MORNING REPORT

Sunday, October 25th 2015

Resident in charge:
Lik/Dut/Waw/Sri/Mun/Gol/Bom/Suq

CHIEF :
dr. Hot

Supervisor :
dr. Sutrisno, SpOG-K
EMERGENCY ROOM :4
DELIVERY ROOM
Physiological Delivery :5
Pathological Delivery
 Pervaginam :-
 Perabdominam :1
DELIVERY ROOM

1. Mrs. D/21 y.o

G1P0000Ab000 part 32-34 weeks S/L
+ First stage latent phase
+ Partus prematurus

Ptx: Spontaneous vertex delivery, 25-10-2015

Outcome : 09.55 am, Male/ 1950 gr/ 43 cm/ AS 7-9

2. Mrs. M/32 y.o

G2P1001Ab000 gr 42-43 weeks S/L
+ Post term
+ Mild pre eclampsia
+ Fetal compromised

Ptx: Termination CS Cito, 25-10-2015

Outcome : 12.30 pm, Female/ 4196 gr/ 48 cm/ AS 6-8
3. Mrs. E/ 20 y.o
G1P0000Ab000 part 38-39 weeks S/L
+ First stage active phase

Ptx: Spontaneous vertex delivery, 25-10-2015

Outcome : 01.40 pm, Male/ 3100gr/ 48/AS 7-9
4. Mrs. F/ 22 y.o
G2P1001Ab000 part 37-38 weeks S/L
+ Second stage
+ Obesity

Ptx: Spontaneous vertex delivery, 25-10-2015

Outcome : 01.45 pm/ Female / 2650 gr/47 cm /AS
7-9
5. Mrs. S/37 y.o
G6P5005Ab000 part 34-36 weeks G/L/L
+ Head presentation-head presentation
+ Partus prematurus imminens
+ Grande multipara
+ Conservative treatment day-1
+ Age > 35 y.o
+ Post lung maturation induction

Ptx: Spontaneous vertex delivery

Outcome : 25-10-2015
04.35 pm Baby I : Male 2400 gr/46 cm/AS 7-9
04.45 pm Baby II : Male 2180 gr/45 cm/AS 7-9
6. Mrs. F/38 y.o
G4P3003Ab000 part 37-38 weeks S/L
+ First stage active phase
+ Gestational hypertension

Ptx : Spontaneous vertex delivery

Outcome : 26-10-2015
05.05 am : Male/2650 gr/48 cm/AS 7-9
EMERGENCY ROOM
1. Mrs. K / 58 y.o
 Dx : Normal Gynecology
+ Retensio Urine
+ Hiponatremia
Tx : There are currently no specific abnormality in
OBGYN. Back to Surgery department.

2. Mrs S / 35 y.o
 Dx : Ruptured of ectopic pregnancy
+ Syok hipovolemik
+ Leukositosis
Tx : Tubal rupture pars ampularis sinistra
Partial salphyngectomy sinistra
 3. Mrs.F / 37 y.o
 Dx : G2P1001Ab000 gr 39-40 wks S/L
 + Severe Pre-eclampsia
 + Urgency Hypertension

 + Fetal Compromised

 + Uncontrolled DM

 + Hypoalbuminemia

 + Age > 35 y.o

 SC cito + IUD pp, 25-10-2015, at11.15 pm

 Female baby / 2460 gr/ 46 cm/ AS 6-8
4. Mrs. S / 55 y.o
 Dx : Ca cervix IIIB pro radiation

+ Anemia
+ Hydroureteronephrosis gr III Dextra
+ Fatty liver
+ Elektrolit imbalance

Tx : Pro general improvement with tranfusion

PRC 2 kolf/day until Hb > 11 gr/dl
 Radiation
1
 IDENTITY

Register: 1531005
Mrs. M/ 32 y.o/ 12 y.o.e/ Housewife
Mr. H/ 32 y.o/ 12 y.o.e / Laundry employee
Married 1 x, 10 years
Address : Jl. Suropati raya RT 24/3 Bululawang
Admission: 25-10-2015 at 09.30 am
 Patient came by herself with chief
complaint of uterine contraction
SUBJECTIVE
October, 24th 2015 at 04.00 pm
 Patient felt uterine contraction still stay at
home

October, 25th 2015 at 09.00 am

 Patients felt uterine contraction more
frequent went to RSSA
SUBJECTIVE

 History of hypertension before pregnancy was

denied

 History of hypertension during pregnancy since

1 month of pregnancy when patient went for
ANC at midwife was 140/90 mmHg

 Nausea, vomit, epigastric pain, dizziness,

blurred vision was denied
SUBJECTIVE
 History of Pregnancy
1. P/2100 gr/ Spontaneous delivery/ Midwife/ F/
9y.o/ L
P/2100 gr/ Spontaneous delivery/ Midwife/ F/
9y.o/ L
2. This pregnancy

