MORNING REPORT

21st March 2015

Supervisor: dr. Edi P. W., Sp.OG
Medical Students:
Fara, Titin, Ryan, Dede

CASE RESUME

NORMAL LABOR -

PATHOLOGIES CASE 1. G1P0A0L0 35-36 weeks S/L/IU breech

presentation active phase of labor
Name: Mrs. LH
Age:
Address:
Admitted at: 24st March 2017
MR : 134213
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

24/04/ Patient reffered from Lingsar PHC w/ General status G1P0A0L0 39-40 w DM plan:
17 G1P0A0L0 36 weeks S/L/IU breech GC/cons: well/E4V5M6 S/L/IU head Tell mother about the
19.15 presentation laten phase of labor. She BP : 110/70 mmHg presentation with examination result
confessed abdominal pain spread to the PR: 78 tpm HbsAg positive Tell mother about the
flank since 15.00 (24/4/2017). Bloody RR: 19 tpm procedure and risk of
slime (+), water leaked out from her womb Tax: 37,0 C the next planning
(-), fetal movement (+). Demam (-) Obs mother and fetal
Localis status well being
History of DM (-), HT (-), asthma (-), Eye : an (-), ict (-) Obs progress of labor
allergic (-) Pulmo ves (+/+), rh (-/-), wh (-/-) Ask mother to eat and
Cor : S1S2 single regular, murmur drink
LMP: 20/07/2017 (-), gallop(-) Ask mother to back to
EDD: 27/04/2017 Abdomen: the left side
Scar (-), striae gravidarum (+), linea
History of ANC: 7x @midwife of PHC, 7x nigra (+) DM co to GP, GP acc
@RSUP NTB Extremity: oedema (-/-) warm acral
Last ANC: 22/04/17 (+/+)
Result: BP 110/80 mmHg, BW 62kg, 38-
39 w, UFH 29 cm, head presentation, back Obs status:
to the left side, FHB (+) , HbsAg (+) L1 : Breech
L2 : back to the left side
History of USG: 3x L3 : Head
Last USG : 22/4/17 L4 : 4/5
S/L/IU head presentation BPD :36 w, AC UFH: 29 cm
34 w, FL 32 w, EFW 2378 +/- 356 grm EFW : 2790 gr
Placento on corpus anterior FHB : 11-11-12
UC : 1x10~35
History of family plan: injection (2006- VT : 4 cm, eff 50%, amnion (+),
2009), Oral KB 3 months (2009) breech palpable (+), sacrum
Next family planning: inj 3 months transverse, HI, not palpable small
Obstetrical history: part & umbilical cord
1. This
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

Chronologist (20/02/2015) ZA score: 8

Patient came to Lingsar PHC on 21st of Parity: primi (0)
March 2015 @03.00 am. She confessed History of breech presentation: (0)
abdominal pain spread to the flank since EFW: <3176 g (2)
20th of march 2015 08.00 pm. Bloddy Station: > -1 (2)
slim (+), water leaked out from her GW: < 38 weeks (2)
womb (-), FM (+) Dilatation: 4 (2)
GC: well
Cons: E4V5M6 laboratory exam (21/03/2015):
BP: 110/80 mmHg HGB: 11.8
PR: 81 bpm RBC: 4.34
RR: 20 bpm HCT: 35.6
Tax: 36.5C MCV: 82.0
MCH: 27.2
Obs Status: MCHC: 33.1
UFH: 28 cm WBC: 14.69
UC: 3x10~35 PLT: 216
FHB: 11-12-12 BT: 230
L1: head CT; 630
L2: back to the right side HbSAg non reactive
L3: breech
L4: 4/5

