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Morning Report
th
september 4 2015
NORMAL
LABOR
PATHOLOGIES
LABOR
Case Resume
1. G1P0A0L0 37-38 weeks S/L/IU head
presentation with 2nd stage of labor
1.
Case 1
Name : Mrs. R
Age : 26 years old
Address : Gunung Sari
Admitted : 03-09-2015
No. RM : 56-62-70
G2P0A1L0 39-40 weeks S/L/IU head
presentation with PROM > 12 hours +
oligohidramnion + suspect CPD
TIME
SUBJECTIVE
01/09/201
5
21.53 wita
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.3C
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 : 5/5
UFH: 31 cm
EFW : 2945 g
UC : FHB : 13-13-13
VT : 1 cm, eff 25%, amnion
(-), clear, head presentation,
H0, denominator unclear, not
palpable small part &
umbilical cord
ASSESSMENT
PLANNING
G2P0A1L0 39-40
weeks S/L/IU head
presentation with
PROM > 12 hours +
oligohidramnion +
suspect CPD
DM planning:
Diagnostic : CBC,
HbsAg,, BT, CT, CTG
Therapy :
Pro cervix maturation
with misoprostol
followed by oxytocin
drip
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
advice :
C-Section cito
CIE Family
TIME
SUBJECTIVE
Obstetric History:
I. Abortus
II. This
OBJECTIVE
PE :
Promontorium unpalpable
Os coccygeus mobile
Arcus pubis >90o
Spina ischiadica non
prominemt]
Pelvic score = 3
Dilatation of cervix : 1
Length of cervix : 0
Station : 0
Consistency : 1
Position : 1
Laboratory (03/09/2015
22.19):
HB: 10.2 g/dl
RBC: 3.61
HCT: 30.7 %
WBC: 10.90
PLT: 395
HbsAg: non reactive
BT : 200
CT : 700
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
Chronology at Penimbung
PHC (03/09/2015)
20.30
S:
Patient 9month of pregnancy
come to PHC confessed
water leaked out a little since
2th sept 2015 at 03.00. LMP
25-11-2015, EDD 19-2015,
FM (+)
O:
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 81 bpm
RR: 20 bpm
T: 36.7C
Obstetric status
Breech palpable in fundus,
back on the right side, head
presentation, 3/5
UFH: 29 cm
EFW : 2945 g
UC : 1x10~20
FHB : 11-12-12
VT : 1 cm, eff 10%, amnion
(-), clear, head presentation,
HI, denominator unclear, not
palpable small part & umbilical
cord
USG : oligohidramnion + PROM
> 12 hours
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
A:
G2P1A0L1 40-41 weeks S/L/IU
head presentation with mother
and fetal well being +
PROM>12 hours +
oligohidramnion
P:
Explanation to the family
about examination result
Infusion RL 20 dpm
Injection ampicillin 1 gr
Refer to NTB GH
OBJECTIVE
ASSESSMENT
PLANNING
TIME
23.10
SUBJECTIVE
Patient transffered to OK
OBJECTIVE
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.6C
UC : FHB : 12-11-12
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part & umbilical
cord
ASSESSMENT
G2P0A1L0 39-40
weeks S/L/IU head
presentation with
PROM > 12 hours
+ oligohidramnion
+ suspect CPD
PLANNING
DM planning:
Diagnostic : Therapy :
CIE :
Monitoring :
C Section begin at
4/9/2015 00.00
At 00.10 Baby was
born,male, BW 2800 g,
BL 48 cm, A-S 7-9
Placenta was born
completely at 00.20
Do the management of
4th stage of labor
TIME
04/09/201
5
2.30
SUBJECTIVE
Patient confessed about
abdominal wound pain
OBJECTIVE
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 2 fingers below umbilical
UO : 200 cc/2 hours
Active bleeding (-)
ASSESSMENT
PLANNING
2 hours post
partum
DM planning:
Diagnostic :
Therapy :
Injection ampicillin 1
gr/6 hours
Injection ketorolac 30
mg/8 hours
Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink
DM planning:
Diagnostic :
Therapy :
Injection ampicillin 1
gr/6 hours
Injection ketorolac 30
mg/8 hours
Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink
Baby in NICU :
HR : 152x/minute
RR : 54x/minute
T : 36,3oC
04/09/201
5
07.00
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.7C
UC : well
UFH : 2 fingers below umbilical
UO : 500 cc/4 hours
Active bleeding (-)
Lochea rubra (+)
Baby in NICU :
HR : 148x/minute
RR : 50x/minute
T : 36,5oC
Case 2
Name : Mrs. H
Age : 27 years old
Address : Batu Layar
Admitted : 03-09-2015
No. RM : 56-62-64
G1P0A0L0 38 weeks S/L/IU head
presentation with APB e.c. suspect
placenta previa marginalis
TIME
SUBJECTIVE
01/09/201
5
21.53 wita
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 130/90 mmHg
PR: 86 bpm
RR: 20 bpm
T: 36.7C
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 left side
L3 : head
L4 : 5/5
UFH: 32 cm
EFW : 3100 g
