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Morning Report

September 7th, 2015


Supervisor : dr. H. Doddy Ario
Kumboyo, SpOG (K)
Med student:
Tia

G1P0A0L0 39-40 wk S/L/IU head


presentation with neglected first stage of
labor

Case
Name

: Mrs. L

Age

: 27 years old

RM

: 566358

Address

: Lingsar

Admitted to Hospital : September, 5th 2015

TIME

SUBJECT

05/09/15
18.00

Patient referred from Narmada PHC


with G1P0A0L0 39-40 weeks S/L/IU
head presentation mother and fetus
well being, with arrested active
phase of labor.
Patient confessed abdominal pain
and water leaked out from her
womb since 23.00 (04/09/2015),
bloody slim (+), FM (+).
No history of DM, HT, allergy and
asthma.
LMP : 02/12/2014
EDD : 09/09/2015
History ANC : 9x at PHC
Last ANC : 25/08/2015
Result : BP : 100/70 mmHg, BW 61
kg, 37-38 wk, head presentation,
UFH : 35cm, FHB (+)
History USG : 1x (22/07/15)
Result : fetal S/L head presentation,
35-36 weeks, placenta on fundus,
amnion enough, EFW 2600gr,
female, EDD 27/08/2015
History of family planning: Next family planning: Obstetric History:
1. This

OBJECT
General status
GC : well
GCS: CM
BP : 120/60 mmHg
HR: 96 tpm
RR: 22 tpm
T: 37,7 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (-), scar (-)
Ext : edema (-/-)
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 3/5
UFH: 36 cm
EFW : 3875 gram
UC : 3 x 10 ~ 35
FHB : 13.13.13 (156 x/minute)
VT : 8 cm, eff 75%, amnion
(-) meconeal, head palpable
HII, caput (+), impalpable
small part of fetal & umbilical
cord.

ASSESSMENT

PLANNING

G1P0A0L0 39-40
wk S/L/IU head
presentation with
neglected first
stage of labor

DM planning:
Diagnostic
CTG

Therapy
Intrauterine

resuscitation
Pro
abdominal

termination
(CSection)

Inj. Ceftriaxon 2 gr
(iv)
Observation mother

and fetal well being


Suggest patient to

eat, drink and lie


down to left side
Observation

progress of labor
DM co to GP, GP co to
SPV, SPV advice
(18.30):
- Pro CTG
- Rehidration
- Pro C-Section

TIME

SUBJECT
Chronology (05/09/2015) , at Narmada
PHC):
17.00
S: Patient patient 9th month of pregnancy
confessed abdominal pain and water
leaked out from her womb since 23.00
(04/09/2015), bloody slim (+), FM (+).
O: General status : GC well, con. CM,
BP 120/70mmHg, HR 84 x/minute, RR
24 x/minute, T 37,4 C.
Obstetric status:
UFH: 35 cm, EFW 3720gr, head
presentation,
UC : 4 x 10 ~ 45
FHB : 12-12-12 (144x/m)
VT : 8 cm, eff. 75 %, Amnion (-),
head palpable, denom: ROA, HII.
impalpable small part of fetal & umbilical
cord.
A : G1P0A0L0 39-40 weeks S/L/IU head
presentation mother and fetus well
being, with arrested active phase of
labor.
P:
14.30 : IV line, RL flash I
15.30 : RL flash II
16.30 : D5% flash I
Skin test (-)
14.30 Inj. Ampicillin 1 gr iv
10.00 Amoxicillin oral 500 mg

OBJECT
Pelvic evaluation :
Spina ischiadica not prominent
Arcus Pubis > 900
Os Coxygeus Mobile
Lab :
Hb = 11,1 g/dl
RBC = 4,30
HCT = 32,5 %
WBC = 20,7
PLT = 285
HCT = 33,2%
HbSAg = (-)
BT = 225
CT = 610

ASSESSMENT

PLANNING

TIME

SUBJECTIV
E

OBJECTIVE

ASSESSMENT

PLANNING

20.00

Preparing for C-section

20.30

CS was began
baby was delivered(20.40 WITA),
female, BW: 3600 gr, BL : 50
cm, HC : 34 cm, A-S:7-9 ,
congenital anomaly (-), anus( +),
amnion meconeal.
Placenta delivered manually,
complete.

