Morning Report

July, 21st 2014

Supervisor:
dr. I Made Putra Juliawan, Sp.OG
DM Jaga:
Zia, Yid, Santi, Ayu

Morning Report
st
July 21 2014
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G3P1A1L1 37-38 wks/S/L/IU with

LABOR
history of ROM + history of CS
2. G1P0A0H0 40 weeks/ S/L/IU head
presentation + prolong 2 nd
stage of labor and failed of VE

Case 1
Name : Mrs. N
Age : 16 years old
Address : Gn.sari, Lobar
Admitted : 21-07-2014
No. RM : 54-48-09
G2P0A1L0 29-30 weeks/S/L/IU head
presentation + PROM > 24 hours

Time

Subject

21-072014
12.00

Patient come to policlinic

NTB GH, referred from
Sigerongan PHC with
G2P1A0L1 A/S/L/IU head
presentation with
suspect macrosomia.
Patient confessed water
come out from her
womb since 17-08-2014
(02.00 am), bloody slim
(-), abominal pain (+)
and FM (+).
No history of DM, HT,
asthma.
LMP : 24 January 2014
EDD : 03 November
2014
History ANC : 8x at
Posyandu
Last ANC : 18-08-2014
result: BP : 110/70, BW
41 kg, 29-30 weeks, UFH
23 cm, head
presentation, FHB (+)

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 84 x/m
RR: 20 x/m
T: 36,6 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 right
side
L3 : head
L4 : 4/5
UFH: 35 cm
EFW : 3720 gram
UC : (-)
FHB : 12-12-12

Assessment

Planning

G2P1A0L1
A/S/L/IU with
latent phase

Obs. Mother and

fetal well being
Pro CTG
Preop CS

Time

Subject
History of USG : 1x
Last USG (18-082014): S/L/IU head
presentation, female,
placenta at fundus
grade II, 28-30
weeks , EFW 1377 gr,
EDD : 01/11/2014
History of family
planning : Next family planning :
injection
History of obstetric :
I. AB 3 months
II.This

Object
VT: 2 cm, eff. 25%, amnion
(+), head palpable, denom
unclear, H1, unpalpable
small part/umbilical cord
Lab:
HGB = 10.7 g/dl
RBC = 3.86 K/ul
WBC = 8.81 M/ul
HCT : 32.7 %
PLT = 196 M/ul
HBsAg = (-)

Assessment

Planning

Time

Subject

14.00

16.00

Abdominal
wound pain

Object

Assessmen
t

Planning
Do CTG
Co to GP, acc drip

GC: well
BP: 120/80 mmHg
HR: 82 bpm
T 36,70C
RR 20 x/m
UC: 2x/10 ~ 20
FHB: 11-12-12

Start acceleration
(oxytocin drip) 8 dpm

16.30

UC: 2x/10 ~ 20
FHB: 12-12-12

Oxytocin drip 12 dpm

17.00

UC: 2x/10 ~ 20
FHB: 12-11-12

Oxytocin drip 16 dpm

17.30

UC: 2x/10 ~ 20
FHB: 12-12-12

Oxytocin drip 20 dpm

Time
17.30

Subject
Patient
confessed
abdominal pain

Object
UC: 4x/10 ~ 40
FHB: 13-13-12 (152x/mnt)
VT: 8 cm, eff. 80%,
amnion (-) clear, head
palpable, denom unclear,
H1, unpalpable small
part/umbilical cord

Assessmen
t

Planning

Active phase
of labor

Left lateral decubitus

Suggest mother to eat &
drink

20.00

GC: well
BP: 120/80 mmHg
HR: 82 bpm
T 36,70C
RR 20 x/m
UC: 4x/10 ~ 40
FHB: 12-12-12

Oxytocin drip 32 dpm

20.30

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

Oxytocin drip 32 dpm

21.00

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

Oxytocin drip 32 dpm

Time

Subject

Object

Assessmen
t

Planning

21.30

UC: 4x/10 ~ 40
FHB: 12-12-12
VT: 6 cm, eff. 25%,
amnion (+), head palpable,
denom unclear, H1,
unpalpable small
part/umbilical cord

Oxytocin drip 32 dpm

Ganti drip flash II

22.00

Patient
confessed water
came out from
her womb

UC: 4x/10 ~ 40
FHB: 12-11-11
VT: complete, eff. 100%,
amnion (-) clear, head
palpable, denom unclear,
H2, unpalpable small
part/umbilical cord
Inspection: perineum
bulging, opening vulva,

Oxytocin drip 32 dpm

Conduct the labor

Mother wants to
bearing down

22.30

Baby was born, male,

3500 gram, 50 cm, A-S 79, caput (-), anus (+),
anomaly congenital (-).
Placenta
was
born
spontaneous, complete.
Bleeding 100 cc
Perineum intact

Time

Subject

Object

Assessment

Planning

01.30

Abdominal pain

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 79x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 150cc/ 2 hours
Lokea rubra (+) 10cc

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

22-072014
7.00
am

Abdominal wound
pain

GC: well
cons:E4V5M6
BP: 100/60 mmHg
PR: 80x/m
RR: 20x/m
T: 36,8 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 60cc/hour
Lokea rubra (+) 5 cc

1 day post partum

Observed mother and

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

Baby:
Pulse : 144 bpm
RR : 52x/m
T : 36,7 C

.. Thank
You ..