Morning Report

APRIL 10th 2017

Supervisor:
dr. I Made Juliawan, Sp.OG

Medical Students:
Faisal, Ika, Pandu, Ainun, Ranova
 Morning Report
APRIL 10th 2017
Case Resume
NORMAL
LABOR
PATHOLOGIES 1. G2P1A0H1 38-39 weeks S/L/IU with arrested
active phase 1st stage of labor
LABOR 2. G1P0A1L0 34-35 weeks S/L/IU breech presentation
with PROM >12 hours + anhidramnion

REMAIN 1. G1P0A0H0 20-21 weeks S/IUFD/IU + mild

anemia + failed oxytocin drip +
PATIENTS termination with misoprostol
TIDAK ADA PERTANYAAN YANG
SALAH
Name : Mrs. DMS
Age : 25 yo
Adress : Kuripan, Lombok Barat
Admitted: April 9th 2017 at 02.20 AM
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

9/4/20 Patient arrived at IGD RSUD General Status G2P1A0H1 38-39 Observe pervaginam
17 Provinsi NTB at 01.30 am weeks S/L/IU with delivery using
GC : well
(9/4/17) Patient confessed active phase 1st partograf
01.30 Consciusness : CM
abdominal pain spread to flank stage of labor CTG
BP : 130/90 mmHg
since 00.30 (09/4/2017), water DM co to SPV,
PR : 96 bpm
leaked from her womb(-). Bloody advice : Observation .
RR : 20 bpm
slime (+), FM (+). T : 36,6oC
No history of DM, HT, asthma. Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
LMP : 15-7-16
EDD : 22-4-17 Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
History of ANC : 8x at PHC Kediri Abdomen : scar (-), striae
Last ANC : 29/03/2017 gravidarum(+), linea nigra (+).
History of USG : 1x Extremity : edema (-/-), warm acral
Last USG : 17/01/2017 (+/+)

Result: Obstetrical Status

Fetus S/L/IU head presentation, L1 : breech
male, GW 26 weeks, EFW 1764 L2 : back on the left side
gr EDD 21/4/17, FHB (+), L3 : head
Amnion clear, placenta at fundus L4 : 4/5
UFH : 28 cm
History of family planning : EFW : 2635 g
implant UC :2x/10 ~ 30
Next family planning : IUD FHB : 12-12-12 (144 bpm)
VT : 4 cm, eff 50%, amnion (+),
Obstetrical History : head palpable H I +, denominator
I. Aterm/female/spt/midwife/250 unclear, impalpable small part /
0g/3 yo/L umbilical cord.
II. This is
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
Pelvic score = 7
Dilatation of cervix : 2
Length of cervix : 1
Station : 1
Consistency : 2
Position : 1

Lab:
Hgb : 11,9
Rbc : 4,99
Hct : 37,3
Wbc : 12,84
Plt : 208
HBsAg : -
Gds : 74

General Status
9/4/17 GC : well G2P1A0H1 38-
03.30 S : Mother confessed abdominal pain + Consciusness : CM 39 weeks S/L/IU Suggest mother lay
FM(+) BP : 130/90 mmHg active phase 1st to the sideways,
PR : 94 bpm stage of labor eat, and drink.
RR : 22 bpm Observe mother
T : 36,6oC and fetal well being
UC :2x/10 ~ 30 Observe progress
FHB : 12-12-12 (144 bpm) of labor
VT : 4 cm, eff 50%, amnion
(+), head palpable H I +,
denominator unclear,
impalpable small part /
umbilical cord.
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
9/4/17 S : Patient moved to VK Teratai General Status G2P1A0H1 38- Suggest mother lay
06.00 39 weeks S/L/IU to the sideways,
Mother confessed abdominal pain + GC : well
active phase 1st eat, and drink.
Consciusness : CM
FM(+) stage of labor Observe mother
BP : 110/60 mmHg
and fetal well being
PR : 84 bpm
Observe progress
RR : 20 bpm
of labor
T : 36,6oC
CTG
UC :3x/10 ~ 30
FHB : 11-12-11 (136 bpm)

9/4/17 : Mother confessed abdominal pain + GC : well

07.30 G2P1A0H1 38- CTG reactive
FM(+) Consciusness : CM
39 weeks S/L/IU Observe mother
BP : 110/70 mmHg
with arrested and fetal well being
PR : 88 bpm
active phase 1st Observe progress
RR : 20 bpm
stage of labor of labor.
T : 36,4oC
UC :1x/10 ~ 30
FHB : 12-12-13 (136 bpm)

