MORNING REPORT

12th February 2018

Supervisor: dr. Edi Prasetyo Wibowo, Sp.OG

Medical Students:
Arsy, Maya, Nuril, Devi
CASE RESUME
NORMAL LABOR -

PATHOLOGIES CASE 1. G4P3A0L1 42-43 weeks S/L/IU head

presentation with failure induction oxytocin +
Hepatitis

REMAIN CASE 1. G2P1A0H1 38-39 weeks S/L/IU head presentation

with anemia + trombositopenia
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Case Report

Name : Mrs. NS
Age : 34 years old
RM : 142183
Address : Narmada-West Lombok
Admitted : 10th February 2018 (13.00 pm)
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

10th Feb Patient came to Polyclinic of Obstetric with G4P3A0L1 42- General Status : G4P3A0L1 42- Diagnostic:
2018 43 weeks S/L/IU head presentation and hepatitis. Patient GC : Well 43 weeks • Check Lab ( CBC)
(13.00 confessed needs to control her pregnancy cause of post BP : 100/70 mmHg S/L/IU head • Glucose
pm) date. Patient confessed abdominal pain since 5 days ago. PR : 88 bpm presentation + • Hemostasis
Abdominal pain is not consist and referred to her back. RR : 20 bpm Hepatitis • CTG
There is no water leaked, bloody slime (-), fetal movement T : 36,6oC
(+). There is no fever, headache and epigastrical pain. Monitoring :
Local Status : • Observation mother and fetus
History of DM (-), HT (-), asthma (-), allergic (-). History of Eye : anemis (-/-), icteric (-/-), well being ( Vital sign, FHB)
hepatitis (+). ptosis (+/+)
History DM in family (-), HT (-), asthma (-), allergic (-) Cor : S1S2 regular, murmur (-), Therapy:
gallop (-). • IVFD RL 500 ml 20 dpm
LMP : 16-04-2017 Pulmo : vesicular (+/+), wheezing • Pro induction with oxytocin drip
EDD : 23-01-2018 (-/-), rhonki (-/-).
GW : 43 weeks 5 days Abdomen : scar (-), striae
gravidarum (+), linea nigra (+).
History of menarche at 15 years old Extremity :
Cycle : Regular Superior: edema (-/-), warm (+/+)
Inferior: edema (-/-), warm (+/+)
History of ANC : 8 times Obstetrical Status :
Last ANC : 10 th February 2018 L1 : breech
Result:BP:100/60 L2 : back at the right side
GW: 42-43 weeks L3 : head
UFH: 30 cm L4 : 4/5
head presentation, FHB (+) 140 x/m UFH : 30 cm
History of USG : 1 time EFW : 2945 gram
- Fetus S/L/IU UC : (-)
- BPD 9,41 cm 38 w 2 days FHB: 12-12-12 (144x/mins,
- AC 36 weeks 1 day regular)
- FL 38 weeks 3 days VT : Ø 2 cm, eff 25%, amnion (+)
- EDD 28/2/2018 head palpable, H1, not palpable
- EFW 3127 gram small part & umbilical cord
- Less amnion
- Placenta in the anterior corpus grade III
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
History of family planning : Lab Examination (10/2/18) in
Injection used till less than 1 NTB GH:
month.
Next family planning : IUD. Hb : 10,5 g/dl
Obstetrical History : HCT : 33 %
1. 2001/Preterm/RSUD/Midwife/S RBC : 3,80 M/uL
pontaneous WBC : 6570 K/uL
pervaginam/Male//Death PLT : 223 K/uL
2. 2002/Preterm/RSUD/Midwife/S
pontaneus
pervaginam/Female/Death PPT: 15.4/13,0
3. 2012/Aterm/Polindes/Spontane APTT: 30,7/29,8
us pervaginam/Female/Life
4. This one. Glucose 75 mg/dL

Social history :
- Married since 8 years ago begin
at 25 years old
- This is first marriage
- Occupation : house wife
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
10/2/18 There is no complaining from patient GC: Well G4P3A0L1 42-43 - IVFD RL 500 ml 20 dpm
BP : 110/70 mmHg weeks S/L/IU head
14:00
PR : 80 bpm presentation + - Consult SPV :
RR : 20 bpm Hepatitis - Pro induction oxytocin drip
T : 36,0oC based on protap

UC : (-)
FHB: 11-11-11 (132x/mins)
10/2/18 There is no complaining from patient GC: Well G4P3A0L1 42-43 • Prepared IVFD D5% 500 ml
BP : 110/70 mmHg weeks S/L/IU head with oxytocin 5 unit start 8
14: 45
PR : 80 bpm presentation + dpm
RR : 20 bpm Hepatitis
T : 36,0oC

10/2/18 There is no complaining from patient GC: Well G4P3A0L1 42-43 • IVFD D5% 500 ml flash I
BP : 110/70 mmHg weeks S/L/IU head • Oxytocin drip 8 dpm
15:00
PR : 82 bpm presentation + • Obs mother and fetus well
RR : 20 bpm Hepatitis being
T : 36,4oC

UC : (-)
FHB : 12-11-11 (frequency 136x/mins)
10/2/18 Patient confessed abdominal pain GC: Well G4P3A0L1 42-43 • IVFD D5% 500 ml flash I
BP : 110/70 mmHg weeks S/L/IU head • Oxytocin drip 32 dpm
18:00
PR : 80 bpm presentation + • Obs mother and fetal well
RR : 20 bpm Hepatitis being
T : 36,6oC • Obs signs of birth

