01 DESEMBER 2008: Morning Report

Morning Report
01 DESEMBER 2008
Supervisor : dr. A. Rusdhy.H, Sp.OG
Dokter Muda Jaga:
1.Nasrullah
2.Sulistiawati
3.Icha aisyah
4. fadhlur Rahman
Cases resume :
1.
Neglected labor + RUI
Neglected labor
2.
Normal labor
1.
Name
: Mrs. Nurjanah
Age
: 24 years old
Address
: Pringgabaya lotim
Wakt
u
Subject
05.0
0
pm
Patient refered by Selong Hospital

with G1P0A0 aterm/single/ life/intra
uterine with neglected of 2nd stage of
labor.
Cronologis :
(30-11-08/ 02.00 am) Patient came to
midwife with intermitten abdominal
pain and vaginal discharge since 3011-08/ 01.00 am.
10.00 am, she was refered to PKM
Batuyang because there was not
progressed.
The last examination in PKM
Batuyang found :
General status : well
BP : 110/70 mmHg
Pulse =84 x/mnt
RR: 24 x/mnt
Temp = 36C
FHR: 11-12-11/mnt
UFH = 3 fingers under PX
Head presentation,desend 4/5.
VT : 8cm, eff 70 %, amnionic
membrane (-), mollage +1, descend
HI+.
At 01.00 pm PKM refered the patient
to Selong Hospital with 1st stage of
proglected labor.
CTH
: 01-12- 2008
: 04.50 pm
Object
General status :
General condition: weakness
Conciousness: CM
BP: 120/80
RR: 20x/mnt
Pulse :94 x/mnt
T: 37,8 C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit
Obstetric status :
L1 : breech
L2 : right back
L3 : head
L4 : desend 4/5
UFH: 31 cm
EFW : 3100 g
UC : Fetal Heart Rate : 155 x/mnt
VT : completed, eff 100 %, amnionic
membrane (-), amniotic fluid (+)
greenish, descend HII, mollage 1+,
unpalpable small organ and umbilical
cord
Bundle (+) as high as umbilicalsymphisis
Pelvic evaluation :
Spina ischiadica : not prominent
Os coxigeus : mobile
Distansia intertuberum : 90
Assesment
Planning
G1P0A0
aterm/single/life/intra
uterine with 2nd stage
of neglected labor.
Observation
mother
and fetal well being.
Laboratory
examination : DL,
HBsAg
05.00 pm
Reported
to
supervisor, proposed
to SC advice :
agreed by supervisor
IU Rescucitation :
- RL:D5=2:1
- O2 5 lpm
- Left side position
Prepared to SC:
Test cefo (-), injection
cefotaxim 2 gr iv
DC
Subject
Object
Examination in Selong Hospital :

01.30 pm
BP : 110/70 mmHg
Pulse =84 x/mnt
RR: 16 x/mnt
Temp = 38,2C
UC : (+)
FHR: 14-14-14/mnt
UFH = 3 fingers under PX (38 cm)
EFW = 4185 g
VT : completed, eff 100 %, amnionic membrane (-),
amniotic fluid (+) clear, descend HII
02.15 pm
Rehidration : RL 1 kolf
Inj cefo 1 gr
Inj xylodella : duradril : 2 :2
Lead mother to bearing down for 1 hour but there
wasnt progressed
Informed the SPOG advised refered patient to
mataram hospital
Lab. result:
HBsAg (-)
HB = 8,4
WB = 45.300
TRB = 371.000
Hct = 28.0
Proteinuri (-)
Wakt
u
Last menstrual period : forgot

History of family planning : Family planning : injection for 3 month
ANC : 3x in polindes
Obstetric history:this
Assesment
Planning
Waktu
Subject
Object
Assesment
Planning
05.00 pm
Pulse : 94
G1P0A0
aterm/single/life/intra uterine with 2nd
stage of neglected labor.
Observation mother
fetal well being.
and
06.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
06.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
07.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
07.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
08.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
08.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
09.00
pulse : 96
VT : completed, eff 100 %,
amnionic
membrane
(-),
amniotic fluid (+) greenish,
descend HII, mollage 1+,
unpalpable small organ and
umbilical cord
Time
Subject
Object
Assesment
Planning
09.20
pm
Sent the patient to operation

room
09.35 pm
Operation begun
09.40 pm
Baby was born with SC,

female, 3000g, body length
48 cm, AS = 7-9, caput (+)
Amniotic fluid greenish :
minimal.
Plasenta was born,
spontaneously, complete
RUI (+)
Bleeding : 500 cc
Waktu
10.00 pm
Subject
Object
Conciousness: CM
BP : 100/80
RR= 24 x/mnt
Tax = 37
Pulse = 116 x/mnt
Uterus contraction : well.
UT : 100 cc
Bleeding = -, lochia (+)
Assesment
Planning
stage IV of labor
Observation maternal well

being
Transfusion of 1 kolf PRC
Observation for hemorrhage
sign
10.15 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
stage IV of labor

being
sign
10.30 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
stage IV of labor

being
sign
10.45 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
1 daay post labor

being
sign
11.00 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Lochia rubra (+)
1 daay post labor