Time
23.00

Subject
-

Object
GC : well
BP : 110/70mmHg
HR : 84 tpm
RR : 20 tpm
Temp : 36,5C
UC : +
UFH : 2 finger below
umbilicus.
UO: 30 cc/hour
Wound Operation : normal
Active bleeding : -

Assessment

Planning

2 hours post CSection

Obs. Mother and


baby well being
(general condition,
vital sign, UC, UFH,
UO, and bleeding)
CIE mother to
mobilization, eat and
drink.

1 day post C-Section

Obs. Mother and


baby well being
(general condition,
vital sign, UC, UFH,
UO, and bleeding)
CIE mother to
mobilization, eat and
drink.

Baby in NICU ;
HR: 148 bpm
RR: 44 tpm
Temp : 36,80C
06/09/15
07.00

Wound pain (+)

GC : well
BP : 120/80mmHg
PR : 88 tpm
RR : 20 tpm
Temp : 36,6C
UC : +
UFH : 2 finger below
umbilicus.
Lochea: +
UO: 50 cc/hour
Baby in NICU ;
HR: 140 bpm
RR: 36 tpm
Temp : 36,60C

TIME
07/09/2015
07.00

SUBJECTIVE

OBJECTIVE
GC : well
BP : 120/70mmHg
PR : 88 tpm
RR : 20 tpm
Temp : 36,6C
UC : +
UFH : 2 finger below umbilicus.
Lochea: +
UO: 50 cc/hour
Baby in NICU ;
HR: 140 bpm
RR: 36 tpm
Temp : 36,60C

ASSESSMENT
2 days post CSection

PLANNING
Observation general
condition and vital sign
Observation UC, UFH,
and lochea
CIE mother to eat and
drink
CIE mother to breast
feeding
CIE mother to
mobilization

Thankyou

Case 2
Name

: Mrs. S

Age

: 35 years old

RM

: 566362

Address

: Gunung Sari

Admitted to Hospital : September, 5th 2015

TIME

SUBJECT

05/09/15
19.00

Patient referred from Gunung Sari


PHC with G3P3A0L3 39-40 weeks
G/L/IU head presentation mother
and fetus well being, with latent
phase 1st stage of labor .
Patient confessed abdominal pain
since 20.00 two days before
(02/09/2015), water leaked out from
her womb (-), bloody slim (-), FM
(+).
No history of DM, HT, allergy and
asthma.
LMP : 15/12/2014
EDD : 22/09/2015
History ANC : 6x at PHC
Last ANC : 12/08/2015
Result : BP : 110/70 mmHg, BW 55
kg, 32 wk, head presentation, UFH :
33cm, FHB (+), gemelli
History USG : 1x (14/07/15)
Result : fetal G/L-L/IU head
presentation-head presentation, 2930 weeks, placenta on fundus,
amnion enough, EFW 1147gr/
1732gr, female-female, EDD
17/09/2015
History of family planning: injection
Next family planning: IUD

OBJECT
General status
GC : well
GCS: CM
BP : 110/70 mmHg
HR: 88 tpm
RR: 20 tpm
T: 36,6 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular M(-),
G(-)
Abd : striae gravidarum (+),
linea nigra (-), scar (-)
Ext : edema (-/-)
Obstetric status
L1 : breech-head
L2 : back on the left and right
side
L3 : head-breech
L4 : 4/5
UFH: 36 cm
EFW : 3875 gram
UC : 3 x 10 ~ 35
FHB :
i. 12.11.11 (136 x/minute)
ii. 12-13-12 (148x/minute)
VT : 3 cm, eff 50%, Amnion
(+), head palpable, denom
unclear, HI, impalpable small
part of fetal & umbilical cord.

ASSESSMENT

PLANNING

G4P3A0L2 38-39
wk G/L-L/IU head
presentationbreech
presentation with
latent phase of
labor

DM planning:
Diagnostic
CTG

Therapy
Observation mother

and fetal well being


Suggest patient to

eat ,drink and lie


down to left side

Observation
progress of labor
DM co to GP, GP co to
SPV, SPV advice
(20.30):
- Observation progress
of labor