VT : 4 cm, eff 50%, amnion

(+), head palpable H I +,
denominator unclear,
impalpable small part /
umbilical cord.
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
9/4/17 S : Mother confessed abdominal pain General Status G2P1A0H1 38- DM co to SPV pro
08.30 +FM(+) 39 weeks S/L/IU acceleration, advice :
GC : well
with arrested Acc acceleration.
Consciusness : CM
active phase 1st
BP : 110/70 mmHg
stage of labor
PR : 84 bpm
RR : 20 bpm
T : 36,6oC
UC :1x/10 ~ 30
FHB : 12-13-12 (148 bpm)

09.00 Abdominal pain (+) UC : 2x/10~30 Dryp oxy began 8 tpm

FHB : 12-12-12(144 bpm)

09.30 Abdominal pain came and relieved UC : 4x/10~40 Dryp oxy 12 tpm
FHB : 12-11-11 (136 bpm)
10.00 Abdominal pain came and relieved UC : 4x/10 ~ 45 Dryp oxy 16 tpm
FHB : 12-2-12 (144 bpm)
10.30 Abdominal pain came and relieved UC : 4x/10 ~ 345 Dryp oxy 20 tpm
FHB : 12-12-12 (148 bpm)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10.35 Mother confessed water came GC : well 2nd stage of labor Conduct mother to bearing
out from her womb UC : 4x/10 ~ 30 down.
Mother wants to bearing down FHB : 12-12-12 (144 bpm)
VT : complete, amnion (-) clear,
head palpable H III+, denom
LOA, impalpable small part/
umbilical cord.
Baby was born, Amnion
10.40 Teknus Perjol Vulka clear, male, AS 7-9, 2800
gram, Body length 50 cm,
HL 33 cm, arm
circumference 10 cmcm
Anus (+), congenital
anomaly (-)
Placenta was born
spontaneous, completed,
bleeding 200cc

12.4 Delivery wound pain GC : well 2 hours post Observed mother and
0 BP : 110/60 mmHg partum baby well being.
PR : 84 bpm Suggest mother to
RR : 20 bpm mobilisation.
T : 36,5 C
UC : (+) well
UFH : 2 finger below umbilicus
Active bleeding : (-)
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
10/04/ Delivery wound pain GC : well One day post Observed mother and
2017 BP : 110/80 mmHg partum baby well being
PR : 88 bpm Suggest mother to
06.00
RR : 20 bpm mobilisation, eat, and
T : 36,40C drink, medication.
UFH : 2 finger below umbilicus
UC : (+) well
Lochea rubra : (+)
3

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Lubchenco Curve
Case 2

Name : Mrs. E
Age : 30 yo
Adress : kediri
Admitted: April 8th 2017
 Time Subject Object Assessment Planning
8/04/17 Patient come to Emergency General status G1P0A1L0 34-35 -Dm Planning
Unit of GH NTB confessed GC : well weeks S/L/IU breech -Obs. Mother and fetal
22.30 GCS: E4V5M6 presentation with well being.
water leak from her womb BP : 120/90 mmHg PROM <12 hours - Check CBC and HBsAg
since 19.30, clear. PR: 88 tpm -Inj Ampicillin 1gram/ 6
RR: 20 tpm h
Bloody slim (-) abdominal pain T: 36,6C
(-) - DM co. to GP, advice :
History of DM (-), HT (-), Local status pro CTG
Eye : an (-/-), ict (-/-) - GP co. CTG result to
asthma (-) Pulmo: ves (+/+), rh (-/-), wh (-/-) SPV, advice:
Cor /S1S2 single reg. M(-), G(-) - Obs. and move to VK
Family health history : DM (-), Abd : striae gravidarum (+), linea Teratai.
HT (-), asthma (-) nigra (+), scar (-) -Inj. Ampicillin 1 g/8 h
Ext : edema (-/-), warm (+/+) -Pro USG
LMP : 10-08-2016 Obstetric status
L1 :head UFH: 26 cm AC : 104
EDD : 17- 05-2017 cm
History ANC : 3x in Posyandu L2 : back on the right side
History of USG : - L3 : breech
L4 : -
History of family planning: - UC : -
Next family planning: - FHB : 12.12.12 (144bpm)
EFW :2575 gram
Obstetric History: VT : CD 1 cm, eff 10%, amnion
1. This (-), breech presentation, denom
unclear, H I, small part of fetus
or umbilical cord unpalpabled.

