Morning Report

August, 31st 2014

Supervisor:
dr. Edi Prasetyo Wibowo, Sp.OG
DM Jaga:
Santi, Faisol, Aluh

Morning Report
st
August 31 2014
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G3P1A1L0 39-40 weeks/S/L/IU

LABOR
head presentation with arrested
active phase + history of ROM

Case 1
Name : Mrs. S
Age : 27 years old
Address : KLU
Admitted : 31-08-2014
No. RM : 54-56-59
G3P1A1L0 39-40 weeks/S/L/IU head
presentation with arrested active
phase + history of ROM

Time

Subject

31-082014
05.10

Patient come to NTB GH,

referred from KLU GH
with G3P1A1L0 39-40
weeks/S/L/IU head
presentation with
prolonged active phase
Patient confessed water
come out from her
womb since 29-08-2014
(23.00) clear, bloody
slim (+), abominal pain
(+) since 30-08-2014
(21.30) and FM (+)
No history of DM, HT,
asthma.
LMP : 28-11-2013
EDD : 5-9-2014
History ANC : 9x at PHC
Last ANC : 18-08-2014
result: BP : 110/70
History of USG (-)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 100/60 mmHg
HR: 72 x/m
RR: 18 x/m
T: 36 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular,
M(-), G(-)
Abd : striae gravidarum
(+), linea nigra (+), scar
(-)
Ext : edema (-/-), warm
(+/+)
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 33 cm
EFW : 3410 gram
UC : 2x/10 ~ 25
FHB : 12-12-11
(140x/min)

Assessment

Planning

G3P1A1L0 39-40
weeks/S/L/IU
head
presentation
with arrested
active phase +
history of ROM

Obs. Mother and

fetal well being
Inj. Ceftriaxon 1
gr/IV
DM co to GP
advice :
rehydration,
CTG
(acceleration if
reactive)

Time

Subject
History of family planning : Next family planning : injection
History of obstetric :
I. /normal/Mataram GH/3300
gr/IUFD/4y
II.Ab 3 weeks
III.This
Cronologist (KLU GH:
30/08/2014)
13.45
S: patient come from Pemenang
PHC with PROM > 12 hours, and
water came out from her womb
since 20.00. 3rd pregnancy 9
months, USG (-), and FM (+).
O: GC well; BP 110/70; HR 84; RR
18; T 36,7
BH 147 cm; BW 69 kg, AC 25;
oedem extremity (-)
UFH 30 cm; EFW 2945 gr; back on
right; UC (-); FHB 12-11-12
(140x/m)
VT: 1 cm, eff. 25%, amnion(-,
head palpable, denom unclear,
H1, unpalpable small
part/umbilical cord
P: co to spv adv induction oxy start
at 4 dpm, observation/30 minutes

Object
VT: 6 cm, eff. 70%,
amnion(-) clear, head
palpable, caput (+),
molase (3), denom unclear,
H2, unpalpable small
part/umbilical cord
Lab (18-08-2014):
HGB = 13 g/dl
RBC = 4.95 K/ul
WBC = 26.90 M/ul
HCT : 35,2 %
PLT = 275 M/ul
BT = 200
CT = 545
HBsAg = (-)

Assessme
nt

Plannin
g

Time

Subject
15.00
UC (-) FHB 144
Drip oxy 4 dpm
15.30
UC (-) FHB 144
Drip oxy 8 dpm
16.00
UC (-) FHB 140
Drip oxy 12 dpm
16.30
UC 1x/10 ~ 15 FHB 148
Drip oxy 16 dpm
17.00
UC 2x/10 ~ 15 FHB 148
Drip oxy 20 dpm
17.30
UC 2x/10 ~ 15 FHB 144
VT: 3 cm, eff. 25%, amnion(-), head palpable,
denom unclear, H1, unpalpable small
part/umbilical cord
Drip oxy 24 dpm
18.00
UC 2x/10 ~ 15 FHB 13-14-12 (156x/m)
Drip oxy stop, oxygen 4 lpm, obs FHB