UC : FHB : 12-13-13
Inspekulo : OUE (-) fluxus
(+), livide (+), active bleeding
(-)
VT : not perform
ASSESSMENT
G1P0A0L0 40
weeks S/L/IU head
presentation with
placenta previa
marginalis
PLANNING
DM planning:
Diagnostic : CBC,
HbsAg, BT, CT,
Urinalisis,CTG
Therapy :
Pro C-Section
Monitoring : VS mother,
UC, FHB
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
DM co to GP co to SPV
advice :
C-Section cito
CIE Family
TIME
SUBJECTIVE
OBJECTIVE
PE :
Not perform
Obstetric History:
I. This
Laboratory (03/09/2015
22.19):
HB: 12.7 g/dl
RBC: 4.58
HCT: 37.5 %
WBC: 12.87
PLT: 239
HbsAg: non reactive
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
Chronology at Meninting PHC
(03/09/2015)
20.30
S:
Patient 9 month of pregnancy
come to PHC want to
examinated her pregnancy
complained (-), abdominal
pain (-), history of vaginal
bleeding (-), headache (-).
O:
GC : well
consciousness: CM
BP : 140/100 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.5C
Obstetric status
Breech palpable in fundus,
back on the right side, head
presentation, 4/5
UFH: 28 cm
UC : FHB : +
VT : not perform
A:
G1P0A0L0 40 weeks S/L/IU
head presentation mother and
fetal well being with mild
preeclampsia and placenta
previa marginalis
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
P:
Explanation to the family
about examination result
Infusion RL 28 dpm
Urinalisis proteinuria (+1)
Refer to NTB GH
OBJECTIVE
ASSESSMENT
PLANNING
TIME
22.30
SUBJECTIVE
Patient transffered to OK
OBJECTIVE
GC : well
consciousness: CM
BP : 130/90 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.6C
UC : FHB : 12-11-12
VT : 1 cm, eff 10%, amnion
(+), head presentation, H1,
denominator unclear, not
palpable small part & umbilical
cord
ASSESSMENT
G2P0A1L0 40-41
weeks S/L/IU head
presentation with
PROM > 12 hours
+ oligohidramnion
+ suspect CPD
PLANNING
DM planning:
Diagnostic : Therapy :
CIE :
Monitoring :
C Section begin at
3/9/2015 23.10
At 23.20 Baby was
born, female, BW 2600
g, BL 47 cm, A-S 6-8
Placenta was born
completely at 23.25
Do the management of
4th stage of labor
TIME
04/09/201
5
00.30
SUBJECTIVE
Patient confessed about
abdominal wound pain
OBJECTIVE
GC : well
consciousness: CM
BP : 130/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 2 fingers below umbilical
UO : 200 cc/2 hours
Active bleeding (-)
ASSESSMENT
PLANNING
2 hours post
partum
DM planning:
Diagnostic :
Therapy :
Injection ampicillin 1
gr/6 hours
Injection ketorolac 30
mg/8 hours
Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink
DM planning:
Diagnostic :
Therapy :
Injection ampicillin 1
gr/6 hours
Injection ketorolac 30
mg/8 hours
Monitoring : VS mother,
UC, UFH, UO
CIE : suggest mother
to eat and drink
Baby in NICU :
HR : 148x/minute
RR : 54x/minute
T : 36,3oC
04/09/201
5
07.00
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.7C
UC : well
UFH : 2 fingers below umbilical
UO : 500 cc/4 hours
Active bleeding (-)
Lochea rubra (+)
Baby in NICU :
HR : 148x/minute
RR : 52x/minute
T : 36,5oC
Case Report 3
Name
: Mrs. S
Age
Address : Narmada
RM
: 24 years old
: 566247
Time
Subjective
03-09-2015
(15.00
WITA)
Objective
General status
GC : well
GCS: E4V5M6
BP : 100/60 mmHg
PR: 84 tpm
RR: 20 tpm
T: 37,3C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-),
wh (-/-)
Cor : S1S2 single regular
m(-), g(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : warm (-/-) edema (-/-)
Obstetric status
L1 : breech
L2 : left side
L3 : head
L4 : 5/5
UFH: 29 cm
EFW : 2635 gram
UC : FHB : 12-13-13 (152x/m)
VT : 1cm, eff 25%,
amnion (-) clear, head
presentation, HI,
impalpable small part &
umbilical cord
Assessment
G1P0A0L0 37-38
weeks S/L/IU head
presentation with
PROM > 12 h
Planning
DM planning:
Diagnostic planning
Pro CTG
Check CBC, HbsAg,
BT, CT
Therapeutic planning :
Inj Ampicilin 2 gr/IV
Pro termination with
CS
CIE planning
CIE mother and
family about
diagnostic planning
and therapeutic
planning
Obs. Mother and fetal
well being
Suggest mother to lie
down the left side,
eat and drink
Obs. progress of
labor
Time
Subjective
Obstetric History:
I. This
Chronologist:
At Sedau PHC
(03/09/2015) 06.30 WITA
S : Patient confessed water
leaked out from her womb
since
12.00
WITA
(02/09/2015), abdominal pain
spread to the flank since (-)
and bloody slim (-), FM (+).