PE:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeous mobile
Pubic arch > 90
 Time Subject Object Assessment Planning
Lab:
Hgb : 12,2
Rbc : 4,36
Hct : 36,4
Wbc : 7,07
Plt : 270
HBsAg : +

23.1 0 Patient moved to VK teratai GC : well G1P0A1L0 34-35 - Ampicillin 1gr on

some water leak from her womb GCS: E4V5M6 weeks S/L/IU breech Nacl 100c 40 tpm
BP : 120/90 mmHg presentation with
PR: 88 tpm PROM <12 hours
RR: 20 tpm
T: 36,6C

UFH : 25 cm
FHB : 12.12.12 (144bpm)
EFW :2575 gram
 Time Subject Object Assessment Planning
9/4/2017 S:- GC : well G1P0A1L0 34-35
07.00 GCS: E4V5M6 weeks S/L/IU breech
BP : 120/80 mmHg presentation with
PR: 88 tpm PROM <12 hours
RR: 20 tpm
T: 36,6C

UH : -
FHB : 12.11.12 (140bpm)

11.00 S = FM decrease GC : well G1P0A1L0 34-35 - Ampicillin 1gr on

GCS: E4V5M6 weeks S/L/IU breech Nacl 100c 40 tpm
BP : 120/80 mmHg presentation with
PR: 84 tpm PROM >12 hours
RR: 20 tpm
T: 36,5C

UH : -
FHB : 12.13.13 (152bpm

11.50 S = FM (+) Dr. Ario,Sp.OG Visit and did G1P0A1L0 30-31 - Adive from dr. Ario
USG weeks S/L/IU breech SpOG : SC
Result : presentation with - EIC patient about the
: F/L/S/IU, breech PROM >12 hours SC
presentation, placenta in + anhidramnion
corpus posterior, BPD 30/31,
AC 32/32, FL 35/36, EFW
1900gr, AFI: minimal
 Time Subject Object Assessment Planning
14.00 S : FM (+) GC : well G1P0A1L0 34-35
GCS: E4V5M6 weeks S/L/IU breech
BP : 110/70 mmHg presentation with
PR: 84 tpm PROM <12 hours
RR: 20 tpm + anhidramnion
T: 36,6C

UH : -
FHB : 11.12.11 (136bpm)

18.00 S = FM(+) GC : well G1P0A1L0 34-35 - Drip Cefotaxime 2gr

GCS: E4V5M6 weeks S/L/IU breech on 100 cc Nacl
BP : 120/70 mmHg presentation with
PR: 88 tpm PROM >12 hours
RR: 20 tpm + anhidramnion
T: 36,5C

UH : -
FHB : 12.13.13 (152bpm
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
9/04/2 SC Began
017
19.00
19.35 Baby was born, female,
AS 6-8, 2370 gram, 45
cm, Anus (+), congenital
anomaly (-), amnion little
amount
Placenta was born
manually, complete

21.30 Operation wound pain GC: well Cons: E4V5M6 2 hours post SC Observed vital sign
BP: 110/70mmHg mother and baby
HR: 76 bpm Suggest mother to
RR: 20 tpm mobilisation, eat, drink,
T: 36,80C and medication
UC: well
UFH: 2 finger below umbilicus

06.00 GC: well Cons: E4V5M6 One day post SC Observed vital sign
BP: 120/80 mmHg mother and baby
HR : 76 bpm Suggest mother to
RR : 20 tpm mobilisation, eat, and
T : 36,6 C drink, medication.
UFH : 2 finger below umbilicus CIE for lactation
UC : well
Lochea rubra : (+)
3

