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Morning Report

July 11th 2012


Supervisor : dr. I Made P.
Juliawan, Sp.OG
Medical Students :
Sapto, Ika, Ira, Lanira, Yan, Ivan,
Rona
CASE RESUME
NORMAL LABOR 2
PATHOLOGY 1.G1P0A0L0 38-39 weeks S/L/IU with face
LABOR presentation and history of rupture
membrane.
2.G1P0A0L0 41-42 weeks S/L/IU with PROM >
12 hours.
Case Report
Name : Mrs. SA
RM : 046587
Age : 17 years old
Address : Lembuak, Narmada, Lombok
Barat.
Admitted : July 11th 2012
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
11/0 Patient referred from General Status : G1P0A0L0 40 Observe mother
7/20 Narmada PHC with GC : well weeks S/L/IU and fetal well
12 G1P0A0L0 A/S/L/IU with BP : 120/80 mmHg with face being.
face presentation and 2nd PR : 88 bpm presentation + Observe progress
19.1 stage of labor. RR : 20 bpm active phase 1st of labor.
5 Patient confessed T : 37oC stage of labor Skin test Ampicillin
abdominal pain since Eye : anemis (-/-), + history of (-), injection
10.00 (11/07/2012) & icteric (-/-) rupture Ampicillin 1 gr/ IV.
water came out from her Cor : S1S2 single membrane DM consult to GP :
womb since 18.00 regular, murmur (-), pro termination.
(11/07/2012). Bloody slim gallop (-). GP consult to SPV,
(+), FM (+). Pulmo : vesicular (+/ advice :
No history of DM, HT, +), wheezing (-/-), Observation
asthma. ronkhi (-/-). progress of labor
Abdomen : scar (-), until 2 hours. If
LMP : 20/11/2011 stria (+), linea nigra there is no
EDD : 27/08/2012 (+). progress, prepare
Extremity : edema CS at 22.00
History of ANC : > 4x at (-/-), warm acral (+/ (11/07/2012).
Polindes +).
Last ANC : 18/06/2012
History of USG : 1x at Obstetrical Status :
Sp.OG L1 : breech
(05/07/2012) L2 : back on the left
Result : Fetus S/L/IU with side
head presentation, 38-39 L3 : head
weeks, EFW 3504 gram, L4 : 3/5
EDD : 11/07/2012. UFH : 30 cm
EFW : 2945 gram
History of family planning UC : 2x/10 ~30
: (-) FHB : 11-12-12 (140
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist at PE :
Polindes : Spina ischiadica not
11/07/2012 (12.15) prominent
S : Patient came with Os coccygeus mobile
abdominal pain that Arcus pubis > 90o
spread to frank since
10/07/2012. Bloody slim Lab Examination :
(+). Hb : 14,0 g/dl
RBC : 4,52 x 106/L
O : GC : well HCT : 42,7 %
BP : 110/70 mmHg WBC : 16,08 x 103/L
PR : 80 bpm PLT : 274 x 103/L
RR : 22 bpm HbSAg : (-)
T : 36,5oC
UFH : 33 cm
EFW : 3410 gram
Head presentation, back
on the right side, 4/5.
UC : 2x/10~40
FHB : 136 bpm
VT : 4 cm, effacement
50%, amnion (+), head
palpable HII,
impalpable small part
and umbilical cord.
A : G1P0A0L0 A/S/L/IU
head presentation,
mother & fetal well with
inpartu active phase 1st
stage of labor.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
11/07/2012 (16.15)
S : (-)
O : GC : well
BP : 110/80 mmHg PR : 82
bpm
RR : 22 bpm T : 36,5oC
VT : 7 cm, effacement 75%,
amnion (+), head palpable HII,
impalpable small part and
umbilical cord.
A : G1P0A0L0 A/S/L/IU head
presentation, mother & fetal well
with inpartu active phase 1st stage
of labor.
P :
Observe mother & fetal well being
Observe progress of labor
Suggest mother to eat and drink

11/07/2012 (18.00)
S : Mother wants to bearing down
O : FHB : 136 bpm UC :
3x/10~45
VT : 10 cm, effacement 100%,
amnion (-) meconeal, mouth
palpable HIII+, impalpable
small part and umbilical cord.
A : G1P0A0L0 A/S/L/IU face
TIME SUBJECTIVE OBJECTIVE ASSESSME PLANNING
NT
Chronologist at Narmada
PHC :
11/07/2012 (18.20)
S : (-)
O : GC : well
BP : 120/70 mmHg PR : 80
bpm
RR : 22 bpm T : 36,5oC
FHB : 140 bpm UC :
3x/10~45
VT : 10 cm, amnion (-), mouth
palpable.
A : G1P0A0L0 A/S/L/IU face
presentation with 2nd stage of
labor.
P:
Observe mother & fetal well
being
Amoxicilin tablet at 18.10
(11/07/2012)
Refer to NTB GH

20.0 Mother wants to bearing down GC : well 2nd stage of Conduct mother
5 UC : 11-11-11 (132 labor to bearing down.
bpm) Baby was born
FHB : 4x/10 ~45 (20.10) :
Teknus perjol vulka Male, 3400 gram,
Fetus mouth 48 cm, AS 3-5.
TIME SUBJECTIVE OBJECTIVE ASSESSME PLANNING
NT
21.0 Patient confessed GC : weak HPP et Observe vital sign &
0 delivery wound BP : 110/70 mmHg causa bleeding.
PR : 92 bpm Atonia Uteri Suggest mother to
RR : 20 bpm + Suspect take a rest, eat, and
T : 36,7C Rest drink.
UC : (+) soft Placenta Massage fundus uteri
UFH : 2 fingers upper and exploration.
umbilicus Drip oxytocin 2 ampul
Active bleeding : (+) 20 tpm
Injection Metergin 1
ampul/IM
DM consult to SPV :
pro USG.
Advice : Observation
and USG tomorrow
morning.

22.0 Patient confessed GC : well 2 hours post Observe vital sign &
0 delivery wound BP : 120/80 PR : 80 partum bleeding.
bpm Suggest mother to
RR : 20 bpm T: take a rest, eat, and
36,4C drink.
UC : (+) well
UFH : 1 fingers below
umbilicus
Active bleeding : (-)
12/0 Patient confessed GC : well 1st day post Observe mother and
7/20 delivery wound BP : 100/60 PR : 92 partum baby well being.