O:
General status
GC : well
GCS: E4V5M6
BP : 110/80 mmHg
PR: 72 bpm
RR: 20 tpm
T: 36,6C
Obsetrical status :
FH : 29 cm
UC : 2x10~15
FHB ; 120 bpm
VT: 1 cm, eff 10%, amnion (-)
clear, head presentation, HI,
impalpable small part & umbilical
cord
Objective
PS : 3
Cervix Dilatation : 1
Cervix length : 1
Station : 0
Cervix Consistency : 0
Cervix position : 1
PE :
Promontorium unpalpable
Spina ischiadica
nonprominent
Os coccygeus mobile
Arkus pubis > 90
Lab:
HB: 10,5 g/dl
HCT : 31,8%
RBC: 4,07 M/dl
WBC: 12,91 K/dl
PLT: 370
MCV : 78,1 fL
MCH : 25,8 pg
MCHC : 33,0 g/dl
BT : 2 00
CT : 600
HbSAg: non reactive
Assessment
Planning
Time
Subjective
3/9/2015
10.30
S : abdominal pain (+)
O:
BP : 120/80 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,5C
UC : 2x10~15
VT : 1 cm, eff 10%, amnion (-)
clear, head presentation, HI,
impalpable small part & umbilical
cord
3/9/2015
14.00
S : abdominal pain (+)
O:
BP : 110/80 mmHg
PR: 80 bpm
RR: 20 bpm
T: 36,6C
UC : 2x10~15
VT : 1 cm, eff 10%, amnion (-)
clear, head presentation, HI,
impalpable small part & umbilical
cord
Objective
Assessment
Planning
Time
Subjective
A : G1P0A0L0 37-38 weeks
S/L/IU, head presentation, mother
and fetal well being with PROM >
12 h
P:
IVFD RL
Inj. Ampicilin I (07.00)
Inj. Ampicilin II (14.00)
Objective
Assessment
Planning
Case 4
Name
Age
Address
Admitted
RM
: Mrs. T
: 30 years old
: Kekeri Timur
: 3th of September 2015
: 12 25 87
TIME
3/09/2015
12.00 wita
SUBJECTIVE
Patient referred from Ggunung
Sari PHC with G4P3A0L2 43
weeks S/L/IU head
presentation, mother and fetal
well being with serotinus.
Patient not confessed
abdominal pain spread to the
flank (-), water leaked out from
her womb (-), bloody slim (-),
FM (+).
History of DM (-), HT (-),
asthma (-) and allergy (-).
LMP : forgot
EDD :History of ANC : 6x at Posyandu
Last result: (15/07/2015)
BP 100/70 mmHg, GW: 32
weeks, UFH 25 cm, head
presentation, FHB (+)
History of USG : 1x at SpOG
Last result: (01/09/2015)
Result
:
S/L/IU,
head
presentation GW: 42 weeks,
FHB
(+),
EDD:20/08/2015,
plasenta in fundus, AF: unclear
and oligohidramnion
History of family planning:
injection 3 months
Next family planning : IUD
OBJECTIVE
General status
GC : well
consciousness: CM
BP : 120/70 mmHg
PR: 96 bpm
RR: 20 bpm
T: 36,3C
Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm acral
(+/+).
