MORNING REPORT

27 July 2016

Supervisor: dr. Edi P. Wibowo, Sp.OG

Medical Students:
M, Nabila, Cokorda
CASE RESUME

NORMAL LABOR -

PATHOLOGIES CASE 1. G3P2A0L2 40-41 weeks S/L/IU head presentation,

inpartu active phase of labor, with gestational
hypertension

REMAIN CASE 1. Abortus incomplete

2. G5P3A1L2 29-30 weeks S/L/IU head presentation
with antepartum bleeding susp placenta previa
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 Case 1
Name : Mrs. R
Age : 37 yo
Address : Bug Bug, Lingsar
Admitted : 27 July 2016
RM : 58-11-72
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

27/07/ Patient referred from Lingsar PHC General status G3P2A0L2 40-41 DM planning:
2016 with G3P2A0L2, 41 weeks S/L/IU GC: well weeks S/L/IU head Diagnostic:
15.30 head presentation, mother and fetal GCS : E4V5M6 presentation, HbsAg
in good condition with inpartu latent BP : 140/100 mmHg inpartu active CTG
phase of labor + mild pre eclampsia. HR: 85 tpm phase of labor,
Patient confessed abdominal pain RR: 20 tpm with gestational
(contraction) since 03.00 Tax: 36.6 C hypertension Therapy:
(27/7/2016) and get more often ever Observation
since, bloody slime (+). Water Local status progress of labor
leaked from her womb (-) fetal Eye : an (-/-), ict (-/-) with WHO
movement (+). Dizzy (-), headache Pulmo ves (+/+), rh (-/-), wh (-/-) partograph
(-), epigastric pain (-), nausea (-), Cor : S1S2 single regular, murmur Obs mother and
vomiting (-), blurry vision (-). (-), gallop(-) fetal well being
Abdomen:
History of DM (-), HT (-), asthma (-), Scar (-), striae gravidarum (+), DM co to GP, GP co
allergic (-) linea nigra (+) to Spv, advice:
History DM in family (-), HT (+), Extremity: oedema (-/-), warm (+/ - Observation
asthma (-), allergic (-) +) progress of labor

LMP: 13-10-2015 Obs status:

EDD: 20-07-2016 L1 : breech
GW : 40-41 weeks L2 : back to the right side
L3 : head
History of ANC: 9x at PHC L4: 4/5
Last ANC (27/7/16) : Patient UFH: 34 cm
complain flank pain, BP 130/90 EFW : 3565 g
mmHg, GW 41 weeks, head FHB : 13-13-12
presentation, UFH: 33 cm, FHB 132 UC : 2x10~30
bpm, Hb 12 g%, proteinuria +1 VT: 4cm, eff 50%, amnion (+),
head persentation, denom ROA,
History of USG: (-) HI, small parts and umbilical not
palpable
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

History of family planning: Laboratory exam (27/07/2016):

contraception pill HGB: 11,9
Next family planning: IUD RBC: 5,27
HCT: 36,4
Obstetrical history: MCV: 69,1
1. Aterm/male/3300 g/PHC/midwife/ MCH: 22,6
16 y.o/L MCHC: 32,7
2. Aterm/ female/ weight?/ home/ WBC: 17,08
traditional midwife/ 12 y.o/ L PLT: 392
3. this
HbsAg not reactive
GDS 131

Proteinuria (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronology at Lingsar PHC (27/07/2016) 14.00:

S/
Patient 9 month pregnant confessed abdominal
pain since 22.40 (26/7/16), water leaked out
from her womb (-), bloody slime (-). FM (+)

O/
GC: well
BP : 130/90 mmHg
HR: 80 tpm
RR: 20 tpm
Tax: 36,5 C
UFH : 32 cm
Breech at fundus, back on the left side, Head
Presentation, L4: 4/5
UC : 2x10~25
VT : 3 cm, eff 25%, amnion (+), head
palpable, denom unclear, HI, small parts and
umbilical unpalpable

Hb 12,2 g%
Proteinuria +1

A/ G3P2A0L2, 41 weeks S/L/IU head

presentation, mother and fetal in good condition
with inpartu latent phase of labor + mild pre
eclampsia

