Morning Report

Oct 25th, 2017

Supervisor : dr. Windiana Rambu, Sp.OG
Medical Students :
Fulqy, Ayu, Auliya

CASES RESUME
Normal Labor -
Pathology Labor 1. G3P2A0H1 A/S/L/IU with 2nd stage of labor with severe
preeclampsia
2. G1P0A0H0 34-35 weeks S/L/IU head presentation
inpartu latent phase first stage of labour with
prematurity
3. G3P2A0H1 A/S/L/IU inpartu active phase first stage
of labour with preeclampsia
4. G1P0A0H0 38-39 weeks S/L/IU with severe preeclampsia

Remain Patient
Tidak ada pertanyaan yang salah
 Case 1
• Name : Mrs. IR
• Age : 30 yo
• Address : Gunung Sari, West Lombok
• Admitted : 24 October 2017
• RM : 598121
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

24/10/20 Patient referred from Gunung Sari PHC General status: G3P2A0H1 DM planning:
17 with G3P2A0L2 39-40 weeks S/L/IU GC: well A/S/L/IU with 2nd Diagnostic:
15.30 head presentation, with active phase 1st BP: 130/90 mmHg stage of labor with • labratorium
stage of labor severe preeclampsia. PR: 80 bpm severe • Urinalysis (protein)
Patient confessed abdominal pain since RR: 20 bpm preeclampsia, susp
12.00 (24/10/2017). Headache (-), Blurry T: 36,7 macrosomia
vision (-), epigastric pain (-). History Therapy:
water leaked out from her womb (-) Localis status • Bolus MgSO4 40%
Bloody slime (-), FM (+). Eye : an (-/-), ict (-/-) 4gr in 10cc aquabides,
Pulmo: ves (+/+), rh (-/-), wh (-/-) inject IV 5-10 minute
No history of DM, HT, asthma. Cor : S1S2 single regular, murmur (-), • Drip MgSO4 40% 6gr
gallop(-) in RL 500cc, 28 dpm
LMP: 18-1-2017 Abdomen: • Nifedipin 3 x 10 mg
EDD: 25-10-2017 Scar (-), striae gravidarum (+), linea once a day
GW: 39-40 weeks nigra (+) • DC
Extremity: oedema (+/+), warm (+/+)
History of ANC: 5x at PHC
Last ANC: 12/10/2017 Obstetrical status: SPV advice :
Result BP 110/70, head presentation, L1: breech - Pro SC
GW 38-39 weeks, TFU 37 cm L2: back on the right side
L3: head
History USG : 1x (28/7/17) L4: 4/5
29-30 weeks, 1740 gr, EDD 10/10/17, UFH: 39 cm
amnion enough, placenta at corpus grade EFW: 4340 gr
II UC: 3x10’ - 30’’
FHB: 11-11-12 (132x/m)
History of family planning: injection VT: Ø full dilatation, amnion (+),
Next family planning: injection head palpable, ↓HI, denominator front
left fontanel
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
Obstetrical history: Laboratory (24/10/2017):
I. Male/polindes/normal/midwife/3500gr/10yo HGB: 12,4
II. Male/PCH/normal/midwife/2600gr/3yo RBC: 4.44
III.this HCT: 38,1
WBC: 10,62
PLT: 221

Hbs Ag non reactive

Protein: +2
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

16.00 Abdominal pain (+), FM (+) GC : well G3P2A0H1 A/S/L/IU Pro termination with SC
BP : 130/90 mmHg with 2nd stage of labor •Drip Cefotaxim 2gr
PR : 84 bpm with severe
RR : 24 bpm preeclampsi •CIE The mother and
T : 36,7 oC Family about therapeutic
UC : (+) 3x10’~30’’ planning
FHB: 12-11-11 (136x/m)

17.30 C-Section Start

Baby was born, male, BW:

4050, BL: 53cm, AS 6-8,
amnion clear, anus +,
anomaly congenital -.