TIME

SUBJECT
Obstetric History:
1. Aterm/Female/Spontan/TBA/2
yo/death
2. Aterm/Male/Spontan/TBA/12 yo/live
3. Aterm/Female/Spontan/TBA/11
yo/live
4. This
Chronology (05/09/2015) , at Narmada
PHC):
17.00
S: Patient 9th month of pregnancy
confessed abdominal pain since 2 days
ago, water leaked out from her womb (-),
bloody slim (-), FM (+).
O: General status : GC well, con. CM,
BP 120/80mmHg, HR 84 x/minute, RR
20 x/minute, T 36,5 C,
Obstetric status:
.UFH: 37 cm, head presentation, 4/5
.UC : 3 x 10 ~ 30
.FHB : 140x/m
.VT : 3 cm, eff. 25 %, Amnion (+),
head palpable, denom unclear, HI.
impalpable small part of fetal & umbilical
cord.
A : G3P3A0L3 39-40 weeks G/L/IU head
presentation mother and fetus well
being, with latent phase 1st stage of labor
.
P: -

OBJECT
Lab :
Hb = 11,84 g/dl
RBC = 4,30
HCT = 32,5 %
WBC = 8,74
PLT = 179
HCT = 33,2%
HbSAg = (-)
BT = 150
CT = 545

ASSESSMENT

PLANNING

TIME

SUBJECT

OBJECT

ASSESSMENT

PLANNING

21.00

Abdominal pain (+)

GCS: CM
BP : 110/70 mmHg
HR: 88 tpm
RR: 20 tpm
T: 36,6 C
UC : 3 x 10 ~ 35
FHB :
i. 12.11.11 (136 x/minute)
ii. 12-12-12 (140x/minute)
VT : 4 cm, eff 50%, Amnion
(+), head palpable, denom
unclear, HI, impalpable small
part of fetal & umbilical cord

G4P3A0L2 38-39
wk G/L-L/IU head
presentationbreech
presentation with
active phase of
labor

-- patient moved to VK
Teratai
-Observation progress
of labor with partograf

06/09/2015
01.00

Abdominal pain (+)

BP : 110/70 mmHg
HR: 88 tpm
RR: 20 tpm
T: 36, C
UC : 3 x 10 ~ 30
FHB :
iii. 12.11.11 (136 x/minute)
iv. 12-12-12 (140x/minute)
VT : 4 cm, eff 50%, Amnion
(+), head palpable, denom
unclear, HI, impalpable small
part of fetal & umbilical cord

G4P3A0L2 38-39
wk G/L-L/IU head
presentationbreech
presentation with
arrested active
phase of labor

-CTG
DM co to GP, GP co to
SPV, SPV advice:
- Observation progress
of labor

TIME
07.00

09.00

SUBJECT
Abdominal pain (+)

OBJECT
GCS: CM
BP : 110/70 mmHg
HR: 88 tpm
RR: 20 tpm
T: 36,6 C
UC : 3 x 10 ~ 35
FHB :
i. 12.13.13
ii. 12-12-12
VT : 4 cm, eff 50%, Amnion
(+), head palpable, denom
unclear, HI, impalpable small
part of fetal & umbilical cord

ASSESSMENT
G4P3A0L2 38-39
wk G/L-L/IU head
presentationbreech
presentation with
arrested active
phase of labor

PLANNING
-CTG
-- Pro termination with
C-Section
DM co to GP, GP co to
SPV, SPV advice:
- Pro C-section

CS was began
baby was
delivered(09.10
WITA), femalefemale, BW: 1700gr/
2000gr, BL : 48/49
cm, A-S:7-9/7-9 ,
congenital anomaly
(-)/congenital
anomaly (-),
anus( +)/anus( +),
amnion clear /clear
Placenta
deliveredmanually,
complete.

Time
11.00

Subject
Wound pain (+)

Object
GC : well
BP : 110/70mmHg
HR : 84 tpm
RR : 20 tpm
Temp : 36,5C
UC : +
UFH : 2 finger below
umbilicus.
Lochea: + (rubra)
UO: 30 cc/hour

Assessment

Planning

post C-Section

Obs. Mother and


baby well being
(general condition,
vital sign, UC, UFH,
UO, and bleeding)
CIE mother to
mobilization, eat and
drink.

Baby in NICU ;
HR: 148/150 bpm
RR: 44/42 tpm
Temp : 36,8/38,70C
07/09/15
07.00

Wound pain (+)

GC : well
BP : 110/80mmHg
PR : 88 tpm
RR : 20 tpm
Temp : 36,6C
UC : +
UFH : 2 finger below
umbilicus.
Lochea: +
UO: 50 cc/hour
Baby in NICU ;
HR: 140/142 bpm
RR: 36/36 tpm
Temp : 36,6/36,70C

1st

day post
Section

C-

Obs. Mother and


baby well being
(general condition,
vital sign, UC, UFH,
UO, and bleeding)
CIE mother to
mobilization, eat and
drink.

Thankyou