VT: 3 cm, eff 25%, amnion (+), breech

palpable (+), os sacrum, HI, not
palpable small part & umbilical cord

A/ G1P0A0L0 36 weeks S/L/IU breech

presentation mother and baby well being
laten phase of labor

P/ refer to NTB GH
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

4.30 am Abdominal pain (+) UC: 3x10~20

FHB: 11-11-12

5.00 am Abdominal pain (+), water GC: well

uncontrolly leaked out from her GCS: E4V5M6
womb, clear, odorless BP: 120/80 mmHg
PR: 88 tpm
RR: 20 tpm
Tax: 36.6 C
UC: 3x10~30
FHB: 12-11-12
VT: 5 cm, eff 50%, amnion (-), breech
presentation, sacrum transverse, HI, not
palpable small part & umbilical cord

5.30 am Abdominal pain (+) UC: 3x10~30

FHB: 12-12-12

6.00 am Abdominal pain (+) UC: 3x10~30

FHB: 11-12-12
6.30 am Abdominal pain (+) UC: 3x10~30
FHB: 12-12-12
7.00 am Abdominal pain (+) UC: 3x10~30
FHB: 12-12-12
7.30 am Abdominal pain (+) UC: 3x10~35
FHB: 11-12-12

8.00 am Abdominal pain (+) UC: 3x10~35

FHB: 12-12-13
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

08.30 Abdominal pain spread to the UC: 3x10~35

am flank (+) FHB: 11-11-12

09.00 Abdominal pain spread to the GC: well

flank more frequent (+) GCS: E4V5M6
BP: 110/70 mmHg
PR: 88 tpm
RR: 20 tpm
Tax: 36.5 C
UC: 3x10~35
FHB: 12-12-12
VT: 10cm, eff 100%,
breech palpable (+), , HIII,
umbilical cord not palpable
Urine: 300 cc

09.05 Mother want to bearing down Vulva opened, pressure of Conduct of labor
anus, perineum bulging

09.15 Baby was born with manual aid, ,

AS 6-8, BW 2500 grams, BL 48 cm,
anus (+), congenital anomaly (-)
Active management 3rd stage of labor

09.20 Placenta was born Spontaneously,

complete, 500 grams, bleeding : 150
cc, 2nd grade rupture of perineum
Observation 4th stage of labor
GP advice: drip 20 IU oxy 28 dpm, inj
ampicillin 1 g IV
TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

9.00 am Abdominal pain spread to GC: well G1P0A0L0 35-36 Prepare of labor
the flank (+) more GCS: E4V5M6 weeks S/L/IU breech
frequent, water leak out BP: 180/100 mmHg presentation 2nd phase of
from her womb (+) greeny, PR: 95 tpm labor
odorless, RR: 27 tpm
Tax: 36.6 C
UC: 4x10~45
FHB: -
Urine: 300 cc
VT: 10cm, eff 100%, foot
palpable (+), not palpable small
part & umbilical cord

09.05 mother want to bearing Vulva opened, pressure of anus, Conduct of labor
am down perineum bulging

09.15 Baby was born with manual aid, ,

am AS 6-8, BW 2500 grams, BL 48 cm,
anus (+), congenital anomaly (-)
Active management 3rd stage of labor

09.20 Placenta was born Spontaneously,

am complete, 500 grams, bleeding : 150
cc, 2nd grade rupture of perineum
Observation 4th stage of labor
GP advice: drip 20 IU oxy 28 dpm, inj
ampicillin 1 g IV
 Time Subject Object Assessment Planning

11.20 am - GC : well 2 hours post partum. -Obs. Mother well being

BP : 110/70 mmHg -CIE mother to eat, drink,
PR : 88 tpm and mobilization.
RR : 20 tpm
T : 36.5C
UC: (+)
UFH: 2 finger below umbilicus
urine: 30 cc
Lochea: (+)

22/03/201 - GC : well 1 day pp -Obs. Mother well being

5 BP : 110/70 mmHg -CIE mother to eat, drink,
PR : 86 tpm and mobilization.
RR : 20 tpm
T : 36.7C
UC: (+)
UFH: 2 finger below umbilicus
urine: 30 cc
Lochea: (+)
Thank You