Placenta was born

complete at 17.50

19.30 No complaint General status 2 hours post SC -Obs. VS, UC, bleeding
GC : well -Obs mother and baby well
GCS: CM (E4V5M6) being
BP : 130/60mmHg
PR: 76 tpm
RR: 20 tpm
T: 36,8°C
UC: well
UFH: 1 fingers below umbilicus
Bleeding (–)
CTG
Buku KIA
USG
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TERIMA KASIH
 Case 2
• Name : Mrs. SI
• Age : 26 yo
• Address : Sigerongan
• Admitted : October 25th 2017
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23/10/ Patient referred from Sigerongan PHC General Status : G2P1A0L1 35-36 DM planning:
2017 with diagnose G2P1A0H1 35 weeks GC : well weeks S/L/IU head Diagnostic
S/L/IU head presentation with inpartu BP : 130/90 mmHg presentation with •CBC, HbsAg
23.20 latent phase first stage of labour PR : 80 bpm latent phase first •CTG
WITA confessed obdominal pain spread to RR : 20 bpm stage of labor with
her back since 13.00 WITA (23/10/17). Temp : 36,5oC prematurity Observation:
bloody slim (+), water leaked out from •Obs. Mother and fetal well
her womb (-), FM (+) Eye : an (-/-), icteric (-/-) being.
Cor : S1S2 single reguler, murmur
History HT (-), DM( (-), Asthma (-), heart (-), gallop (-). Therapy:
disease (-) Pulmo : vesikuler (+/+), •Infus RL 20 tpm
wheezing (-/-), ronkhi (-/-). •Nifedipin intial dose 30mg,
LMP:20-02-2017 Abdomen : scar (-), striae (+), next 8 hours 20 mg,
EDD:27-11-2017 linea nigra (+). maintanance dose 3x10mg
GW: 35-36 weeks Extremity : edema (-/-), warm
acral (+/+).
History of ANC: 10x at PHC DM co to GP, GP co to SPV,
Last ANC (13/09/2017) Obstetrical status: SPV advice:
Result: BP=120/80 mmHg, BW=58 kg L1 : Breech - Observation mother and
34-35 weeks, UFH=25cm, head L2 : Back on the left side fetal well being
presentation L3 : Head - Keep pregnancy
L4 : 4/5 - Treat as premature
History of USG: - UFH : 26 cm labor-> dexametasone,
EFW : 2325 gram nifedipin
History of family planning : - UC : 1x10’-20’’ - Patient sent to VK teratai
Next family planning : - FHR : 12-12-13 (148 bpm)
History of Obstetric : VT: Ø 31cm, eff 10 %, amnion
1. Aterm/PHC/Normal/Midwife/Fem (+), head palpable, HI
ale/3000gr/4 years
2. This
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
24/10/ Patient went to usg Result: Fetal S/L/IU head Advice spv: Pro Termination with
2017 presentation 36-37 weeks, EFW: induction oxytosin
2400-2500gr oligohydramnion
09.00 (SDP < 1,5cm)
WITA

11.00 Contraction (-) FM (+) FHB : 12-12-11 Drip oxytocin 8 dpm (Flash I)
UC: -
11.30 Contraction (-) FM (+) FHB : 12-12-11 Drip oxytocin 12 dpm
UC: -
12.00 Contraction (-) FM (+) FHB : 12-12-12 Drip oxytocin 16 dpm
UC : -
12.30 Contraction (-) FM (+) FHB : 12-12-12 Drip oxytocin 20 dpm
UC :-
13.00 Contraction (- ) FM (+) FHB : 12-11-11 Drip oxytocin 24 dpm
UC :-
13.30 Contraction (-) FM (+) FHB : 13-12-12 Drip oxytocin 28 dpm
UC :-
14.00 Contraction (+) FM (+) FHB : 12-12-12 Drip oxytocin 32 dpm
UC :1 x 10’ ~ 25”

14.30 Contraction (+) FM (+) FHB : 12-11-11 Drip oxytocin 36 dpm

UC : 1 x 10’ ~ 25”

15.00 Contraction (+) FM (+) FHB : 13-12-12 Drip oxytocin 40 dpm

UC : 1 x 10’ ~ 25”

15.30 Contraction (++) FM FHB : 13-12-12 Drip oxytocin 40 dpm

(+) UC : 2 x 10’ ~ 35”
16.00 Contraction (++) FM FHB : 13-12-12 Drip oxytocin 40 dpm
(+) UC : 2 x 10’ ~ 35”

16.30 Contraction (++) FM FHB : 13-13-13 Drip oxytocin 40 dpm

(+) UC : 2 x 10’ ~ 35”
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
17.00 Contraction (++) FM (+) FHB : 12-12-11 Drip oxytocin 40 dpm (Flash II)
UC: 2 x 10’ ~ 35”
17.30 Contraction (++) FM (+) FHB : 12-12-11 Drip oxytocin 40 dpm
UC: 2 x 10’ ~ 35”
18.00 Contraction (++) FM (+) FHB : 12-12-12 Drip oxytocin 40 dpm
UC : 2 x 10’ ~ 35”
18.30 Contraction (++) FM (+) FHB : 12-12-12 Drip oxytocin 40 dpm
UC :2 x 10’ ~ 35”
19.00 Contraction (++) FM (+) FHB : 12-11-11 Drip oxytocin 40 dpm
UC :2 x 10’ ~ 35”
19.30 Contraction (++) FM (+) FHB : 13-12-12 Drip oxytocin 40 dpm
UC :2 x 10’ ~ 35”
20.00 Contraction (+++) FM (+) FHB : 12-12-12 Drip oxytocin 40 dpm
UC :3 x 10’ ~ 35”
20.10 Abdominal pain (+), fetal Bulging of perineum, 2nd stage of labor Conduct the labor
movement (+), mother want pressure of anus,
to bearing down opening of vulva The baby was born At 20.15,
Male, BW 2700 gram, BL 45 cm,
AS 7-9 anus (+), congenital
anomaly (-), amnion mekoneal
20.30 3rd stage of labor •Placenta was born complete,
bleeding : ± 150 cc,
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

22.30 No complaint General status 2 hours post partum •Obs. Mother and baby well
GC : well being.
GCS: E4V5M6 • CIE mother to mobilization, eat
BP : 110/70 mmHg and drink and breast feeding
HR: 92 bpm
RR: 20 bpm
T: 36,5 °C
UC : (+) well
UFH : 2 fingers below
umbilical
Bleeding : ± 100 cc
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