Morning report 30/4/16

Sani, Widya, Ari

Time
30/4/16
19.00
Wita

Subject
Patient come to NTB GH with
G8P7A0L7 T/S/L/IU head
presentation . Patient confess
water leak out from her womb
since 12.00 (30/04/16).
Abdominal pain referred to
flank(+) since 14.00 (30/04/16),
bloody slime (+), fetal movement
(+)
History of DM (-), HT (+) in
pregnancy, asthma (-).
History of family disease:Hstory of allhergy: LMP : 10-08-2015
EDD : 17-8-2011
History ANC : 1x at posyandu at
23/11/2015 , GW : 12 weeks, UFH
: 2 finger above symfisis
USG History : 1. Last USG at
SPOg (23-03-2016)
Result : fetal S/L/IU head
presentation, EFW 2417 gr,
placenta in fundus posterior, GW:
34-35 weeks
Amnion enough , EDD 24/04/16
History of family planning : IUD
ThisNext family planning : MOW

Object
General status
GC : well
BP : 160/100 mmHg
PR: 60 bpm
RR: 24 t/m
T: 36,5C
Localis status
Eye : an (-/-), ict (-/-)
Pulmo ves (+/+), rh (-/-), wh
(-/-)
Cor : s1s2 single regular M(-),
G(-)
Abd : acites (+)
Ext : edema (+/+)
Obstetric status
L1 : breech UFH : 28cm
L2 : back on the rightside
L3 : head
L4 : 4/5
UC : 3X10~35
FHB : 12.12.13
EFW : 2635 gram
VT : 2cm, eff : 25%,
amnion (-),clear, head
palpable, H1 impapable
small part of fetus/ umbillical
cord
Inspeculo: there is no water
in fornix posterior and lacmus
- (acid)

Assasstment
G8P0A0L8 37-38
weeks S/L/IU head
presentation with
latent phase of labor
and gestasional
hypertention

Planning
DM planning
Diagnostic
-Check CBC,
-HBSAg,
- UL,
-CTG,
-inspeculo,
-lacmus test
Theraphy:
Nifedipine oral 3X10
mg
Observation the
progress of labour
Observation mother
and fetal well being
CIE mother to eat and
drink
-DM Co to GP, GP co
to spv pro SC
observation progress of
labor

Time

Subject
Obstetrical history:
1. aterm/male/3200/GH/midwife
/ spontan/22 yo
2. aterm/female/3000/GH/midwi
fe/ spontan/21 yo
3. Aterm/male/3000/GH/midwif
e/ spontan/17
4. aterm/male/3000/GH/midwife
/ spontan/16 yo
5. Aterm/male/3000/GH/midwif
e/ spontan/14
6. aterm/female/3000/GH/midwi
fe/ spontan/12 yo
7. Aterm/female/3000/GH/midw
ife/ spontan/110
8. this

Object
Lab:
Hb : 10,7
RBC: 4,25
HCT 33,1
Wbc : 8,43
Plt : 298
HBsAg : Proteinuria : -

Assasstment

Planning

Time

Subjective

Objective

Assessme
nt

Planning

19.30

Abdominal pain (++)

Fhb: 12-12-11
UC : 3x 10 ~ 35

G8P0A0L8
37-38 weeks
S/L/IU head
presentation
with latent
phase of
labor and
gestasional
hypertention
labour

Obs. Mother
and fetal well
being
Obs. Progres
of labor
Suggest
mother to eat
and drink
Seggest
mother to lie
tilted left

20.00

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

20.30

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

21.00

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

21.30

Fhb: 12-12-11
UC : 3x 10 ~ 40

Obs. Mother
and fetal well
being

22.00

Fhb: 12-12-11
UC : 3x 10 ~ 40

Obs. Mother
and fetal well

Time

Subjective

22.30

23.00

Objective

Assessme
nt

Fhb: 12-12-11
UC : 3x 10 ~ 35
Patient confesed about
abdominal Pain (++) more
often

General Status
GC: well
Conciousness: CM (E4V5M6)
BP: 160/100 mmHg
PR: 84 x/m
RR: 20x/m
T: 36,9oC
UC: 3x/10 ~ 40
FHB : 12 12 12
VT : 6 cm, eff 25%, amnion
(-),clear, head palpable, HI,
denom unclear, Impalpable
small part of fetus or umblilical
cord

Planning
Obs. Mother
and fetal well
being

G8P0A0L8
37-38 weeks
S/L/IU head
presentation
with active
phase of
labor and
gestasional
hypertention

Obs. Mother
and fetal well
being
Obs. Progres
of labor
Suggest
mother to eat
and drink
Seggest
mother to lie
tilted left

23.30

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

Obs. Mother
and fetal well
being

01/05/20
16
00.00

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

Obs. Mother
and fetal well
being

00.30

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

Obs. Mother
and fetal well

Time

Subjective

Objective

Assessme
nt

Planning

01.00

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

01.30

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

2.00

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

2.30

Fhb: 12-12-11
UC : 3x 10 ~ 35

Obs. Mother
and fetal well
being

03.00

Abdominal pain (+++),

General Status
GC: well
Conciousness: CM (E4V5M6)
BP: 160/100 mmHg
PR: 84 x/m
RR: 20x/m
T: 36,9oC
UC: 3x/10 ~ 40
FHB : 12 12 12
VT : 10 cm, eff 95%,
amnion (-),clear, head
palpable, HIII, denom
unclear, Impalpable small part

G8P0A0L8
37-38 weeks
S/L/IU head
presentation
with active
phase of
labor and
gestasional
hypertention

Obs. Mother
and fetal well
being
Obs. Progres
of labor
Suggest
mother to eat
and drink
Seggest
mother to lie
tilted left

TIME
3.05

SUBJECTIVE
Abdominal pain (+++),
mother wants to bearing
down

OBJECTIVE
General condition : Well
GCS : CM
BP : 150/80 mmHg
HR : 86 bpm
RR : 20 bpm
Temp : 36,6C

ASSESSMENT
G8P0A0L8 37-38
weeks S/L/IU head
presentation with
2nd phase of labor
and gestasional
hypertention

Abdominal pain (-)

General condition : Well

BP : 150/80 mmHg
HR : 72 bpm
RR : 20 bpm
Temp : 37,0C
UC : well
UFH : 2 finger below umbilicus
Active bleeding (-)

Conduct to labor
Baby was born at 3.15:
Female. BW: 3300 g, BL: 49
cm, AS 5-7, anus (+), congenital
anomaly (-).
3rd stage of labourPlacenta was
born complete at 3.30

UC : 4x10~45
FHB 12-12-11
Crowning, bulging of
perineum, pressure on
anus, opening of vulva
5.15

PLANNING

4rd stage of labour

2 hour post partum

DM planning :
Therapy :
- Monitoring : VS mother, UC,
bleeding.
- Obs mother and baby well being

1 day post partum

- Observation mother well being

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

Baby in NICU:
HR : 146 x/minute
RR : 44 x/minute
T : 36.5oC

07.00

No complain

GC : well
consciousness: CM
BP : 120/70 mmHg
PR: 76 bpm
RR: 16 bpm
T: 36,8C
UC : well
UFH : 2 fingers below
umbilicus
Active bleeding (-)