:
HBsAg (-)
Hb : 11,3 gr %
WB = 14.900/mm3
PLT = 232.000
HCT = 33,2 %

Assesment
- G2P1A0H1 preterm/
single/life/intra uterine
tranversal liy
presentation+ active
fase of stage 1 +
suspect IUFD.

Planning
Laboratory
examination
DL,HbSag
informed Supervisor :
- advice : SC.

Wakt
u

Subject

Last menstrual period : march??

Estimate of Delivery Date :
december
History of family planning : Family planning : IUD
ANC : routine in public health
center
Obstetric History :
1. female, traditional attenden, 9
years.
2. Now
Therapy in PHC:
iNfus RL 20 dpm
17.45
Patient reffered to Mataram GH
Reason : baby premature

Object

Assesment

Planning

Waktu

18.45

Subject

Abdominal pain ++

19.15

19.40

Object

Assesment

Planning

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
UC : 2-4x 10 40
FHR -

G2P1A0H1 preterm/
single/life/intra uterine
tranversal liy presentation+
active fase of stage 1 +
suspect IUFD.

Observation maternal well

being
Prepare SC :
Insert Dc
Injection Ampicilin 2 gr IV

BP = 130/80
RR= 24 x/mnt
Tax = 36,8
Pulse = 88 x/mnt
UC : 2-3 x 10 40
FHR -

G2P1A0H1 preterm/
single/life/intra uterine
tranversal liy presentation+
active fase of stage 1 +
suspect IUFD.

Observation maternal
being

stage II of labor

Baby was born death

,maseration +, female, length
39 cm, weight 1500 gram.
Amniotic
fluid
nothing,
placenta low lying position
Placenta was born complete

SC begun

Stage III of Labor

21.40

BP = 100/80
RR= 18 x/mnt
Tax = 36,8
Pulse = 84 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -

stage IV of labor

well

Observation VS, Uterus

Contraction, bleeding and
subjective complain

Waktu

14/10/09
06.00

Subject

Object

BP = 110/80
RR= 20 x/mnt
Tax = 36,5
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -

Assesment
1 st day post SC

Planning

Observation maternal
being

well