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 27 cm
EFW : 2480 gr
UC : FHB : 12-12-11
VT : 1 cm, eff 10%, amnion
(+), head presentation,
denominator unclear, HI,
impalpable small part &
umbilical cord
ASSESSMENT
PLANNING
G4P3A0L2 A/S/L/IU,
head presentation
with severe
oligohydramnion
DM planning:
Diagnostic planning
Check CBC, HbsAg,
BT, CT
Check CTG
Therapeutic planning :
Pro termination
pervaginam, if PS>5
oxytocin drip
CIE planning
CIE mother and
family about
diagnostic planning
and therapeutic
planning
Obs. Mother and
fetal well being
Suggest mother to
lie down the left side,
eat and drink
DM co to GP, GP co
to SPV, advice:
Pro termination
pervaginam with
oxytocine drip
If inpartu CTG
TIME
SUBJECTIVE
Obstetric History:
I. A/female/BW
?/home/
traditional practitioner/ death
II. A/male/3300g/PHC/
midwife/14 y.o/live
III. A/male/3300g/PHC/
midwife/4,5 y.o/live
IV. This
Chronologist at Gunung Sari
PHC
09/08/2015 (08.00 WITA)
S:
Patient 9 months pregnancy, not
confessed abdominal pain
spread to the flank, water leaked
out from her womb (-), bloody
slim (-), FM (+).
O:
GC : well
BP :90/70 mmHg
PR: 80 bpm
RR: 20bpm
T: 37,0C
Obstetric status:
UFH: 26 cm
head presentation, back on the
left side, 4/5
UC : FHB : +
OBJECTIVE
PS : 5
Cervix Dilatation : 1
Cervix length : 1
Station : 1
Cervix Consistency : 1
Cervix position : 1
Laboratory:
HB:10,9 g/dl
RBC: 4,50
HCT: 33,3 %
WBC: 9,72
PLT: 367
BT: 220
CT: 535
HbsAg: non reactive
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
A:
G4P3A0L2 43 weeks S/L/IU,
head presentation , mother and
fetal well being with serotinus
P:-
OBJECTIVE
ASSESSMENT
PLANNING
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
13.00 wita
UC : FHB : 11-11-11
G4P3A0L2
A/S/L/IU, head
presentation with
severe
oligohidramnion
Induction using
oxytocin drip 8 dpm
14.00 wita
UC :FHB : 7-6-7
G4P3A0L2
A/S/L/IU, head
presentation with
severe
oligohidramnion +
fetal distress
14.30 wita
UC : FHB :10-10-10
Observation mother
and fetal condition
15.00 wita
UC : FHB :11-12-11
- Observation mother
and fetal condition
15.30 wita
UC : FHB :11-11-12
- Observation mother
and fetal condition
14.00 wita
UC : FHB : 11-12-12
- Observation mother
and fetal condition
14.30 wita
UC : FHB : 11-12-12
- Observation mother
and fetal condition
16.00 wita
UC : FHB : 11-12-12
- Observation mother
and fetal condition
TIME
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING
16.00 wita
UC : FHB : 11-12-12
- Observation mother
and fetal condition
18.00 wita
UC : FHB : 11-12-12
- Observation mother
and fetal condition
19.00 wita
UC : FHB : 12-11-12
- Observation mother
and fetal condition
20.00 wita
UC : FHB : 12-12-11
Observation mother
and fetal condition
21.00 wita
UC : FHB : 12-12-12
- Observation mother
and fetal condition
22.00 wita
UC : FHB : 11-12-12
- Observation mother
and fetal condition
- Prepare for CS
22.15 wita
CS was began
baby was born (22.25
WITA), female,
BW:2400 gr, BL : 46
cm, HC : 36 cm, AS:7-9 , anomaly
congenital (-),
anus(+), amnion
clear
Placenta born complete
manual
CS finished at 23.00
TIME
01.00 wita
SUBJECTIVE
Mother feeling abdominal
pain (+) and numbness
OBJECTIVE
GC :well
GCS: E4V5M6
BP : 120/70mmHg
PR: 84 bpm
RR: 20 tpm
T: 36.7C
UC: well
UFH: 2 finger below umbilicus
UO : 150 cc/2jam
ASSESSMENT
PLANNING
2 hours post SC
Observation general
condition and vital sign
Observation UC, UFH,
and bleeding
1 day post Sc
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
Baby in NICU
HR: 148 bpm
RR : 50 tpm
T: 36,6C
04/09/2015
07.00
GC :well
GCS: E4V5M6
BP : 110/70mmHg
PR: 80 bpm
RR: 20 bpm
T: 36.9C
UC: well
UFH: 2 finger below umbilicus
UO : 350cc/5jam
Baby in NICU
HR: 146 bpm
RR : 50 tpm
T: 36,5C
.. Thank
You ..