Morning Report

20 April 2016
Supervisor : dr.Agus Thoriq ,
SpOG
DM : Ana, Bela, Brian, Dimas,
Vita

Case 1

Name : Mrs. SN
Age : 21 years old
RM : 57-71-48
Address : Sedau, Lombok Barat
Admitted : 20th April 2016

Time
20th
April
2016
23.00

Subject
Patient referred from Sedau PHC
with G1P0A0L0 40-41 weeks
S/L/IU head presentation with
prolonged second stage of labor.
Patient confessed abdominal
pain (+) since 17.00
(19/04/2016), bloody slime (+)
since 06.00 (20/04/2016), water
leaked from her womb (+) since
08.00 (20/04/2016), FM (+).
History of DM (-), HT (-), asthma
(-), allergy (-).
LMP : 08 / 07 / 2015
EDD : 15 / 04 / 2016
GW : 40-41 week
History ANC : 6x at PHC
Last ANC: 11-02-2016,
Result GW 30 weeks, BP :
120/70 mmHg, BW: 55 kg, head
presentation, UFH: 21cm, FHB
(+) 130x, edema (-). Lab
(07/03/2016): Hb 11,0 gr%.
History of USG : History of family planning: Next family planning: Obstetric history:
1. This

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,6C
Local status
Eye : anemic -/-, icteric -/Cor : S1S2 single regular,
murmur (-), gallop (-).
Pulmo : vesicular (+/+),
wheezing (-/-),
rhonchi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+).
Extremity : edema (-/-), warm
acral (+/+).
Obstetric status
L1 : breech
L2 : back on right side
L3 : head
L4 : 3/5
UFH : 31 cm
EFW : 3100 gr
FHB: 12-12-12
UC : 1 x 10 ~ 10
VT : complete, eff 100%,
amnion (-), head presentation,
caput (+) HII, small part or
umbilical cord unpalpable.

Assessment
G1P0A0L0 40-41
weeks S/L/IU head
presentation with
neglected second
stage of labor.

Planning
DM Planning:
Diagnostic:
CBC
CTG
Therapy:
Ceftriaxone inj. 2 gr.
Termination per
abdominal
DM co to GP, GP co to
SPV, SPV advice:
Termination per
abdominal

Time

Subject

Object
Lab (20/04/2016):
HB: 10,3
RBC: 4,13
HCT: 32,5
WBC: 15,80
PLT: 278
HbsAg: (-)

Assessment

Planning

Time
20/04/
2016
14.00

Subject
Chronology at Sedau PHC
(20/04/2016):
S:
Patient confessed abdominal pain
(+)
O:
General status
GC : well
Consciousness: CM
BP : 110/70 mmHg,
PR : 80 ppm,
RR : 20 rpm,
T : 36, 7 C.
L1 : breech
L2 : back on right side
L3 : head
L4 : 4/5
UFH : 30 cm
UC: 2x10~30
FHB: (+) 140 tpm
EFW: 2945 gr
VT: 4 cm eff 25%, amnion (+),
head palpable, HI, small part or
umbilical cord unpalpable.
A:
G1P0A0L0 40-41 weeks S/L/IU
head presentation, mother and fetal
in good condition with latent phase
first stage of labor.
P:
- CIE about the patient condition.
- Suggest mother to eat and drink.
- Obs. Sign of labor 4 hours again.

Object

Assessment

Planning

Time
20/04/
2016
18.00

Subject
Chronology at Sedau PHC
(20/04/2016):
S:
Patient confessed abdominal pain (+
+)
O:
General status
GC : well
Consciousness: CM
BP : 100/70 mmHg,
PR : 80 ppm,
RR : 20 rpm,
T : 36,5 C.
UC: 4x10~40
FHB: (+) 140 tpm
VT: 8 cm eff 75%, amnion (+),
head palpable, HII, small part or
umbilical cord unpalpable.
A:
G1P0A0L0 40-41 weeks S/L/IU
head presentation, mother and fetal
in good condition with inpartu active
phase first stage of labor.
P:
- CIE about the patient condition.
- Suggest mother to eat and drink.
- Suggest mother to lay to the left
side.
- Obs. Mother and fetal well being.
- Obs. Sign of labor 2 hours again.