being
sign
Waktu
Subject
Object
Assesment
Planning
11.15pm
BP = 110/80
RR= 20 x/mnt
Pulse = 80 x/mnt
Uterus contraction :
well,.
stage IV of labor

being
sign
11.30pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
well.
stage IV of labor

being
sign
11.45pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
well.
Bleeding = Lochia (+)
stage IV of labor

being
sign
06.00 am
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
well, Fundal uterine
length = 2 finger below
umbilical
1 daay post SC

being
sign
Baby well being

T : 36,7, RR : 40x/mnt,
still active care in NICU
PASI : 20 cc
Name
: Mrs. Indar
Age
: 30 years old
Address
: Pujut, loteng
Wakt
u
Subject
00.3
0
am
Patient refered by Sengkol Primary

Health Center with G5P3A1H3
aterm/single/ life/intra uterine with
proglected of 2nd stage of labor +
susp. Big baby
Cronologis :
(01-12-08/ 02.00 pm) Patient came
to Sengkol Primary Health Center
with intermitten abdominal pain
and watery vaginal discharge since
01-12-08/ 01.00 pm

BP : 120/70 mmHg
Pulse =84 x/mnt
RR: 20 x/mnt
Temp = 37,2C
FHR: 12-13-12/mnt
UFH = 38 cm, EFW =4185g
07.30 pm
VT : complete, eff 100 %,
amnionic
membrane
(-),
amniotic fluid (+) clear, descend
HII.
Lead the mother to bearing down
for 2 hour there was not
progressed
CTH
: 02-12- 2008
: 00.25 am
Object
General status :
Conciousness: CM
BP: 150/90
RR: 24x/mnt
Pulse :90 x/mnt
T: 37,9 C
Obstetric status :
L1 : breech
L2 : right back
L3 : head
L4 : desend 2/5
UFH: 37 cm
EFW : 4010 g
VT : completed, eff 100 %, amnionic
membrane (-), amniotic fluid (+) unclear,
descend HII+, caput (+), unpalpable
small organ and umbilical cord
Assesment
Planning
G5P3A1H3
aterm/single/ life/intra
uterine with proglected
of 2nd stage of labor +
susp. Big baby + mild
preeclampsia
Observation
mother
Observation
Blood
Pressure
Laboratory
examination : DL,
HBsAg
00.25 am
Reported
to
to SC advice :
Prepared to SC:
cefotaxim 2 gr iv
Applied DC
Wakt
u
Subject

History of family planning : Family planning : ANC : 3x in polindes
Obstetric history :
1.Male, spt, traditional attenden, 17 th.
4.Abortus, curretage in PKM.
5.This
Object
Lab. result:
HBsAg (-)
HB = 10,1
WB = 15.800
TRB = 371.000
Hct = 30,4
Proteinuri (+1)
Assesment
Planning
Waktu
Subject
Object
Assesment
Planning
01.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
01.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
02.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
02.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
02.30
pm
Sent the patient to

operation room
02.55 am
Operation begun
03.00 am
Baby was born with

SC, male, 3100g,
body length 50 cm,
AS = 7-9, caput (+)
Amniotic fluid
greenish
Plasenta was born,
spontaneously,
complete
Bleeding :
approximately 500
cc
Dx Post Op
Waktu
03.40 am
Subject
Object
Conciousness: CM
BP : 130/80
RR= 24 x/mnt
Tax = 37
Pulse = 89 x/mnt
Urine : 100 cc
Assesment
Planning
stage IV of labor

being
sign
04.00 am
BP = 130/90
RR= 20 x/mnt
Tax = 36,6
Pulse = 85 x/mnt
stage IV of labor

being
sign
04.15 am
BP = 130/80
RR= 20 x/mnt
Tax = 36,7
Pulse = 82 x/mnt
stage IV of labor

being
sign
04.30 am
BP = 130/90
RR= 24 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
1 daay post labor

being
sign
04.45 am
BP = 120/80
RR= 20 x/mnt
Tax = 36,9
Pulse = 80 x/mnt
Lochia (+)
1 daay post labor

being
sign
Waktu
Subject
Object
Assesment
Planning
05.00 am
BP = 120/80
RR= 20 x/mnt
Pulse = 87 x/mnt
well,.
stage IV of labor

being
sign
05.15 am
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
well.
stage IV of labor

being
sign
05.30 am
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 82 x/mnt
well.
stage IV of labor

being
sign
06.00 am
BP = 120/70
RR= 20 x/mnt
Tax = 36,8
Pulse = 86 x/mnt
umbilical
1 day post SC

being
sign
Baby well being

T : 36,5, RR : 44x/mnt,
PASI : 20 cc
Name
: Mrs. Mariani
Age
: 41 years old
Address
: Sundaya-Praya
Wakt
u
Subject
05.0
0
pm
Patient refered by midwife with

