Morning Report

7 Jan 2014
Supervisor : dr. Agus Thoriq., Sp.OG
Medical Students :
Rara, Putri, Akbar, Selvi
Case Report
Identity
Name : Mrs. B
Age : 26 years old
Address : Meninting, Batu Layar, Lombok Barat.
RM : 530432
Hospitalization : January 6
th
2014 at 19.00 WITA
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
06/01/
2014
19.00
Patient come to VK IRD confessed
water came out from her womb
since 15.30 (06/01/2014) &
abdominal pain since 17.00
(06/01/2014). Bloody slim (+). FM
(+).
History of HT (-), DM (-), asthma (-).

LMP : 18/04 /2013
EDD : 2 5/01 /2014

History ANC : > 4x at Posyandu
Last ANC : 11/11/2013
USG : -


History of family planning : -
Next family planning : injection 3
months

Obstetric History :
1. This

General Status
GC : well
BP : 110/70 mmHg
PR : 82 bpm
RR : 22 bpm
T : 36,3
o
C
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single regular, murmur (-
), gallop (-).
Pulmo : vesikuler (+/+), wheezing (-
/-),
ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

Obstetric Status
L1 : breech & head
L2 : -
L3 : head & breech
L4 : 4/5
UFH : 37 cm
UC : 3x10~ 40
FHB : I. 12-12-12 (144 bpm)
II. 13-13-13 (156 bpm)

VT : 4 cm, eff 50%, amnion (-),
clear, breech and foot palpable HI,
impalpable umbilical cord.

G1P0A0L0 37-38
weeks G/L-L/IU
breech
presentation &
head persentation,
active phase 1
st

stage of labor
history rupture of
membrane.

Observe mother and
fetal well being.
Observe progress of
labor.
Skin test (-), injection
Ampicillin 1g/IV.
DM co GP pro SC;
GP consult to SPV.
Advice : SC at 21.30
(6/1/2014)

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist - Lab Evaluation :
Hb : 10,7 g/dl
RBC : 3,84 M/dl
HCT : 32,9 %
WBC : 9,96 K/dl
PLT : 249 K/dl
HbSAg : (-)
BT : 220
CT : 530



TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
21.30 SC began
Male, W : 2500 gram, A-
S 7-9, caput (-), amnion
clear
Congenital anomali (-),
anus (+), Female, W :
2300 gram, A-S 6-8,
caput (-), amnion clear
Congenital anomali (-),
anus (+)

Two plasenta was born
manually, complete
Bleeding 500 cc
SC finish

23.30 Patient confessed wound pain GC: well Cons: CM
BP: 120/70 HR: 84 bpm
RR: 22 tpm T: 37,5
o
C
UC: +
UFH: 1 finger below umbilicus
Lochia rubra: +
2 hours post SC Observed mother and
baby well being
Suggest mother to
mobilisation.
07/01/
2014
07.00
Patient confessed wound pain GC: well Cons: CM
BP: 110/70 HR : 92 bpm
RR : 20 tpm T : 38,1
o
C
UFH : 2 fingers below umbilicus
UC : + UO : 60 cc/hours
Lochia rubra: +

Baby in NICU:
Baby 1 baby : 2
PR:148 PR : 148
RR: 44 RR : 46
T: 37,4 T : 36,6
One day post SC Observed mother and
baby well being
Suggest mother to
mobilisation, eat, and
drink, medication.
CIE Breast feeding
Terimakasih