MORNING REPORT

August 26th
2014

SUPERVISOR : dr. Agus Thoriq, SpOG

DM : Santi, Ria, Ayu, Yuli

MORNING REPORT

CASE RESUME
NORMAL LABOR

PATHOLOGIES
LABOR

1. G5P2A2L2 42-43 weeks / S/L/IU with head presentation

2. G2P1A0L1 39 weeks/S/L/IU with arrested active phase

CASE 1
Name : Mrs.S
Age
: 36 years old
Address : sesaot, lobar
Admitted : 26-08-2014
No. RM
: 11-36-61
G5P2A2L2 42-43 weeks / S/L/IU head
presentation

Time

Subject

26/08/2
014
13.30
am

Patient come to policlinic

NTB GH referred from
midwife in sesaot with
G5P2A2L2 42-43 weeks /
S/L/IU with head
presentation confessed
intermitten abdominal pain
since 1 weeks ago
(19/08/2014), bloody slim
(-), water come out from her
womb (-), blood come out
from her womb (-) and FM
(+).

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/90 mmHg
HR: 84 x/m
RR: 18 x/m
T: 36,3 C

No history of DM, HT,

asthma in patient and her
family

Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)

LMP : forgotten
EDD : ?
History ANC : 8x at polindes
Last ANC : 19-08-2014
result: BP : 120/90, BW 76
kg, 41-42 weeks, UFH 35
cm, FHB (+)

Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 36 cm
EFW : 3875 gram
UC : FHB : 12-12-13 (148x/min)

Assessment
G5P2A2L2
post-term/
S/L/IU with
head
presentation

Planning
Obs. Mother and
fetal well being
Tell patient about
the examniation
DM co to GP pro
induction, GP acc
and advices pro
CTG

CTG reactive
induction drip oxy

Time

Subject
History of USG : 2x
Last USG (26-08-2014):
S/L/IU, head
presentation, female, 4041 weeks, placenta at
anterior grade III,
amniotic was sufficient
History of family
planning : inj 3 mo
Next family planning :
IUD
History of obstetric :
I.
Abortus 3 months
II. Abortus 3 months
III. Female, aterm,
spontan, traditional,
live, 17 yo
IV. male, aterm,
spontan, traditional,
live, 10 yo
V. This

Object
VT: Lab:
HGB = 11.7 g/dl
RBC = 4.02 K/ul
WBC = 15.07 M/ul
HCT : 34.5 %
PLT = 353 M/ul
HBsAg = (-)
BT = 300
CT = 600

Assessment

Planning

Time

Subject

Object

Assessment

Planning

15.00

UC: FHR: 144 bpm

Drip oxytocin 8 dpm

15.30

Patient confessed
abdominal pain
and water came
out from vagina

UC: 2x/10 ~ 30
FHR: 140 bpm
VT: 2 cm, eff. 25%, amnion
(-) clear, head palpable,
denom unclear, H1,
unpalpable small part and
umbilical cord

Drip oxytocin 12 dpm

Inj.amp 1 gr/IV

16.00

Patient confessed
abdominal pain

UC: 2x/10 ~ 30
FHR: 140 bpm

Drip oxytocin 16 dpm

16.30

Patient confessed
abdominal pain

UC: 2x/10 ~ 35
FHR: 144 bpm

Drip oxytocin 20 dpm

17.00

Patient confessed
abdominal pain

UC: 3x/10 ~ 40
FHR: 148 bpm

Drip oxytocin 24 dpm

17.30

Patient confessed
abdominal pain

UC: 3x/10 ~ 40
FHR: 148 bpm

Drip oxytocin 28 dpm

18.00

Mother wants to
bearing down

BP : 110/70 mmHg
HR: 90 x/m
RR: 20 x/m
T: 36,7 C
UC: 4x/10 ~ 35
FHR: 152 bpm

Drip oxytocin 28 dpm

Time

Subject

18.30

Patient confessed
abdominal pain

18.50

Mother
want
bearing down

Object
UC: 4x/10 ~ 45
IFHR: 148 bpm
inspeksi : babys head at
vulva
to

Crowning
Bulging of perineum,
vulva opened, rectal
pressure,

18.55

20.55

Assessment

GC: well
GCS: E4V5M6
BP: 110/70 mmHg
PR: 79x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 150cc/ 2 hours
Lokea rubra (+) 10cc

Planning
Drip oxytocin 28 dpm

2nd stage of labor

Baby was born, male,

3900 gram, 50 cm, A-S 79, caput (-), anus (+),
anomaly congenital (-).