G3P0A2H0
with APH.
aterm/gemelli/life-life
Cronologis :
(02-12-08/ 03.00 am) Patient came to
PKM Pengadang with intermitten
abdominal pain and bleeding since 0112-08/ 10.00 pm.
03.15 am, she was refered to PKM
Batuyang because there was not
progressed.
The last examination in PKM
Batuyang found :
BP : 110/70 mmHg
Pulse =84 x/mnt
RR: 24 x/mnt
Temp = 36C
FHR: 11-12-11/mnt
UFH = 39 cm
03.30 am
Refered to Praya Hospital but the
rooms were full
04.20 am refered the patient to the
Mataram Hospital
infuse RL 1 kolf
CTH
: 02-12- 2008
: 05.00 am
Object
General status :
Conciousness: CM
BP: 120/80
RR: 20x/mnt
Pulse :94 x/mnt
T: 37,8 C
Obstetric status :
L1 :
L2 :
L3 : head, breech
L4 : desend 4/5
UFH: 40 cm
VT : -
Assesment
Planning
G1P0A0
aterm/single/life/intra
uterine with 2nd stage
of neglected labor.
Observation
mother
Laboratory
examination : DL,
HBsAg
05.00 am
Reported
to
to USG advice :
Prepared to SC:
cefotaxim 2 gr iv
DC
Subject
Object
Examination in Selong Hospital :

01.30 pm
BP : 110/70 mmHg
Pulse =84 x/mnt
RR: 16 x/mnt
Temp = 38,2C
UC : (+)
FHR: 14-14-14/mnt
UFH = 3 fingers under PX (38 cm)
EFW = 4185 g
VT : completed, eff 100 %, amnionic membrane (-),
amniotic fluid (+) clear, descend HII
02.15 pm
Rehidration : RL 1 kolf
Inj cefo 1 gr
Inj celodela : duradril : 2 :2
Lead mother to bearing down for 1 hour but there
wasnt progressed
Informed the SPOG advised refered patient to
mataram hospital
Lab. result:
HBsAg (-)
HB = 8,4
WB = 45.300
TRB = 371.000
Hct = 28.0
Proteinuri (-)
Wakt
u

History of family planning : Family planning : injection for 3 month
ANC : 3x in polindes
Obstetric history:this
Assesment
Planning
Waktu
Subject
Object
Assesment
Planning
05.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
06.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
06.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
07.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
07.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
08.00 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
08.30 pm
Pulse : 94
G1P0A0
Observation mother
fetal well being.
and
09.00
pulse : 96
VT : completed, eff 100 %,
amnionic
membrane
(-),
amniotic fluid (+) greenish,
descend HII, mollage 1+,
unpalpable small organ and
umbilical cord
Time
Subject
Object
Assesment
Planning
09.20
pm
Sent the patient to

operation room
21.40 pm
Baby was born with

SC, female, 3000g,
body length 54 cm,
AS = 7-9.
Waktu
Subject
Object
Assesment
Planning
Placenta was born

manuallly, complete.
Amniotic fluid :
Bleeding : 500 cc
dx. Post-op : neglected
labor + RUI
10.00 pm

Conciousness: CM
BP : 100/80
RR= 24 x/mnt
Tax = 37
Pulse = 116 x/mnt
UT : 100 cc
stage IV of labor

being
sign
10.15 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
stage IV of labor

being
sign
10.30 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
stage IV of labor

being
sign
10.45 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
1 daay post labor

being
sign
11.00 pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Lochia rubra (+)
1 daay post labor

being
sign
Waktu
Subject
Object
Assesment
Planning
11.15pm
BP = 110/80
RR= 20 x/mnt
Pulse = 80 x/mnt
well,.
stage IV of labor

being
sign
11.30pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
well.
stage IV of labor

being
sign
11.45pm
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
well.
Bleeding = Lochia rubra (+)
stage IV of labor

being
sign
06.00 am
BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
umbilical
Bleeding = Lochia rubra (+)
1 daay post labor

being
sign
Baby well being

T : 36,7, RR : 40x/mnt,
PASI : 20 cc

01 DESEMBER 2008: Morning Report

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01 DESEMBER 2008: Morning Report

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Morning Report

Neglected labor + RUI

Patient refered by Selong Hospital

Examination in Selong Hospital :

Last menstrual period : forgot

Sent the patient to operation

Baby was born with SC,

Observation maternal well

Observation maternal well

Observation maternal well

1 daay post labor

Observation maternal well

1 daay post labor

Observation maternal well

Observation maternal well

Observation maternal well

Observation maternal well

Observation maternal well

Baby well being

Patient refered by Sengkol Primary

General status : well

Last menstrual period : forgot

Sent the patient to

Baby was born with

Observation maternal well

Observation maternal well

Observation maternal well

1 daay post labor

Observation maternal well

1 daay post labor

Observation maternal well

Observation maternal well

Observation maternal well

Observation maternal well

Observation maternal well

Baby well being

Patient refered by midwife with

Examination in Selong Hospital :

Last menstrual period : forgot

Sent the patient to

Baby was born with

Placenta was born

General condition: weakness

Observation maternal well

Observation maternal well

Observation maternal well

1 daay post labor

Observation maternal well

1 daay post labor

Observation maternal well

Observation maternal well

Observation maternal well

Observation maternal well

1 daay post labor

Observation maternal well

Baby well being

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