Object

Assessment

Planning

Time
20/04/
2016
20.00

Subject
Chronology at Sedau PHC
(20/04/2016):
S:
Patient confessed abdominal pain (+
++)
O:
General status
GC : well
Consciousness: CM
VT: complete eff 100%, amnion
(-), head palpable, HII+, small
part or umbilical cord
unpalpable.
A:
G1P0A0L0 40-41 weeks S/L/IU
head presentation, mother and fetal
in good condition with second stage
of labor.
P:
- CIE about the patient condition.
- Conduct the labor
- Inj. Ampicillin 1 gr / iv

Object

Assessment

Planning

Time
20/04/
2016
21.00

Subject
Chronology at Sedau PHC
(20/04/2016):
S:
O:
General status
GC : well
Consciousness: CM
FHB : 11-12-11 (136)
Bulging of perineum (-)
Pressure of anus (-)
A:
Second stage of labor.
P:
- Rehydration: RL 3 kolf 28 dpm

Object

Assessment

Planning

Time
20/04/
2016
22.00

Subject
Chronology at Sedau PHC
(20/04/2016):
S:
Confessed abdominal pain (+)
O:
General status
GC : well
Consciousness: CM
BP : 110/80 mmHg,
PR : 82 ppm,
RR : 20 rpm,
T : 36,5 C.
FHB: (+) 140 tpm
A:
G1P0A0L0 40-41 weeks S/L/IU
head presentation with prolonged
second stage of labor.
P:
- Refer to NTB GH

Object

Assessment

Planning

Time
01.30

Subject
Abdominal pain (+)

Object
General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,7C
FHB: 12-12-12
UC : 3 x 10 ~ 30

Assessment
G1P0A0L0 40-41
weeks S/L/IU head
presentation with
neglected second
stage of labor.

01.50

Planning
C-section start at
operating room NTB
GH

Baby was born female,

3000 gr, AS 7-9, BL 47
cm, HC 34 cm, anus
(+), congenital anomaly
(-)
Placenta was born
complete at 02.00
Baby moved to NICU

04.00

No complaint

General status
GC : well
Consciousness: CM
BP : 120/70 mmHg
PR: 84 tpm
RR: 20 tpm
T: 36,6C
UC: well
UFH: 1 fingers below umbilicus
Active bleeding (-)
Baby in NICU
HR: 140 x/min
RR: 35 x/min
T: 36,3 C

2 hours post Csection

- Obs. mother and baby

well being

Time
06.00

Subject
No complaint

Object

Assessment

Planning

General status
GC : well
Consciousness: CM
BP : 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
T: 36,7C
UC : well
UFH: 1 fingers below umbilicus
Active bleeding (-)

1st day post C-section

- Obs.mother and baby

well being

Baby in NICU
HR: 140 x/min
RR: 38 x/min
T: 36,5 C

Remaining Case

Name
: Mrs. M
Age : 31 years old
Address : Ampenan
Admitted : April 19th, 2016
No. RM : 12 76 19

Time
19/04/2016
13.00 wita

Subject
Patient from obstetric polyclinic with
G1P0A0L0 41 weeks S/L/IU head
presentation mother dan fetal in
good condition. Patient confessed
abdominal pain (-), bloody slime(-),
FM (+)
No history of DM, HT, asthma(-).

Object
General condition : Well
GCS : CM
BP : 110/80 mmHg
HR : 80 bpm
RR : 20 bpm
Temp : 36,4C

Local status
Eye : an (-/-), ict (-/-)
LMP : 10-07-2015
Pulmo: ves (+/+), rh (-/-), wh
EDD: 17-04-2016
(-/-)
GW: 40-41 weeks
Cor : S1S2 single regular m(-),
g(-)
History of ANC : 11 x at PHC and Abd : striae gravidarum (+),
NTB GH
linea alba (+), scar (-)
Last result: (19/04/2016)
Ext : warm (-/-) edema (-/-),
BP 120/70 mmHg, BW 75 kg, GW
38-39 wk, UFH: 29 cm, head
Obstetrical status:
presentation, FHB (+) 12-12-11
L1 : Breech
L2 : Back on the left side
History of USG : 1 x at OBGYN
L3 : Head
Last result: (19/04/2016)
L4 : 4/5
Fetal S/L/FHB (+), BPD: 35wk, AC:
UFH : 30 cm
38 wk, FL: 35 wk, EFW: 3032 gr,
EFW: 2945 gr
placenta in corpus anterior grade III,
UC : amnion enough
FHB 12-12-12 (132 x/m)
VT : 1 cm, eff 25%, amnion
History of Family planning : implant
(+), head palpable, H I,
Next Family Planning : IUD
denom unclear, not palpable
small part/umbilical cord
Obstetrical History.
1. Male/3000gr/spontanous/
midwife/PHC/15 yo/
2. Male/1900gr/spontanous/
midwife/PHC/11 yo/L
3. Male/3000gr/spt/midwife/GH/5
yo/L
4. This

Assessment
G4P3A0L3 40-41
weeks S/L/IU head
presentation mother
dan fetal in good
condition

Planning
DM planning:
Diagnostic:
CBC
CTG
Therapy:
Induction oxytocin drip
CIE : CIE mother and family
about diagnostic planning
and therapeutic planning
SPV advice :
Termination pervaginam with
induction oxytocin start from
8 dpm if PS Score 5 and
CTG reactive

