MORNING REPORT

CASE RESUME
NORMAL LABOR

PATHOLOGIES LABOR

1. G2P0A1H0, 39 40 wk S/L/IU with

PROM > 12 hours
2. G4P3A0L3 40-41 week S/L/IU
breech presentation with active
phase of 1st stage of labor

TIME

SUBJECTIVE

25/12/
2012
12.39
WITA

Patient referred from Gunung

Sari PHC with G4P3A0L3 4041 week S/L/IU breech
presentation with mother and
fetal in well being with active
phase1st stage of labor.
Patient confessed abdominal
pain since 07.00 (25/12/12)
bloody slim (+) and history of
ROM (-), FM (+),
No History of HT, DM, or
Asthma
LMP: 15th March 2012
EDD: 22th December 2012
History of ANC: >4x at PHC
Last ANC: 6th December 2012
History of USG: History of family planning: Next family planning: injection
per 3 month
Obstetrical history:
I.
, PHC, Spontan, aterm,
3700 g, 19 yo
II. , PHC, Spontan, aterm,
3400 g, 15 yo
III. , PHC, Spontan, aterm,,
3000 g, 10 yo
IV. This

OBJECTIVE
General status:
GC: well
Consciousness: Composmentis
BP: 130/80 mmHg
PR: 88 bpm
RR: 20 rpm
Tax: 37,9oC
Eye : Anemic (-), icteric (-)
Thorax :
Cor : S1S2 single reguler,
murmur (-), gallop (-)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (-/-)
Obstetrical status:
L1: head
L2: back on the right side
L3: breech
L4: UFH: 31 cm
AC: 101
EFW: 3131 g
UC: 2x10 ~ 25
FHB: 13-13-12 (152 x/min)
VT: 3 cm, eff 50%, amnion
(+), breech palpable HI,
denominator unclear,
unpalpable small part /
umbilical cord.

ASSESTMENT

PLANNING

G4P3A0L3 4041 week S/L/IU

breech
presentation
with inpartu
latent phase 1st
stage of labor

Obs mother & fetal

well being
Obs progress of
labor
DM pro obs.
Progression of
labor
SPV Acc to obs.
progression of
labor

TIME

SUBJECTIVE

OBJECTIVE

Chronologist:
S
Patient pregnant 9 month confessed
abdominal pain frequently since
25/12/2012 at 06.30 WITA. History of
ROM (-), FM (+)
O
General status: good
Concsiousness: CM
BP: 100/70 mmHg,
PR: 86 bpm
RR: 20 rpm
Tax: 36,4 oC
UFH: 31 cm
AC: UC: 2x/10 ~25
VT: 2 cm, eff 25%, amnion (+),
breech presentation, palpable
HI, denominator unclear,
unpalpable small part / umbilical
cord.
A
G4P3A0L3 40-41 week S/L/IU breech
presentation with mother and fetal in
good condition with active phase of
1st stage of labor.
P
Tell mother about the examination
result
Observe mother and fetal well being
Suggest mother to eat and drink

ZA Score: 5
Parity: Multy 1
History of breech pres.: 0
EFW: 3131 2
Gestation age: Aterm
0
Station: -2 1
Cervix Dilatation: 3 cm
1
Lab result:
HGB: 12,3 g/Dl
HCT : 37,2
RBC : 3,75
WBC: 14,57
PLT: 144
HbsAg : -

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

12.39

Patient moved
to VK Teratai

14.05

Consul to SPV

15.00

Patient
confessed
intermittent
abdominal
pain

UC: 3x/10 ~ 40
FHR : 172 bpm
VT: 4 cm, eff 50%,
amnion (+), breech
palpable HI,
denominator unclear,
unpalpable small part /
umbilical cord.

15.05

Patient
confessed
water come
out from her
womb

VT: 8 cm, eff 50%,

amnion (-), breech
palpable HII,
denominator unclear,
unpalpable small part /
umbilical cord.

15.30
16.00

ASSESTME
NT

PLANNING

Observe
mother and
fetal wellbeing
Observe
progress of
labor.
G4P3A0L3
40-41 week
S/L/IU
breech
presentation
with
febris+fetal
takicardi

-pro CTG
-Observe
mother and
fetal wellbeing
Observe
progress of
labor.
-IU
resusitation

G4P3A0L3
40-41 week
S/L/IU
breech
presentation

Conduct
mother to
bearing down

UC:3x/10 ~40
FHR:160 bpm
Mother wants
to bearing
down

UC: 3x/10 ~ 45
FHR: 158 bpm
Head crowning in vulva,
diameter 4-5 cm.