MORNING REPORT

8 August 2015
th

Supervisor : dr. I Made Putra Juliawan, SpOG

Medical Student:
Yande,Cinta

Name : Mrs. M
Age : 33 years old
Address : Batu Layar, Lobar
Admitted : 8th August 2015, 11.45
No. MR : 121975

Time

Subject

Object

08/08/
2015
11.15

Patient reffered from Meninting

PHC with G2P1A0L1 36-37
weeks/S/L/IU head presentation,
mother and fetal well being +
confirmation diagnose. Patient
confessed about blood leaked
out from her womb since 21.00
(07/08/2015). Abdominal pain (-).
Bloody slim (-), FM (+). Water
leaked out from her womb (-).
No history of HT, DM, and
asthma from patient and her
family.

GC : well
GCS : E4V5M6
BP : 110/70
HR: 84 bpm
T : 37 C
RR : 21 bpm
General Status :
Eye : an (-/-) , ict (-/-)
Thorax :
C : S1S2 single reguler, murmur (-),
gallop (-).
P : ves +/+ , wh (-/-). Rh (-/-)
Abdomen : scar (-) , striae (+)
Extremity : edema (-/-)

LMP : 22-11-2014
EDD : 29-08-2015
History of ANC : 10x at PHC
Last ANC : 8/8/15
Result mother confessed
bleeding from vagina, BP 130/90,
36-37 weeks, UFH 30 cm, head
presentation, FHB (+)
USG : 2x at SpOG
Last USG: 8/8/15
Fetal S/L/IU , Head presentation,
plasenta at corpus posterior,
aterm, EFW 3531 gram
History of family planning : Next family planning : Obstetrical history :
1.Aterm/
female/
spontan/
midwife /PHC / 4 y.o/ alive

Obstetrical status :
L1 : breech
31cm
L2 : back on the right side
L3 : head
L4 : 5/5
EFW : 2945 gr
UC : (-)
FHR : 12.13.13 (152 bpm)
VT : not evaluated
Lab :
HGB : 12,6
RBC : 4,58
HCT : 37,9
WBC : 11,10
PLT : 305
HBSAg : non reactive
USG :

Assesment

UFH :

G2P1A0L1 36-37
weeks/S/L/IU head
presentation, with
APB e.c plasenta
previa parsial

Planning
Check CBC, BT/CT,
HbSAg
Pro CTG
termination
Pro
perabdominal
with
CS
Obs mother & fetal
well being.
mother
and
KIE
family about exam
result
Consult for Termination
with CS to SPV, SPV
agree, advice : CS at
16.00 WITA.

Time

Subject

Object

08/08/
2015
08.00
WITA

Chronologist
in
PHC
Meninting
S:
Patient confessed about blood
leaked out from her womb
since
21.00
(07/08/2015).
Abdominal pain (-). Bloody slim
(-), FM (+). Water leaked out
from her womb (-).
O:
GS: well
BP : 110/70 mmHg
PR:80bpm
RR: 20 x/minutes
T: 36,5 C
UFH : 30cm
UC : (-)
FHR : 12-11-11 (136 bpm)
Palpable breech on fundus,
back on the right side.
VT : dilatation (-)
Inspekulo : there are much
blood slim.
A:
G2P1A0L1 36-37 weeks/S/L/IU
head presentation, mother and
fetal well being + confirmation
of diagnose.
P:
Needed
diagnose

confirmation

of

Assesment

Planning

Time

Subject

Object

Assesment

Planning

12.30
WITA

Blood leaked out from her

womb (-)
Lower abdominal pain (-)

General Status :
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR : 82 bpm
RR : 20 tpm
T : 36,9 OC
UC : (-)
FHR : 12.12.13 (148 bpm)
VT : not evaluated

G2P1A0L1 36-37
weeks/S/L/IU head
presentation, with
APB e.c plasenta
previa parsial.

Pro USG, result :

placenta
previa
parsial, aterm, efw :
3530 gr.
Pro CTG
termination
Pro
perabdominal
with
CS
Pro delivery patient
to VK teratai

14.00
WITA

Blood leaked out from her

womb (-)
Lower abdominal pain (+)
minimal

General Status :
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR : 86 bpm
RR : 21tpm
T : 36,8 OC
UC : (-)
FHR : 13.12.12 (148 bpm)
VT : not evaluated

G2P1A0L1 36-37
weeks/S/L/IU head
presentation, with
APB e.c plasenta
previa parsial.

Check CBC, BT/CT,

HbSAg
Preparation for CS
Obs mother & fetal
well being.
Observation bleeding
for
family
CIE
planning

15.30
WITA

Blood leaked out from her

womb (-)
Lower abdominal pain (+)
minimal

General Status :
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR : 83 bpm
RR : 20 tpm
T : 36,9 OC
UC : (-)
FHR : 12.12.12 (144bpm)
VT : not evaluated

Delivery patient to OK
Cito

Time

Subject

Object

Assesment

16.00
WITA

Planning
CS was begun

16.15
WITA

-Baby was born, male,

3200 gram, HC: 32cm,
BL 51 cm, A-S 7 and 9,
anus
(+),
anomali
congenital (-).
Plasenta
was
born
manual, complete.

16.35
WITA
18.35
WITA

CS Finished
Wound pain (+)
Dizziness (-)

General Status :
GC : well
GCS: E4V5M6
BP : 120/70 mmHg
PR : 86 bpm
RR : 21 tpm
T : 36,6 OC
UFH : 2 finger below umbilical
Lochea (+)
Bleeding (50 cc)

2 hours post CS

Observe mother well

being
Suggest mother to eat
and drink if mother not
feel nausea or didint
vomit
Suggest mother to do
early mobilization
mother
for
KIE
breastfeeding

Time
09/08/2
015
07.00
WITA

Subject
Operation wound pain (-)

Object
General Status :
GC : well
GCS: E4V5M6
BP : 110/70 mmHg
PR : 84 bpm
RR : 21 tpm
T : 36,9OC
UFH : 2 finger below umbilical
Lochea (+)
Bleeding (-)
Baby:
GC : well
PR : 149 bpm
RR : 48 tpm
T : 36,6OC

Assesment
1 day post CS

Planning
Observe mother well
being
Suggest mother to
eat and drink
mother
for
KIE
breastfeeding