Time

Subject

Object
Pelvic Score :
Pelvic dilatation : 1 cm : 1
Cervic length : 2 cm : 2
Cervix consistence : soft : 2
Cervix posisition: post : 0
Station : -2 : 1
Total : 6
Lab:
HB: 11,9
RBC: 4, 57
HCT : 38,1
WBC: 10,12
PLT: 150
HbSAg: non-reactive
PPT: 11,9
APTT:25,9

Assessment

Planning

Time

Subjective

Objective

Assessment
G4P3A0L3 40-41
weeks S/L/IU head
presentation mother
dan fetal in good
condition

Planning

19/04/2016
13.30

Confessed (-)

General condition : Well

GCS : CM
BP : 110/80 mmHg
HR : 80 bpm
RR : 20 bpm
Temp : 36,4C
FHB: 11-12-11
UC: (-)

Oxytocin drip started at

8 dpm

14.00

Confessed (-)

FHB: 12-12-11
UC: (-)

Oxytocin drip 12 dpm

14.30

Confessed (-)

FHB: 12-11-11
UC: (-)

Oxytocin drip 16 dpm

15.00

Confessed (-)

FHB: 12-12-12
UC: (-)

Oxytocin drip 20 dpm

15.30

Confessed (-)

FHB: 12-11-12
UC: (-)

Oxytocin drip 24 dpm

16.00

Confessed (-)

FHB: 12-12-12
UC: (-)

Oxytocin drip 28 dpm

16.30

Confessed (-)

FHB: 11-12-12
UC: (-)

Oxytocin drip 32 dpm

17.00

Confessed (-)

FHB: 12-12-11
UC: (-)

Oxytocin drip 36 dpm

17.30

Confessed (-)

General condition : Well

GCS : CM
BP : 110/80 mmHg
HR : 80 bpm
RR : 20 bpm
Temp : 36,4C
FHB: 11-12-12
UC: (-)

Oxytocin drip 40 dpm

Time

Subjective

Objective

Assessment

Planning

18.00

Confessed (-)

FHB: 12-12-12
UC: (-)

Oxytocin drip 40 dpm

18.30

Confessed (-)

FHB: 12-11-12
UC: -

Oxytocin drip 40 dpm

19.00

Confessed (-)

FHB: 11-11-12
UC: -

Oxytocin drip 40 dpm

19.30

Confessed (-)

FHB: 12-11-12
UC: -

2nd flash of Oxytocin started

Oxytocin drip 40 dpm

20.00

Confessed (-)

FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

20.30

Confessed (-)

FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

21.00

Confessed (-)

FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

21.30

Confessed (-)

GC : well
GCS: CM (E4V5M6)
BP : 110/70mmHg
PR: 88 x/m
RR: 23 x/m
FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

22.00

Confessed (-)

FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

22.30

Confessed (-)

FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

23.00

Confessed (-)

FHB: 12-12-12
UC: -

Oxytocin drip 40 dpm

Time

Subjective

Objective

Assessment

Planning

Abdominal pain (+)

GC : well
GCS: CM (E4V5M6)
BP : 130/90mmHg
PR: 88 x/m
RR: 23 x/m
T: 36,7C
FHB: 12-12-11
UC: 1 x 10 ~ 15

G4P3A0L3 40-41
weeks S/L/IU
head presentation
with oxytocin
drip1st series
failed

DM Planning
Rest the patient for 24 hours at
nursing room
Pro oxytocin drip 2nd series after
24 hours rest

20/04/2016
06.00

Abdominal pain (+)

GC : well
GCS: CM (E4V5M6)
BP : 130/90mmHg
PR: 88 x/m
RR: 23 x/m
T: 36,7C
FHB: 12-12-11
UC: 1 x 10 ~ 15

G4P3A0L3 40-41
weeks S/L/IU head
presentation
with oxytocin
drip1st series failed

- Observation mother well being

- Suggest mother to mobilitate if can
- Sugest mother to eat and drink

14.00

Abdominal pain (-)

GC : well
GCS: CM (E4V5M6)
BP : 130/90mmHg
PR: 80 x/m
RR: 18 x/m
T: 36,5C

G4P3A0L3 40-41
weeks S/L/IU head
presentation
with oxytocin
drip1st series failed

- Observation mother well being

- Suggest mother to mobilitate if can
- Sugest mother to eat and drink

23.30

FHB: 12-12-11
UC: -

Time
21/04/2016
06.00

Subjective
Abdominal pain (+)

Objective
GC : well
GCS: CM (E4V5M6)
BP : 130/90mmHg
PR: 88 x/m
RR: 23 x/m
T: 36,7C
FHB: 12-11-12
UC: -

Assessment
G4P3A0L3 40-41
weeks S/L/IU head
presentation
with oxytocin
drip1st series failed

Planning
- Observation mother well being
- Suggest mother to mobilitate if can
- Sugest mother to eat and drink