Object

Assessme
nt

Plannin
g

Time

Subject
18.30
UC 2x/10 ~ 15 FHB 13-13-14 (160x/m)
19.00
UC 2x/10 ~ 15 FHB 12-12-12 (144x/m)
19.30
UC 2x/10 ~ 15 FHB 12-12-12 (144x/m)
Obs. Progres of labor
21.30
VT: 6 cm, eff. 50%, superior portio oedem, amnion
(-), head palpable, H2, unpalpable small
part/umbilical cord
Inj. Ampicillin 1 gr/IV
01.30
VT: 6 cm, eff. 50%, superior portio oedem, amnion
(-), head palpable, H2, unpalpable small
part/umbilical cord
02.00
Co to GP, GP to to SPV adv: referred to NTB GH,
rehydration

Object

Assessme
nt

Plannin
g

Time

Subject

Object

Assessmen
t

Planning

07.15

Do CTG
Co CTG result to GP,
adv: acceleration

08.30

UC: 2x/10 ~ 25
FHB: 12-11-11

Drip oxy start at 8 dpm

09.00

GC : well
GCS: CM (E4V5M6)
BP : 110/60 mmHg
HR: 72 x/m
RR: 18 x/m
T: 36,7 C
UC: 2x/10 ~ 25
FHB: 12-11-11

Drip oxy start at 8 dpm

GP adv: evaluation at
11.00

09.30

UC: 3x/10 ~ 25
FHB: 12-12-11

Drip oxy 12 dpm

10.00

UC: 3x/10 ~ 30
FHB: 12-12-12

Drip oxy 16 dpm

10.30

UC: 3x/10 ~ 35
FHB: 12-12-13

Drip oxy 20 dpm

11.00

UC: 3x/10 ~ 35
FHB: 12-12-12
VT: 8 cm, eff. 77%,
amnion(-)
clear,
head
palpable, caput (+), molase
(1), denom unclear, H2,
unpalpable
small
part/umbilical cord

Prolonged
active phase

Drip oxy 24 dpm

Co to GP, adv: CTG
Co CTG result, adv:
resusitation

Time

Subject

Object

Assessmen
t

Planning

11.30

UC: 3x/10 ~ 40
FHB: 12-12-11

Drip oxy 28 dpm

12.00

UC: 4x/10 ~ 40
FHB: 12-11-11

Drip oxy 28 dpm

12.25

Mother wants to
bearing down

GC : well
GCS: CM (E4V5M6)
BP : 110/70 mmHg
HR: 72 x/m
RR: 18 x/m
T: 36,5 C
UC: 4x/10 ~ 40
FHB: 12-12-11
Inspection: opening vulva
(+), bulging of perineum
(+), pressure of anus (+)

Drip oxy 28 dpm

Conduct the labor

12.30

Baby was born, male,

3500 gram, 52 cm, A-S 68, anus (+), anomaly
congenital (-).
Placenta
was
born
spontaneous, complete.
Bleeding 200 cc
Perineum intact

Time

Subject

Object

Assessment

Planning

14.30

Abdominal pain

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 80x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: +
Lokea rubra (+)

2 hours post
partum

Observation mother
and baby well being
Suggest mother to
eat and drink
Suggest mother to
mobilization
Suggest mother to
early breast feeding

1-092014
7.00
am

Abdominal pain

GC: well
cons:E4V5M6
BP: 110/70 mmHg
PR: 80x/m
RR: 20x/m
T: 36,8 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: +
Lokea rubra (+)

1 day post partum

Observed mother and

baby well being
Suggest mother to
mobilization
Suggest mother to
eat and drink

Baby rooming in:

Pulse : 144 bpm
RR : 68x/m
T : 36,7 C

.. Thank
You ..