3rd stage of labor

Placenta
was
born
spontaneous, complete.
Bleeding 150 cc
Perineum
rupture
grade1hecting

2 hours post partum

Observation 4th stage of

labor mother and baby
well being
Suggest mother to eat
and drink
Suggest mother to
mobilization
Suggest mother to early
breast feeding

Time
26-082014
07.00

Subject

Object
GC: well cons:E4V5M6
BP: 120/80 mmHg
PR: 80x/m
RR: 20x/m
T: 36,8 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: 60cc/hour
Lokea rubra (+) 5 cc
Baby:
Pulse : 140 bpm
RR : 56x/m
T : 36,5 C

Assessment
1 day post
partum

Planning
Observed mother and baby
well being
Suggest mother to
mobilisation
Suggest mother to early
breast feeding
Suggest mother to eat and
drink

CASE 2
Name : Mrs.S
Age
: 35 years old
Address : Lingsar, lobar
Admitted : 26-08-2014
No. RM
: 54-42-94
G2P1A0L1 39 weeks/S/L/IU with
arrested active phase

Time
26/08/2
014
11.30
am

Subject

Object

Patient come to NTB GH

referred from Lingsar PHC
with G2P1A0L1 39 weeks /
S/L/IU with head
presentation mother and
fetus in well condition +
arrested active phase.

General status
GC : well
GCS: CM (E4V5M6)
BP : 150/90 mmHg
HR: 72 x/m
RR: 20 x/m
T: 36 C

Patient confessed
intermitten abdominal pain
since 22.00 (25/08/2014),
bloody slim (+), water come
out from her womb (-), and
FM (+).

Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)

No history of DM, HT,

asthma in patient and her
family
LMP : 26-11-2013
EDD : 2-9-2014
History ANC : 6x at PHC
Last ANC : 12-08-2014
result: BP : 120/80, BW 65
kg, 37-38 weeks, UFH 30
cm, FHB (+)

Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 3/5
UFH: 35 cm
EFW : 3720 gram
UC : 3x/10 ~ 20
FHB : 13-12-13 (152x/min)

Assessment
G2P1A0L0 39
weeks / S/L/IU
with head
presentation
with active
phase +
gestasional
hypertension

Planning
Obs. Mother and
fetal well being
Tell patient about
the examniation
DM co to GP pro
acc, GP adv acc if
CTG reactive
CTG non-reactive,
resusitation intrauterine

Time

Subject
History of USG : (-)
History of family planning : inj 3 mo
Next family planning : implant
History of obstetric :
I.
Aterm/normal/PHC/
midwife/2600gr/ male/12
yo/live
II. This
Chronologist
26-8-2014 (at Lingsar PHC)
06.00
S: mother confessed abdominal
pain more frequently
O: GC well; BP 120/80; HR 82; RR
20; T 36,5; UC 2x/10 ~ 35; FHB
132
VT: 4 cm, eff. 50%, amnion (+),
head palpable, denom unclear,
H1, unpalpable small part and
umbilical cord
A: G2P1A0L1 39 wks/S/L/IU head
presentation mother & fetal well
with inpartu 1st stage active
phase
P: Explain the examination
-. Sugest eat & drink
-. Obs. Mother & fetal well being
-. Evaluation in 4 hours

Object
VT: 4 cm, eff. 50%,
amnion (+), head
palpable, horizontal,
H1, unpalpable
small part and
umbilical cord
Lab:
HGB = 12.6 g/dl
RBC = 4.30 K/ul
WBC = 14.38 M/ul
HCT : 36,4 %
PLT = 351 M/ul
HBsAg = (-)
Proteinuria (-)