 ANC :
Midwife, 6x (last controlled 22-10-2015)
 LMP : 4-1-2015 ~ 42-43 weeks
 Contraception : IUD, aff 1 years ago
OBJECTIVES
GA : Good, Compos mentis
BH : 156 cm BW : 70 kg
BP : 140/90 mmHg
PR : 88 x/mnt
RR : 20x/mnt
Tax : 36,6C, Trec : 36,8C
Head : conj. an -/- , ict -/-
Thorax : C/S1-S2 single murmur (-)
P/ RH Ξ|Ξ WH Ξ|Ξ
Abd : FH : 35 cm, longitudinal lie U
FHR : 110-120 x/mnt (doppler),
EFW : 3565 gr, uterine contraction (+) rarely
 VT : ø 1 cm, eff 25% , H I, amniotic fluid (+) , head
presentation, denominator ~ difficult to evaluate,
pelvic measurement~ wnl
 Dipstick +1
USG
 Fetal intrauterine single life, longitudinal lie, head
below
BPD : 100 (41w0d)
AC : 352 (39w1d)
FL : 72.5 ( 37w1d)
EFW : 3743 gr
AFI : 6,0
Placental implantation at corpus lateralis dekstra.
Maturation grade III
NST
Baseline rate : 125 bpm
Variability : <2 bpm
Acc : (-)
Dec : (-)

Conclusion : Patologic CTG

LABORATORY

CBC : 9.40/ 8.010/30,2/412.000

FH : 9,5 /29.4
UL : protein trace
ASSESSMENT
G2P1002 Ab000 gr 42-43 weeks S/ L
+ Mild pre eclampsia
+ Post term
+ Fetal compromised
PLANING
 Pdx : -
 Ptx :
 Resusitation intrauterine :
Left lie recumbent position
O2 NRBM 10 lpm
 Proposed termination with CS Cito+ IUD
 Operation preparation :
IVFD RL 1000 cc
Insert foley catheter
inj Cefazolin 1 gr iv (skin test)
inj Ranitidin 1 amp iv
Inj Metoclopramide 1 amp iv
 blood preparation/ register OR / c. anesthesiologist

 PMo : obs VS, subjective complain, uterine contraction, FHR

 CIE (Inform consent)
 c/ spv___________________________Acc dr. Sutrisno,Sp.OG-K
OUTCOME

On October, 25th 2015

at 12.30 pm,
Female baby was born
4196 gr/ 48 cm/ AS : 6-8
LAST CONDITION

Mother : Baby :
RR obgyn In perinatalogy room
Good Condition, GCS 456 Infus (-)
BP : 120/70 mmHg O2 (-)
PR : 88 x/mnt Good movement (+)
RR : 20 x/mnt
Urine production : 50 cc GDA: 72 mg/dl
2
 SUBJECTIVE

Mrs. S/35 y.o/ Married 1x, 16 ys/P2002Ab000/ LC: 8 y.o

Contraception: Pill, stopped 3 months ago/
LMP:25-8-2015 ~ 8-10 wks

Patient was disposed from EM Dept. with suspect of

ruptured of ectopic pregnancy
SUBJECTIVE
October 25th 2015
04.00 am
Patient felt abdominal pain  patient still stay at home
10.00 am
Patient complained pain did not relieved  got massage on her
stomache
11.00 am
Patient complained lower abdominal pain more severe  went to
ER RSSA
11.45 am
Patient arrived at ER RSSA and was received by EM Dept. 
examined and performed resuscitation because sign of hypovolemic
shock (+)
12.50 pm
Because suspected ruptured of ectopic pregnancy  disposed to
Obgyn Dept.
SUBJECTIVE
 Patient didn’t know that she was pregnant
 History of amenore for 2 months, with history of
menstruation regularly 1x/month, 6-7 days,
change female napkins 3-4x/day, dysmenorrhea (-
)
 History of abdominal massage (+)

 History of leucorrhea 1 month ago, but didn’t

seek any medication
OBJECTIVES
GA : Look severely ill, GCS : 456
BP : 80/palpation mmHg
PR : 120 x/mnt
RR : 20 x/mnt
Head : conj. An +/+ , ict -/-
Thorax : C/S1-S2 single murmur (-)
P/ RH Ξ|Ξ WH Ξ|Ξ
Abd : slight distended, defans muscular (+), pain
(+) whole abdominal region, bowel sound
(+) decrease
GE : v/v Flex (-), Fluor(-)
Insp : v/v flex (-), Fluor (-)
POMP closed, smooth, lividae
VT : v/v flux (-), fluor(-)
POMP closed, smooth, slinger pain (+)
CUAF ~ slightly enlarge
AP D/S : mass (-), pain (+)
CD : prominent
LABORATORY

CBC : 10.4/27.270/31.6/334.000
FH : 13 /29.3
Pregnancy test positive
ASSESSMENT
Ruptured of ectopic pregnancy
+ Hypovolemic shock
+ Leucocytosis
PDx : -
PTx :
O2 ~ NRBM 10 lpm
IVFD double line : I. RL fast drop
II. Haes 20 dpm
 Proposed laparotomi exploration cito
 Preparation :
 insert DC
 inj Cefazolin 1 gr iv (skin test)
 Inj Metronidazole 500mg iv
 Inj Gentamicyn 80 mg iv
 inj Ranitidin 1 amp iv
 Inj Metoclopramide 1 amp iv
 Inform consent/ blood preparation/ register OR
 C/ anesthesiologist
 PMo : obs VS, subjective complain
CIE
C/ Supervisor ____________________ approved by dr .Sutrisno, SpOG-K
DURANTE OP
 Ruptur Tuba pars Ampularis Sinistra
 Blood loss:
 Blood : 2000 cc
 Blood clot: 500 gr