P/
Infuse RL 24 dpm
Refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
19.30 Abdominal pain (contraction) same as GC: well Arrest active phase DM Planning :
before BP : 110/70 mmHg of labor -Intrauterine
HR: 86 tpm Inertia uteri rehydration :
RR: 20 tpm RL : D5 = 2:1
Tax: 36,8 C 02 4 lpm
Lying to the left side
FHB : 13-12-12 -Acceleration with
UC : 1x10~20 oxytocin drip
VT: 4cm, eff 50%, amnion
(+), head persentation, DM co to GP, GP co to
denom ROA, HI, small Spv :
parts and umbilical not - C-section at 22.00
palpable

20.30 Abdominal pain (contraction) same as GC: well

before BP : 120/70 mmHg
HR: 88 tpm
RR: 20 tpm
Tax: 36,9 C

FHB : 13-13-13
UC : 1x10~20

21.30 Abdominal pain (contraction) same as GC: well

before BP : 110/70 mmHg
HR: 86 tpm
RR: 20 tpm
Tax: 36,7 C

FHB : 13-13-13
UC : 1x10~20
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

22.00 Patient was sent to the operating room Baby was born, at
22.30 Male, BW :
3500 gr, BL : 51 cm,
AS : 7-9, anus (+),
anomaly congenital (-).

Placenta was born

complete at 22.32

00.30 Pain from operation wound GC: well 2 hours post C-section Obs. Mother well being
nausea (-), vomiting (-) GCS: E4V5M6 Observation GC, VS,
BP: 110/60 mmHg bleeding
HR: 100 bpm
RR: 24 rpm
T: 36,90 C
UC (+) well
UFH at umbilical
Active bleeding (-)

06.00 Pain from operation wound GC: well 1 day post C-section Obs. Mother well being
nausea (-), vomiting (-) GCS: E4V5M6
BP: 110/80 mmHg
PR: 94 bpm
RR: 20 rpm
T: 36,50 C
UC (+) well
UFH 2 finger below
umbilical
Active bleeding (-)
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 Case 2
Name : Mrs. S.N
Age : 33 yo
Address : Pagesangan Barat
Admitted : 27 July 2016
RM : 58-11-89
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

27/07/ Patient referred from sedau PHC General Status : Abortus DM Planning
2016 with abortus incomplate, Patient GC : well incomplete Diagnostic:
confessed blood came out from GCS : E4V5M6 CBC
22.30 her womb since 08.00 (12-07- BP : 110/60 mmHg USG
2017). Characteristic of blood is PR : 100 bpm
red color and clotted. At 14.30 RR : 20 bpm Therapeutic
patient feel abdominal pain. fetal T : 37oC Infuse RL 20 tpm
tissue came out from her womb. Evacuation of fetal
Eye : anemis (-/-), icteric (-/-).
History of trauma (-). tissue with finger
Cor : S1S2 single regular, murmur
Observation vital sign
History of DM (-), HT (-), asthma (-), gallop (-). and bleeding every 30
(-), allergic (-) Pulmo : vesicular (+/+), wheezing minute for 2 hours
History DM in family (-), HT (+), (-/-), ronkhi (-/-). after evacuation
asthma (-), allergic (-) Abdomen : UFH not palpable, scar
(-), striae gravidrum (-), linea nigra DM co to GP;
LMP: 03-06-2016 (-). GP co to SPV, advice:
GW : 8-9 weeks Extremity : edema (-/-), warm acral USG tomorrow morning.
(+/+).
History of ANC: 1x at PHC
(27/7/16) : Patient complain Gynecology Status :
nausea, dizzy, BP 110/80 mmHg, Inspeculo : (+), livide (+), tissue
weight 59 kg, GW 8-9 weeks, (+), fluxus (+), active bleeding (-),
head presentation, fundus not erosion (+).
palpable, PPT (+) VT : (+), tissue (+), cavum uteri
anteflexion, slinger pain (-), APCD
History of USG: (-) normal
History of contraception : inj 3
month
Next contraception : inj 3 month
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetrical History : Lab Examination :

1. Aterm/male/weight?/PHC/Midwife/perva HB : 10,6
ginam/4 y.o/alive RBC : 3,96
2. This WBC : 20,90
PLT : 121
Chronology at Lingsar PHC (27/7/2016)
S/ Patient 3 month pregnant came to PHC HbSAg : not reactive
at 15.30, confessed blood came out of her
womb since 11.00. At 14.30 patient
confessed abdominal pain and blood with
clot came out of her womb.

