MORNING REPORT

12th March 2018

Supervisor: dr. Windiana Rambu, Sp.OG
Medical Students:
Tannia, Arsy, Jihan, Elys, Muliana,Vannia

CASE RESUME

NORMAL LABOR

PATHOLOGIES CASE 1. G3P2A0H2 40-41 weeks S/L/I/U

Head presentation with susp.
Makrosomia+ shoulder distocia
Remain Case -
Tidak Ada Pertanyaan
Yang Salah
 Case Report
• Name : Mrs. S
• Age : 38 y.o
• Address : Lingsar, West Lombok
• Admitted : March, 11th 2018
• RM : 602801
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

11/03/ Patient came to NTB General General status G3P2A0L2 DM planning:

2018 Hospital referred from Sigerongan GC: well A/S/L/IU Diagnostic:
11.00 PHC with G3P2A0L2 A/S/L/IU GCS : E4V5M6 inpartu • Check CBC,
am inpartu active phase 1 of labor BP : 120/70 mmHg active phase • Blood Glucose
suspect Gemelly, confessed PR: 88 bpm 1 of labor+ • CTG
abdominal pain since this morning RR: 22 bpm Makrosomia
(05.00 am, 11th March 2018) The Tax: 37,1◦ C Therapy:
patient felt the pain migrates to the • Obs mother and
right and left flank. Blody slime (+) Localis status fetal well being
since this morning too at (05.00 am), Eye : an (-), ict (-) • Observation of
fetal movement (+). Pulmo ves (+/+), rh (-/-), wh (-/-) labor
Cor : S1S2 single regular, murmur
History of DM (-), HT (-), asthma (-), (-), gallop (-) DM co to GP,
allergic (-) Abdomen: advice:
History DM in family (-), HT (-), Scar (-), striae gravidarum (+), linea • Observation of
asthma (-), allergic (-) nigra (+) labor
Extremity: oedema (-/-) warm (+/+)
LMP: 2-06-2017
EDD: 09/03/2018 Obs status:
GW : 40-41 weeks L1 : head
L2 : back to the left side
History of ANC: 6x at PHC L3 : breech
Last ANC: 17/2/18 L4 : 4/5
Result: BP 100/90 mmHg, B: 60 kgs, UFH: 38 cm
UFH 35 cm, GW: 35 weeks head EFW : 4.185 gram
presentation, FHB (+). FHB : (144x/menit)
UC : 4x10-40’’
History of USG: none VT : Ø 8 cm, eff 90 %, amnion (+),
head palpable, denominator
unclear,↓HI, not palpable small part
& umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
gina
m
History of family planning: (-) laboratory exam (11/03/2018):
Next family planning: injection 3
months

Obstetrical history:
1. 2008/
Female/2200/Pervaginam/Midwif
e/PHC/Life
2. 2012/Female/3300/Pervaginam/
Midwife/PHC/Life
3. this

12.30 Mother wanted to bear down General status Phase II of Labor Conduct the
Water leaked out from her womb GC: well labor
GCS : E4V5M6
BP : 120/70 mmHg
PR: 82 bpm
RR: 24 bpm
Tax: 36.6◦ C
FHB : (145x/minutes)
UC : 4x10-45’’
VT : Ø complete, eff 100 %,
amnion (-), head palpable,
denominator unclear,↓HIII, not
palpable small part & umbilical cord
 TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

12.50 Mother wanted to bear General status Phase II of labor+ -McRobert

down GC: well Shoulder distocia Manuver
GCS : E4V5M6 -Wood corkscrew
BP : 120/70 mmHg maneuver
PR: 82 bpm -Massanti
RR: 24 bpm manuver
Tax: 36.6◦ C
FHB : 145x/minutes
UC : 5x10-45’’

Head was born

Turtle sign (+)
Shoulder hasn’t born yet
13.00 - -Baby was born Start the phase III
Female, BW: 4700 of labor
gram, BL: 49 cm Undergo baby’s
Head circ: 36 cm, resuscitation
anus (+), congenital
abnormality (-)
A-S: 3-5
13.15 Active Bleeding (+) General status Placenta was born Evaluation of
GC: well complete perineum
GCS : E4V5M6 rupture Grade
BP : 120/70 mmHg III  hecting
PR: 82 bpm
RR: 24 bpm
Tax: 36.6◦ C
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
gina
m
13.20 - General status Post partum -Observation 2
GC: well hours post
GCS : E4V5M6
partum
BP : 160/80 mmHg
PR: 88 bpm -Check complete
RR: 24 bpm urinalisis
Tax: 37◦ C
TFU: 1 finger bellow umbilicus
Bleeding 50 cc
15.00 - General status 2 hours post -Patient move to
GC: well partum segara anak
GCS : E4V5M6
BP : 150/80 mmHg
PR: 88 bpm
RR: 24 bpm
Tax: 37◦ C
TFU: 2 finger bellow umbilicus
Bleeding 60 cc
CTG
Referral Letter
KIA Book
Baby’s Documentation
Thankyou