Morning Report

September, 14th 2015

Supervisor:
Dr. Made Putra Juliawan, SpOG
DM Jaga:
Rian

Morning Report
th
september 14 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES
LABOR

1.

GYNECOLOGI
C CASE

G1P0A0L0 34-35 weeks S/IUFD with APB e.c. solutio

placenta

Case 1
Name : Mrs. Z
Age : 24 years old
Address : Ampenan
Admitted : 13-09-2015
No. RM : 56-67-44
G1P0A0L0 34-35 weeks S/IUFD with
APB e.c. solutio placenta

TIME

SUBJECTIVE

13/09/201
5
10.26 wita

Patient refered from Ampenan

PHC with G1P0AL0 34-35
weeks S/IUFD/IU with suspect
placenta previa and IUFD.
Patient confessed about vaginal
bleeding followed with
abdominal pain since 09.20
(08/09/2015). History of water
leaked out from her womb (-)
History of bloody slim (+), FM (-)
since 09.00 (13/09/2015)
History of DM (-), HT in
pregnancy (-), asthma (-) and
allergy (-).
LMP : forget
EDD :
History of ANC : 8x at PHC
Last result: (13/09/2015)
BP 140/90 mmHg, BW 79 kg,
GW 35-36? w UFH 30 cm, head
presentation, FHB (+),
120x/minute, proteinuria +2
History of USG : 1x, at SpOG
Last : 12/06/2015
S/L/IU head presentation, GW
21-22 weeks, EDD 22/10/2015
EFW 420 g
History of family planning: Next family planning : -

OBJECTIVE
General status
GC : severe
consciousness: CM
BP : 80/p mmHg
PR: 118 bpm
RR: 26 bpm
T: 37.3 C
UO : 0 cc
Local status
Eye : an (+/+), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema of lower
extremity(-/-), warm acral (+/
+).
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 29 cm
EFW : 2790g
UC : 2x10~20
FHB : Inspekulo : +, fluxus (+),
livide (+), active bleeding (+)
bloody slim (+)
VT : not perform

ASSESSMENT

PLANNING

G1P0A0L0
34-35
weeks S/IUFD with
APB e.c. solutio
placenta
dd/
placenta previa +
preeclampsia

DM planning:
Diagnostic :
Therapy :
Infusion RL till 4th flash
followed by Colloid 1
flash followed by WB
O2 3 lpm canula
Elevation of both of
legs
Injection ceftriaxon 2gr
Pro C-Section cito
Monitoring : VS mother,
UC, UO, active
bleeding
CIE : CIE mother and
family about
therapeutic planning
DM co to GP advice :
Pro C-Section cito

TIME

SUBJECTIVE
Obstetric History:
I. This

OBJECTIVE
Laboratory (13/09/2015
10.39):
HB: 6.7 g/dl
RBC: 2.58
HCT: 20.9 %
WBC: 16.08
PLT: 111
HbsAg: non reactive
BT : 640
CT : 800

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Chronology at Ampenan PHC
(13/09/2015)
09.20
S:
Patient confessed abdominal
pain and vaginal bleeding
suddenly.
O:
GC : severe
BP : 90/60 mmHg
PR: 94 bpm
RR: 20 bpm
T: 36.7C
Obstetric status
UFH: 30 cm
FHB : VT : not perform e.c. active
bleeding
Co to GP advice :
Infusion RL high dpm
Refer to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
A:
G1P0A0L0 39-40 weeks /S/L/IU
head presentation mother and
fetal well being with postterm
P:
CIE mother about examination
result
RL infusion 20 dpm
Refer to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME
11.15

SUBJECTIVE

OBJECTIVE

ASSESSMENT

Patient transferred to OR

PLANNING
C-Section begin at
11.20
At 11.30 Baby was
born, female, still birth,
2000 g, BL 45 cm,
Placenta was born
disruptly at 11.35
solutio placenta
Do the management of
4th stage of labor

14.15

Patient confess about

abdominal wound pain

General status
GC : moderate
consciousness: CM
BP : 120/80 mmHg
PR: 102 bpm
RR: 24 bpm
T: 36.5 C
Acral : warm (+/+)
UC : well
UFH : 1 fingers below
umbilical
UO : 50 cc/3 hours
Active bleeding (-)

2 hours post CS

DM planning:
Diagnostic :
Therapy :
Monitoring :
Observation for shock
condition
Observation for VS,
UC, active bleeding
CIE : CIE mother to
rest and start to drink
slowly

TIME
14/09/201
5
07.00

SUBJECTIVE
Patient confess about
abdominal wound pain

OBJECTIVE
General status
GC : moderate
consciousness: CM
BP : 90/60 mmHg
PR: 84 bpm
RR: 22 bpm
T: 36.8 C
Acral : warm (+/+)
UC : well
UFH : 1 fingers below
umbilical
UO : 100 cc/2 hours
Active bleeding (-)

ASSESSMENT
1 day post CS

PLANNING
DM planning:
Diagnostic :
Therapy :
Monitoring :
Observation for shock
condition
Observation for VS,
UC, active bleeding
CIE : CIE mother to
rest and start to drink
slowly

.. Thank
You ..