Assessment

Planning

Time

Subject
10.00
S: mother confessed abdominal pain more
frequently
O: GC well; BP 150/80; HR 80; RR 20; T 36,7;
UC 3x/10 ~ 35; FHB 136
VT: 4 cm, eff. 50%, amnion (+), head
palpable, denom unclear, H1, unpalpable
small part and umbilical cord
A: G2P1A0L1 39 wks/S/L/IU head
presentation mother & fetal well with inpartu
1st stage arrested active phase
P:
- Explain the examination
- Rehydration RL:D5 = 2:1
- Evaluation in 1 hours
11.00
S: mother confessed pain more frequently
O: GC well; BP 120/80; HR 80; RR 20; T 36,7;
UC 3x/10 ~ 35; FHB 140
VT: 4 cm, eff. 50%, amnion (+), head
palpable, denom unclear, H1, unpalpable
small part and umbilical cord
A: G2P1A0L1 39 wks/S/L/IU head
presentation mother & fetal well with inpartu
1st stage arrested active phase
P:
- Explain the examination
- Referred to NTB GH
- Evaluation in 1 hours

Object

Assessment

Planning

Time

Subject

15.30

Patient confessed
water came out from
her womb

17.00

Patient confessed
abdominal pain

Object
GC : well
GCS: CM (E4V5M6)
BP : 150/80 mmHg
HR: 84 x/m
RR: 20 x/m
T: 36,2 C
UC: 3x/10 ~ 25
FHR: 144 bpm
VT: 6 cm, eff. 50%,
amnion (-) clear, head
palpable, horizontal,
H1, unpalpable small
part and umbilical cord

Assessment
+ ROM

Planning
Obs. Progrs of labor
Inj. Ceftriaxon 1 gr/IV
CTG post resusitation
(16.30) reactive
DM co to GP pro
acceleration, GP acc

UC: 3x/10 ~ 30
FHR: 148 bpm

Drip oxytocin 8 dpm

17.30

UC: 3x/10 ~ 30
FHR: 148 bpm

Drip oxytocin 12 dpm

18.00

UC: 3x/10 ~ 30
FHR: 148 bpm

Drip oxytocin 16 dpm

18.30

UC: 3x/10 ~ 30
FHR: 148 bpm

Drip oxytocin 20 dpm

Time

Subject

19.00

19.30

Patient confessed
abdominal pain

Object

Assessment

Planning

GC : well
BP : 150/80 mmHg
HR: 84 x/m
RR: 20 x/m
T: 36,2 C
UC: 3x/10 ~ 35
FHR: 148 bpm
VT: 7 cm, eff. 65%, amnion
(-) green, head palpable, caput
(+), H1, unpalpable small
part and umbilical cord

Neglected
active phase

Drip oxytocin 20 dpm

Obs. Mother & fetal well
being
DM co to GP, GP co to SPV,
adv: evaluation 21.30
Inf. Metronidazol (WBC
22,94)
Drip stop

UC: 3x/10 ~ 35
FHR: 140 bpm

20.00

UC: 3x/10 ~ 35
FHR: 140 bpm

20.30

UC: 3x/10 ~ 35
FHR: 144 bpm

21.00

UC: 3x/10 ~ 40
FHR: 148 bpm

Time
21.30

Subject
Mother wants to
bearing down

Object
GC : well
BP : 150/90 mmHg
HR: 104 x/m
RR: 20 x/m
T: 36,8 C
UC: 3x/10 ~ 40
FHR: 152 bpm
VT: complete, eff. 65%,
amnion (-) meconeal, head
palpable, caput (+), H3,
unpalpable small part and
umbilical cord

Assessment

Planning

2nd stage of
labor +
nelected

Obs. Mother & fetal well

being
DM co to GP, GP co to SPV,
adv: Vacuum Estraction
Prepare VE

21.50

21.10

VE began
Baby was born (22.05),
female, 2900 gram, 51 cm,
A-S 3-5, anus (+), anomaly
congenital (-).

3rd stage of
labor

Placenta
was
born
spontaneous, complete.
Bleeding 150 cc
Perineum
episiotomy

hecting

Time

Subject

Object

Assessment

Planning

20.55

GC: well
GCS: E4V5M6
BP: 150/90 mmHg
PR: 79x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: +
Lokea rubra (+) 10cc

2 hours post partum

Observation 4th stage of

labor mother and baby
well being
Suggest mother to eat
and drink
Suggest mother to
mobilization

27-814
07.00

GC: well
GCS: E4V5M6
BP: 150/90 mmHg
PR: 79x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 2 fingers below
umbilicus
Active bleeding: (-)
UO: +
Lokea rubra (+) 10cc
Baby in NICU:
HR: 132
T: 36
RR: 68

1 day post partum

Observation 4th stage of

labor mother and baby
well being
Suggest mother to eat
and drink
Suggest mother to
mobilization

TERIMA KASIH