MORNING REPORT

September 12th, 2015

Supervisor : dr. Gede Made Punarbawa, Sp.OG
(K)
Medical Students :
Tia
Obstetric Case

Case

NORMAL LABOR

PATHOLOGIC
LABOR

1.

Gynecologic Case

G1P0A0L0 37-38 weeks S/L/IU Head Presentation with PROM > 12

hours

PATIENT IDENTITY

Name
: Mrs. S
Age
: 20 years old
Address
: Narmada
Admitted : September 11th, 2015
No. RM
: 566670

G1P0A0L0 37-38 weeks S/L/IU Head

Presentation with PROM > 12 hours

Time

Subject

11/9/15

Patient referred from Sedau PHC

with G1P0A0L0
37-38 weeks
S/L/IU Head Presentation mother
and fetus well being with latent
phase of labor + PROM > 12
hours.
Patient confessed abdominal pain
and water leaked out from her
womb since 03.00 WITA (11-092015).

19.30
WITA

Object
General condition : Well
GCS : CM (E4V5M6)
BP : 120/80 mmHg
PR : 86 x / m
RR : 20 x/m
Temp : 37 C
General Status
Eyes : an-/-, ict -/Neck: in normal range
Cor : s1s2 single, m -, g
Pulmo : Ves +/+, rh -/-, whz -/Abdomen : linea nigra (+), Striae
gravidarum (+)
Upper Ext : oedem-/-, warm +/+
Lower Ext : oedem-/-, warm -/Obstetrical status:
L1 Breech
L2 Back on the left side
L3 Head
L4 4/5
UFH 29 cm, EFW 2790 g
UC 1x/10 15,
FHB 11-12-12 (140 x/m)
VT: 1 cm, eff 10%, amnion (-)
clear, head palpable, denom
unclear, HI, impalpable small part
of fetal and umbilical cord .

Assessment
G1P0A0L0
37-38 weeks
S/L/IU Head
Presentation
with PROM >
12 hours

Planning
DM planning:
Diagnostic:

Pro CTG
Therapy:
Pro
termination
of

labor with oxy drip

Ampicillin 2 g

CIE
Suggest patient to

eat ,drink and lie down

to left side

Obs
mother
VS,
progress of labor, and
FHB
DM

co
to
GP
for
termination with oxy
drip, GP co to SPV,
SPV advice:
- Termination with oxy drip
- Ampicillin 1 gr/6 hours

Time

Subject
History of Family planning : Next Family Planning : injection 3
months
Chronology at Gunung Sari PHC
(17.00)
S/ patient came to the PHC
confessed abdominal pain and
water leaked out from her womb
since 03.00 WITA 11/09/15.
bloodyslime (+), his (-)
O/ BP: 120/80, HR: 88x/m, RR:
20x/m, T: 36,8.
UFH: 28cm, back on the left side,
head presentation, FHB (+)
140bpm. His (+) 2x10~20.
17.00 : VT 1 cm, eff 10%,
amnion (-), head palpable HII,
impalpable small part of fetal and
umbilical cord . Pelvic seems
normal.
A/ G1P0A0L0
37-38 weeks
S/L/IU Head Presentation mother
and fetus well being with latent
phase of labor + PROM > 12
hours.
P/ IVFD RL 20 dpm
Inj. Ampicillin 1 gr iv

Object
PE: seems normal
Promontorium not palpable
Spina ischiadica not prominent
Arcus Pubis > 900
Os Coxygeus Mobile
PS : 5
Cervic dilatation : 1
Cervix length : 1
Cervix consistency : 1
Cervix position : 1
Station H I : 1
Lab exam
Hb 10,1 g/dL
Rbc 4,52 x 106/uL
Hct 31,8%
Wbc 8,99 103/uL
Plt 295 x103/uL
HBsAg non reactive

Assessment

Planning

Time

Subject

Object

Assessment

Planning

22.00

Abdominal pain (+)

BP : 120/80 mmHg
PR : 88 x / m
RR : 20 x/m
Temp : 36,7C
UC 2x/10 20,
FHB 11-12-11 (140 x/m)

Start
oxytocyn
dpm

drip
on 8

22.30

Abdominal pain (+)

UC 2x/10 25,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
12 dpm

23.00

Abdominal pain (+)

UC 2x/10 25,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
16 dpm

23.30

Abdominal pain (+)

UC 2x/10 30,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
20 dpm

00.00

Abdominal pain (+)

UC 2x/10 30,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
24 dpm

00.30

Abdominal pain (+)

UC 2x/10 30,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
28 dpm

01.00

Abdominal pain (+)

UC 2x/10 35,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
32 dpm

01.30

Abdominal pain (+)

UC 2x/10 35,
FHB 11-12-11 (140 x/m)

drip oxytocyn on
36 dpm

02.00

Abdominal pain (+)

UC 3x/10 35,
FHB 11-12-11 (140 x/m)
VT: 1 cm, eff 15%, amnion (-) clear, head
palpable, denom unclear, HI, impalpable small
part of fetal and umbilical cord .

drip oxytocyn on
40 dpm

Time

Subject

Object

Assessment

Planning

02.30

Abdominal pain (+)

UC 3x/10 35,
FHB 12-12-11 (140 x/m)

drip oxytocyn on
40 dpm

03.00

Abdominal pain (+)

UC 3x/10 35,
FHB 11-12-11 (136 x/m)

drip oxytocyn on
40 dpm

03.30

Abdominal pain (+)

UC 3x/10 35,
FHB 11-12-12 (140 x/m)

drip oxytocyn on
40 dpm

04.00

Abdominal pain (+)

UC 3x/10 35,
FHB 12-12-11 (140 x/m)

drip oxytocyn on
40 dpm

04.30

Abdominal pain (+)

UC 3x/10 35,
FHB 11-12-11 (136 x/m)

drip oxytocyn on
40 dpm

05.00

Abdominal pain (+)

UC 3x/10 35,
FHB 11-12-12 (140 x/m)

drip oxytocyn on
40 dpm

05.30

Abdominal pain (+)

UC 3x/10 35,
FHB 1-12-11 (140 x/m)

drip oxytocyn on
40 dpm

06.00

Abdominal pain (+)

UC 3x/10 35,
FHB 1-12-11 (140 x/m)
VT: 3 cm, eff 25%, amnion (-) clear, head
palpable, denom unclear, HI, impalpable small
part of fetal and umbilical cord .

Latent phase of labor

drip oxytocyn on
40 dpm
DM planning: pro
2nd series of
oxy drip
DM co to GP, GP
co to SPV,
SPV advice :
- Termination with
C-section

Thankyou