UC : (-)
FHB : 11-12-12 (frequency 140x/mins)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

10/2/18 Patien confessed back GC : well G4P3A0L1 42-43 -IVFD D5% 500 ml flash I
pain BP : 110/70 mmHg weeks S/L/IU head -Oxytocin drip 40 dpm
20:00
PR : 82 bpm presentation + -Obs mother and fetal well
RR : 20 bpm Hepatitis being
Temp : 36,6oC -KIE patient to eat and drink
UC : (-) well
DJJ 12-11-12 (Frequency 140x/minutes)

11/2/18 Patient confessed lower GC : well G4P3A0L1 42-43 - IVFD D5% 500 ml plus
abdominal pain BP : 110/70 mmHg weeks S/L/IU head oxytocin drip flash II end
01:00
PR : 88 bpm presentation with - Obs nother and fetal well
am
RR : 20 bpm failure induction being
Temp : 36,5oC oxytocin + Hepatitis
UC : 1x10’~15 “
DJJ : 12-12-12 (Frequency 144x/minutes)
VT : Ø 2 cm, eff 25%, amnion (+) head palpable,
H1, not palpable small part & umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

11/2/18 GC : well G4P3A0L1 42-43 -IVFD D5% 500 ml flash I

BP : 110/70 mmHg weeks S/L/IU head -Oxytocin drip 40 dpm
06:00
PR : 82 bpm presentation with -Obs mother and fetal well
am
RR : 20 bpm failure induction being
Temp : 36,6oC oxytocin + Hepatitis -KIE patient to eat and drink
UC : (-) well
DJJ 12-11-12 (Frequency 140x/minutes)

11/2/18 Patient confessed lower GC : well G4P3A0L1 42-43 - IVFD D5% 500 ml plus
abdominal pain BP : 110/70 mmHg weeks S/L/IU head oxytocin drip flash II end
01:00
PR : 88 bpm presentation with - Obs nother and fetal well
am
RR : 20 bpm failure induction being
Temp : 36,5oC oxytocin + Hepatitis
UC : 1x10’~15 “
DJJ : 12-12-12 (Frequency 144x/minutes)
VT : Ø 2 cm, eff 25%, amnion (+) head palpable,
H1, not palpable small part & umbilical cord

11/2/18 Patient confessed lower GC : well G4P3A0L1 42-43 - IVFD RL 500 ml 20 dpm
back pain BP : 110/70 mmHg weeks S/L/IU head - Obs mother and fetus well
06:00
PR : 80 bpm presentation with being
RR : 20 bpm failure induction - Consul SPV :
Temp : 36,7oC oxytocin + Hepatitis - Pro SC
UC : 1x10’~15 “
DJJ : 12-13-13 (Frequency 152x/minutes)
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

11/2/18 There is no complaining GC : well G4P3A0L1 42-43 -IVFD RL 500 ml 20 dpm

from patient BP : 110/70 mmHg weeks S/L/IU head -Obs mother and fetus well
07:30
PR : 86 bpm presentation with being
am
RR : 20 bpm failure induction -Fasting preparation for CS plus
Temp : 36,6oC oxytocin + Hepatitis inform concent to husband and
UC : (-) family
DJJ 12-13-12 (Frequency 148x/minutes)

11/2/18 There is no complaining GC : well G4P3A0L1 42-43 -Cefotaxime 1 gram in RL 200

from patient BP : 110/70 mmHg weeks S/L/IU head ml 20 dpm intravena
10:00
PR : 86 bpm presentation with -Obs mother and fetus well
am
RR : 20 bpm failure induction being
Temp : 36,6oC oxytocin + Hepatitis
DJJ 12-12-12 (Frequency 144x/minutes)

11/2/18 There is no complaining GC : well G4P3A0L1 42-43 - Patient moved to OK Cito

from patient BP : 110/70 mmHg weeks S/L/IU head
11:30 am
PR : 84 bpm presentation with
RR : 20 bpm failure induction
Temp : 36,6oC oxytocin + Hepatitis

11/2/18 GC : well G4P3A0L1 42-43 SC was begin

BP : 110/70 mmHg weeks S/L/IU head
12:00
PR : 84 bpm presentation with
am
RR : 20 bpm failure induction
Temp : 36,6oC oxytocin + Hepatitis
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

11/2/18 GC : well -Baby was born

BP : 110/70 mmHg -Male. BW 2.500 gram, BL 48
12:19
PR : 86 bpm cm, anus (+), meconium (+),
am
RR : 20 bpm knee hiperextention (+),
malformation genitalia (+) AS 1-
1

-Baby was bagging for 45

minutes in Cito and moved to
NICU

-13:14 pm baby has passed

away
11/2/18 Patient confessed cough GC : well Post SC - Drip tramadol and oxytocin
and dizzy BP : 100/70 mmHg 20 dpm
13:00
PR : 80 bpm - Obs mother (TTV, bleeding,
am
RR : 20 bpm uterus contraction)
Temp : 36,6oC
Uterus contraction well
Bleeding (-)
11/2/181 Patient confessed cough GC : well Post SC 2 hours - Advice post SC
15:40 BP : 110/70 mmHg - IVFD RL : D5 3:1
PR : 84 bpm - Cefotaxime 1 gram/ 8 hours
RR : 20 bpm intravenous
Temp : 36,6oC - Kaltopren supp 500 mg/8
hours
- Misoprostol 4 tablets

- Patient moved to Segara

Anak Room
PAPER OF
OPERATION’S
REPORT
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CTG
Baby’s Documentation
Baby’s Documentation
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