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Lubchenco Curve
 Case Report
Name : Mrs. AP
Age : 18 years old
RM : 164136
Address : Sesela, Gunung Sari
Admitted to Hospital : April 8th 2017
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
8/4/ Patient referred from obstetric poly with General Status : G1P0A0H0 DM planning:
2017 G1P0A0L0 20-21 weeks S/IUFD/IU, GC : well 20-21 weeks
mother condition well. Patient confessed BP : 110/60 mmHg S/IUFD/IU + Monitoring :
09.30 not feel her fetal movement since 5 days PR : 76 bpm mild anemia VS mother
ago (3/4/2017). Water leaked out from RR : 16 bpm
womb (-). Abdominal pain (-), bloody T : 36,1oC Therapy :
slime (-). history of trauma (-) - pro termination by
Local Status : misoprostol and
History of HT, DM, asthma (-), Eye : anemis (-/-), oxytocin drip
LMP : 8-11-2016 icteric (-/-)
EDD : 15-8-2017 Cor : S1S2 single Communicate, inform
History of ANC : 3x ( 2x at PHC, 1x at and educate mother
regular, murmur (-), and family about
NTB GH) gallop (-). diagnostic planning
Last ANC : 8/4/2017 Pulmo : vesicular (+/+), and therapeutic
Result:BP:100/60 wheezing (-), rhonki (-). planning
BW:40 kg Abdomen : scar (-),
GW:20-21 weeks striae gravidarum (+),
UFH 19 cm linea nigra (+). SPV advice:
Ballotement (+), FHB (-) Extremity : edema (-/-), -pro termination by
warm acral (+/+). oxytocin drip
History of USG : 2x at Sp.OG
Last USG (8-4-2017) Obstetrical Status :
Result : L1 : breech
Fetal S/IUFD L2 : back at the right
BPD 20 weeks side
AC 20 weeks 1 day L3 : head
FL 21 weeks 1 day L4 : 5/5
EFW 373 gr 128 gr UFH : 19 cm
Amnion enough UC : - FHB : (-)
VT: (-), palpable fornix,
History of family planning : - the lowest part is unclear
Next family planning : -
Obstetrical History :
1. This
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Lab: (8/4/2017)
HB 10,0 g/dl
RBC 4,34 x 10^6/uL
HCT 32,6 %
WBC 8,91 x 10^3/uL
PLT 263 x 10^3/uL
HbSAg non reactive
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

12.30 Patient was moved to VK Teratai

14.30 No complaint UC (-) G1P0A0H0 20- -start oxytocin drip 8

FHB : (-) 21 weeks dpm
S/IUFD/IU +
mild anemia

15.00 No complaint UC (-) Oxytocin drip 12 dpm

FHB : (-)

15.30 No complaint UC (-) Oxytocin drip 16 dpm

FHB : (-)

16.00 No complaint UC (-) Oxytocin drip 20 dpm

FHB : (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
16.30 No complaint GC : well G1P0A0H0 20- -Oxytocin drip 24 dpm
BP : 110/60 mmHg 21 weeks
PR : 76 bpm S/IUFD/IU +
RR : 16 bpm mild anemia
T : 36,1oC
UC (-)
FHB : (-)

17.00 No complaint UC (-) Oxytocin drip 28 dpm

FHB : (-)
17.30 No complaint UC (-) Oxytocin drip 32 dpm
FHB : (-)
18.00 No complaint UC (-) Oxytocin drip 36 dpm
FHB : (-)

18.30 No complaint UC (-) Oxytocin drip 36 dpm

FHB : (-)
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

19.00 No complaint UC (-) G1P0A0H0 20- -Oxytocin drip 40 dpm

FHB : (-) 21 weeks
S/IUFD/IU +
mild anemia

20.30 No complaint UC (-) - start 2nd flash of

FHB : (-) oxytocin drip 40 dpm

09/04/20 No complaint UC (-) G1P0A0H0 20- - 2nd flash of oxytocin

17 FHB : (-) 21 weeks drip ends co SPV :
S/IUFD/IU + Advice :
00.30
mild anemia + -pro repeat oxytocin
failed oxytocin drip in 24 hours
drip - starts IVFD RL 20 tpm
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
09/04/2017 No complaint GC : well G1P0A0H0 20- - Co SPV advice :
BP : 110/60 mmHg 21 weeks Misoprostol tab/6
07.05
PR : 76 bpm S/IUFD/IU + hours
RR : 16 bpm mild anemia + Evaluation of pelvic
T : 36,1oC failed oxytocin score --> pelvic score
UC (-) drip + <5
FHB : (-) termination
with
07.30 No complaint misoprostol - Insertion of
misoprostol 50 mcg

13.30 No complaint - Insertion of

misoprostol 50 mcg

14.00 Abdominal pain(+) UC : 1x10~ 10

FHB : (-)

19.30 Abdominal pain (+) UC : 1x10~ 10 - Insertion of

FHB : (-) misoprostol 50 mcg
- Co SPV advice :
continue untill the 4th
misoprostol, if there are
no dilatation and
ripening of cervix, do
the balloon catheter
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10/4/2017 Abdominal pain (+) GC : well G1P0A0H0 20- - Insertion of
BP : 110/60 mmHg 21 weeks misoprostol 50 mcg
01.30
PR : 76 bpm S/IUFD/IU +
RR : 16 bpm mild anemia +
T : 36,1oC failed oxytocin
UC : 1x10~ 10 drip +
FHB : (-) termination
with
misoprostol
06.30 Abdominal pain - Insertion of balloon
(+) Water leak out catheter (6.45)
from womb (+)