 Performed Partial Salphyngectomy Sinistra

 Fundus Uteri

Caudal
Cranial

Ovarium S
Ruptur Tuba
Pars Ampularis
Sinistra
 Caudal

Fundus Uteri

Fallopian
Tube D

Cranial
3
 IDENTITY

Register:
Mrs. F / 37 y.o / 12 y.o.e / Kindergarten teacher
Mr. M / 41 y.o / 12 y.o.e / Mushroom farmer
Married 1 x, 6 years
Address : Jl. Abdul Hamid RT 4/2, Malang
Admission: 25-10-2015 at 20.05
 Patient refferred by obstetrician
with diagnose G2P1001Ab000 gr
39-40 weeks S/L with PEB +
Diabetes mellitus + Hypertension
urgency + Age > 35 years old
SUBJECTIVE
October, 25th 2015 at 12.00 pm
 Patient came to RS Muhammadiyah for ANC to
obstetrician  because patient has history of
diabetes mellitus and hypertension  suggested
for SC  went to observation at delivery room

October, 25th 2015 at 07.00 pm

 Because the blood pressure is not diminish, BP:
200/110 mmHg  suggested to refferred to
RSSA  family still discussed

October, 25th 2015 at 08.10 pm

Patient arrived at RSSA
SUBJECTIVE

 History of hypertension before and during

pregnancy was denied

 Nausea, vomit, epigastric pain, dizziness,

blurred vision was denied

 History of diabetes mellitus since 1 year ago

patient didn’t take the medicine regularly
SUBJECTIVE
 History of Pregnancy
1. At/2900 gr/ Spontaneous delivery/ RSSA/ F/ 5
y.o/ L
2. This pregnancy

 ANC :
Obstetrician , 6x (last controlled 11-10-2015)
 LMP : 25-1-2015 ~ 39-40 weeks

 Contraception : -
OBJECTIVES
GA : Look moderately ill, CM
BH : 160 cm BW : 80 kg
BP : 200/110 mmHg
PR : 90 x/mnt
RR : 20x/mnt
Tax : 36,6C, Trec : 36,8C
Head : conj. an -/- , ict -/-
Thorax : C/S1-S2 single murmur (-)
P/ RH Ξ|Ξ WH Ξ|Ξ
Abd : FH : 30 cm, longitudinal lie U
FHR : 150 x/mnt (doppler), EFW : 2790 gr,
uterine contraction (-)
 VT : ø 0-1 cm, eff 25 % , H I, amniotic fluid (+) ,
head presentation, denominator ~ difficult to
evaluate, pelvic measurement ~ wnl
NST
Baseline rate : 150 bpm
Variability : <5 bpm
Acc : (-)
Dec : (-)
Conclusion : Patologic CTG
LABORATORY

CBC : 12,4/13.110/40,9/336.000
FH : 8,9/29,4
OT/PT : 13/7
SE : 133/4,05/107
RBS : 192
Albumin : 2,96
LDH : 534
HbA1C : 10,70
Ur/Cr : 17,8/0,6
UL : Protein +2
ASSESSMENT
G2P1001 Ab000 gr 39-40 weeks S/ L
+ Severe Pre-eclampsia
+ Hypertension Urgency
+ Fetal Compromised
+ Uncontrolled DM
+ Hipoalbuminemia
+ Age > 35 y.o
PLANING
 Pdx : C/ Cardiology, internist departement
 Ptx :
 Proposed termination with CS Cito + IUD
 Resuscitation intrauterin :
 Mother left lie reccumbent
 O2 10 lpm NRBM
 Inj SM Fulldose ( injected at RS Muhamadiyah)
SM maintanance SM 40 % 10 g in RD5 500 cc/12 hr until 24 hr post partum
 Operation preparation :
Insert foley catheter
inj Cefazolin 1 gr iv (skin test)
inj Ranitidin 1 amp iv
Inj Metoclopramide 1 amp iv
 Inform consent/ blood preparation/ register OR / c. Anestiologist
 Fluid balance
 PMo : obs VS, subjective complain, uterine contraction, FHR, sign of impending,
fluid balance
 CIE
 c/ spv___________________________ Acc dr. Sutrisno,Sp.OG-K
OUTCOME

On October,25th 2015
At 11.15 pm,
Female baby was born
2460 gr/ 46 cm/ AS : 6-8
LAST CONDITION

Mother :
At RR OK ER Baby :
Good Condition, GCS 456
BP : 188/93 mmHg
PR : 92 x/mnt
In perinatalogy room
RR : 20 x/mnt Infus (-)
Sat O2 98% with O2 O2 (-)
10Lpm NRBM Good movement (+)
Urine production : 50 cc
THANK YOU