Morning Report

December 4th 2012

Supervisor : dr. Edi Prasetyo

W., Sp.OG
Medical Students :
Indah, Subi, Faried, Era, Adit,
Weni
CASES RESUME

NORMAL LABOR

PATHOLOGY
LABOR

1. G1P0A0L0 40-41 weeks S/L/IU with active phase

1st stage of labor + history rupture of membrane
+ mild pre-eclampsia.
2. G2P1A0L1
37-38 weeks G/L-L/IU head
presentation head presentation with latent
phase 1st stage of labor and history rupture of
membrane.

Case Report
Identity
Name : Mrs. J.Q.
Age : 18 years old
Address
: Keru, Narmada, Lombok Barat.
RM : 068864
Hospitalization : December 4th 2012 at 11.40 WITA

TIME

SUBJECTIVE

04/12
/2012

Patient was referred from

Sedau PHC with G2P1A0L0 38
weeks/G/L-L/IU
head
presentation, mother and fetal
condition well with latent phase
1st stage of labor.
Patient confessed abdominal
pain since 20.00 (03/12/2012).
No history of water came out
from her womb. Bloody slim (-).
FM (+).
History of HT (-), DM (-),
asthma (-).

11.40

LMP : forgot
History ANC : 9 x at Posyandu
and PHC
Last ANC : 24/11/2012
USG : 1x at Narmada PHC
(24/11/2012)
Result
:
Gemelli,
head
presentationbreech
presentation, placenta fundus
gr III, amnion enough, 38-39
weeks.
I : , EFW 2763 g, EDD
21/12/2012
II :, EFW 2500 g, EDD
21/12/2012
History of family planning :
injection 3 months
Next family planning : iUD
Obstetric History :

OBJECTIVE
General Status
GC : well
BP : 120/80 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36,7oC
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 : back on the left side &
right side
L3 : head & breech
L4 : 4/5
UFH : 41 cm
UC : 2x10~ 25
FHB : I. 11-11-12 (136 bpm)
II. 12-12-11 (140 bpm)
VT : 2 cm, eff 25%, amnion
(+),
head
palpable,
denominator
unclear,
HI,
impalpable
small
part
/
umbilical cord.

ASSESSMENT
G2P1A0L1
A/G/L-L/IU head
presentation breech
presentation,
latent phase 1st
stage of labor.

PLANNING
Observe mother
and fetal well
being.
Observe progress
of labor.
DM co GP; GP
consult to SPV.
Advice :
observation and
evaluation at
15.40 WITA.

TIME

SUBJECTIVE
Chronologist at Gunung Sari PHC
(01/08/2012) :
09.30
S : Patient with pregnancy 9 months
confessed abdominal pain that spread to
the frank since 03/12-2012. NO history
water come out from her womb, bloody
slim (-). FM (+).
O:
GC : well
BP : 110/80 mmHg
PR : 80 bpm
RR : 18 bpm
T : 36,7C
UFH : 40 cm
UC : 1x10~20
FHB I : 140 bpm
FHB II : 136 bpm
VT : 2 cm, eff 10%, amnion (+), head
palpable HI, denominator unclear,
impalpable small part / umbilical cord.
A:
G2P1A0L1 38 weeks G/L-L/IU head
presentation-breech presentation, mother
and fetal condition well with latent phase
1st of labor
P:
CIE patient and family
Refer to NTB GH

OBJECTIVE
Lab Evaluation :
Hb : 8,8 g/dl
HCT : 30,0 %
WBC : 11,8 K/dl
PLT : 442 K/dl
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

04/1
2/20
12

Abdominal pain came and

relieved

15.4
0

19.4
0

OBJECTIVE
GC : well
UC : 2x10~ 20
FHB : I. 11-11-12 (136 bpm)
II. 11-11-11 (132 bpm)
VT : 2 cm, eff 25%, amnion
(+),
head
palpable,
denominator unclear, H-I
impalpable
small
part
/
umbilical cord.

Abdominal pain came less

frequently

GC : well
UC : 1x10~ 20
FHB : I. 11-11-12 (136 bpm)
II. 11-12-12 (140 bpm)
VT : 2 cm, eff 25%, amnion
(+),
head
palpable,
denominator unclear, H-I
impalpable
small
part
/
umbilical cord.

20.0
0

ASSESSMENT

PLANNING

G2P1A0L1 A/G/LL/IU head

presentation breech
presentation, latent
phase 1st stage of
labor.

Observe mother
and fetal well being.
Observe progress of
labor
Evaluation 19.40

G2P1A0L1 A/G/LL/IU head

presentation breech
presentation, latent
phase 1st stage of
labor.

Observe mother
and fetal well being.
Dm consult to SPV
pro induction with
drip oxytocin. SPV
Advice : CS at 22.00
WITA.

Prepare for CS
CIE patient and
family

TIME
23.30

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING
C-section began
Baby was born :
I : Male, AS: 7-9, BL: 46 cm, BW:
2750 gram.
I : Male, AS: 7-9, BL: 46 cm, BW:
2800 gram.
1 placenta and 2 chorion
Amnion (+) clear, 500 cc
Placenta was born manually,
complete, bleeding 300 cc.
Placenta weight : 500 gram
Anus (+), congenital anomaly (-),
amnion (-).
C-section finished

TIME
05/1
2/20
12

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

Patient confessed
wound pain.

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 280
cc/2 h
Operation wound good

2 hours post CS

Observe
mother
well being.
CIE mother to take
a rest.
Medication :
Infuse RL 20
tpm
Injection
Ampicillin
1
gram IV
Inj. Ketorolax

Patient confessed
wound pain

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below
umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 350 cc
Operation wound good

One day post CS

Observed mother
and baby well
being
Suggest mother to
mobilisation, eat,
and drink,
medication.

01.3
0

05/1
2/20
12
07.0
0

Baby in NICU
GC : well
PR : 124 bpm/ 132 bpm
RR : 54 bpm / 48 bpm