O/ Mother in good condition

GC : Compos mentis
BP : 100/70 mmHg
HR : 80 tpm
RR : 20 tpm
T : 38 C
Fundus not palpable
VT 2 cm, tissue (+)
Inspeculo : tissue (+), active bleeding (+)

A/ G2P1A0L1, 8-9 weeks with abortus

incomplete

P/
Infuse RL 28 dpm
Paracetamol tab
Inj ampicllin 1 g iv
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

06.00 Abdominal pain (+) GC : well Abortus Observe vital sign and bleeding
BP : 100/70 mmHg incomplete Pro USG
PR : 96 bpm
RR : 20 bpm
T : 36,4oC
TFU : not palpable
Active bleeding : (-)
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 Case 3
Name : Mrs. E
Age : 34 yo
Address : Narmada
Admitted : 28 July 2016
RM : 58-11-96
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

28/07/ Patient referred from Sedau PHC General status G5P3A1L2 29-30 DM planning:
2016 with G5P3A1L2, A/S/L/IU head GC: well weeks S/L/IU head Diagnostic:
02.30 presentation, mother and fetal in GCS : E4V5M6 presentation with DL
good condition with susp placenta BP : 130/80 mmHg antepartum USG
previa. Patient pregnant 7 month, HR: 96 tpm bleeding susp
confessed blood came out of her RR: 20 tpm placenta previa Therapy:
womb at 22.00 (27/7/16), the blood Tax: 36.5 C Infuse RL 20 bpm
was red, abdominal pain (-), fetal PRC transfusion
movement (+). Dizzy (+). Local status Inj
Eye : an (+/+), ict (-/-) dexamethasone
History of DM (-), HT (-), asthma (-), Pulmo ves (+/+), rh (-/-), wh (-/-) 2x6 mg im
allergic (-), trauma (-) Cor : S1S2 single regular, murmur Obs. Bleeding,
History DM in family (-), HT (-), (-), gallop(-) vital sign, FHB
asthma (-), allergic (-) Abdomen: every 6 hours
Scar (-), striae gravidarum (+), Bed rest
LMP: forgot linea nigra (+)
EDD: - Extremity: oedema (-/-), warm (+/ DM co to GP, GP co
GW : - +) to Spv, advice:

History of ANC: 4x at PHC Obs status:

Last ANC (21/7/16) : Patient L1 : breech
complain dizzy, BP 120/80 mmHg, L2 : back to the right side
weigt 60 kg, GW 28 weeks, head L3 : head
presentation, back on the right side, L4: 5/5
UFH: 26 cm, FHB 136 bpm UFH: 26 cm
EFW : 2170 g
History of USG: (-) FHB : 12-12-13
History of contraception : inj 3 month UC : -
Next contraception : inj 3 month Inspeculo: (+), erotion at portio
(-), livide (+), active bleeding (+),
red fluxus (+)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetrical history: Laboratory exam (28/07/2016):

1. Aterm/female/3400 g/PHC/midwife/ HGB: 10,7
16 y.o/L RBC: 4,03
2. Preterm/ male/ weight?/ home/ HCT: 32,9
traditional midwife/ 1 day/ D MCV: 81,6
3. Abortus/ 2 month/ curettage MCH: 26,6
4. Aterm/female/2100 g/PHC/midwife/ MCHC: 32,5
11 y.o/L WBC: 11,05
5. This PLT: 200

HbsAg not reactive

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Chronology at Sedau PHC 00.00 (28/7/2016)

S/ Patient confessed a lot of blood came out

of her womb since 23.45. the color of blood
was red, clotted (+)

O/ GC : well, compos mentis

BP : 120/80 mmHg
HR : 82 tpm
RR : 20 tpm
T : 36,5 C
UFH 28 cm
Breech at fundus, back on the left side, L4 :
5/5
FHB (+) 148 x/minute
UC (-)
Inspeculo : active bleeding

A/ G5P3A1L2, A/S/L/IU head presentation,

mother and fetal in good condition with susp
placenta previa.

P/ infuse RL 28 dpm
Refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
06.00 Abdominal pain (-) GC: well -Bed rest
GCS : E4V5M6 -USG
BP : 130/80 mmHg
HR: 96 tpm
RR: 20 tpm
Tax: 36.5 C

FHB (+) 148 x/minute

UC (-)
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