MORNING REPORT

August, 30

th 2014

SUPERVISOR : dr. Agus Thoriq, SpOG

DM : Santi, Ayu, Ria, Yuli

MORNING REPORT
AUGUST, 4TH 2014
CASE RESUME
NORMAL LABOR

PATHOLOGIES
LABOR

1. G2P1A0L1 36-37 weeks/S/L/IU head presentation with

PROM > 12 hours
2.

CASE 1
Name
Age
Address
Admitted
No. RM

:
:
:

Mrs. N
23 years old
Langko-Lingsar
: 29-08-2014
: 11-37-57

G2PA0L0 36-37 weeks/S/L/IU head

presentation with PROM > 12 hours

Time
29-08-2014
11.20

Subject
Patient came to NTB GH
reffered Sigerongan PHC
with G2P1A0L1 36-37
weeks
/S/L/IU
head
presentation with PROM
> 12 hours
Patient confessed water
come out from her vagina
since 28-08-2014 (11.00).
She
didnt
confess
abdominal pain, bloody
slim (-), and FM (+).
History of DM (-), HT (-),
asthma (-).
LMP : 14-12-2013
EDD : 21-09-2014
History ANC : 7x at PHC
Last ANC : 29-08-2014 at
PHC
result: BP : 100/80,
weight: 55 kg, UFH: 27
cm, head presentation.

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/80 mmHg
HR: 88 x/m
RR: 22 x/m
T: 36,5 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (-/-), warm (+/+)
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH: 29 cm
EFW : 2790 gram
UC : FHB : 13-13-13 (159x/min)

Assessment

Planning

G2P1A0L1 3637
weeks
/S/L/IU
head
presentation
with PROM >
12 hours

Obs. Mother and

fetal well being
DM co to GP pro
CTG and Inj. Ampi 1
g/6 h, GP acc
Doing CTG
Inj.ampi 1 gr/6h

Time

Subject
History of USG :History of family planning :
injection 3 months
Next family planning :
injection 3 month
History of obstetric :
1. Preterm/ 2600/ male/
midwife/ NTB GH/ 4
years old/ life
2. This

Object
VT : 1 cm, eff. 0 % amnion (-)
clear, head palpable, HI, denom
unclear, unpalpable small part of
fetus/ umbilical cord
PS :
Cervic dilatation 0 cm : 0
Cerviks length 4 cm: 1
cerviks consistency soft: 2
Cerviks position posterior: 0
Station H I: 1
Total: 4
Lab:
HGB = 12,2.9 g/dl
RBC = 4,22 K/ul
WBC = 13,62 M/ul
HCT : 36,6 %
PLT = 252 M/ul
HBsAg = (-)

Assessment

Planning

Time

Subject
Chronologist : at Sigerongan PHC (02-082014 06.30)
S : Patient confessed flank pain and abdominal
pain since yesterday . Bloody slim (-) Water
come out from her vagina (+) since
yesterday , FM (+).
O : GC : well
Cons : CM
BP : 100/80mmHg
HR : 80x/m
RR : 20x/m
T : 36
UFH : 27cm
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
FHB : 144x/m
UC : VT : 1cm, eff 25%, amnion (+), head
palpable, HI, unpalpable small part of fetus/
umbilikal cord
A : G2P1A0L1 36 weeks/S/L/IU with PROM
P : amox 1 x 500 mg
Reffered to NTB GH

Object

Assessment

Planning

Time

Subject

Object

Assessment

Planning
Co CTG to GP, GP co to
SPV, adv: induction with
drip oxy 5 IU
CIE patient and family to
induction

Time

Subject

Object

Assessment

Planning
Start drip oxytocin at 8 dpm

14.00

UC : FHB : 11-12-12 (140x/min)

14.30

UC : FHB : 11-11-12 ( 136x/min)

Oxy drip: 12 dpm

15.00

Abdominal pain

UC FHB : 12-11-11 ( 136x/min)

Oxy drip: 16 dpm

15.30

Abdominal pain

UC : 2 x 10 ~ 30
FHB : 11-11-12 (136 x/min)
5 cm, eff. 50 % amnion (-) clear, head
palpable, HI, denom unclear, unpalpable
small part of fetus/ umbilical cord

Oxy drip: 20 dpm

16.00

Abdominal pain

UC : 3 x 10 ~ 25
FHB : 12-12-12 (144 x/min)

Oxy drip: 24 dpm

16.30

Abdominal pain

UC : 3 x 10 ~ 30
FHB : 12-11-12 (140 x/min)

Oxy drip: 28 dpm

17.00

Mother want to bearing

down

UC : 4 x 10 ~ 40
FHB : 12-13-12 (148 x/min)
Inspection : opening of vulva, bulging of
perineum, pressure of anus

2nd of labor

Oxy drip: 32 dpm

Time

Subject

Object

Assessment

17.25

17.30

Planning
Baby was born. male. 2600
gram. 48 cm, AS 7-9. Anus
(+). Congenital anomaly(-).

UC : well
UFH : 2 finger bellow umbilicus

3rd of labor

Placenta was born spontan.

Complete. 500gram.
Bleeding 200 cc

Time

Subject

Object

Assessment

Planning

19.30

GC: well cons:E4V5M6

BP: 110/70 mmHg
PR: 82x/m
RR: 20x/m
T: 36,5 0C
UC: (+) well
UFH: 2 fingers below umbilicus

2 hours post partum

Observation mother and baby well

being
Suggest mother to eat and drink

30-082014
07.00

GC: well cons:E4V5M6

BP: 110/70 mmHg
PR: 84x/m
RR: 20x/m
T: 36,4 0C
UC: (+) well
UFH: 2 fingers below umbilicus
Active bleeding: (-)
Lokea rubra +

1 day post post partu

Observed mother and baby well being

Suggest mother to eat and drink
suggest mother to breast feeding
Suggest mother to mobilisation.

CASE 2
Name
Age
Address
Admitted
No. RM

:
:
:

Mrs. ES
28 years old
Sumbawa
: 29-08-2014
: 11-37-38

G1P0A0L0 38 weeks/G/L-L/IU head

presentation-head presentation
with active phase of labor

Time
29-082014
10.30

Subject
Patient come to NTB GH
reffered Brangrea PHC with
G1P0A0L0 +/-39 weeks G/LL/IU.
Patient confessed abdominal
pain since 28-08-14 (22.00),
water come out from her
vagina (-) since 14-08-2014
(01.00), bloody slim (+) 29-0814 (03.00), and FM (+).
History of DM (-), HT (-),
asthma (-).
LMP : 4-12-2013
EDD : 11-09-2014
History ANC : >9x at
posyandu
Last ANC : 28-08-2014
result: BP : 120/80, 38 weeks,
mothers and fetals condition
is well.
History of USG : 2x at doctor
Last : 12-08-14 : result :
gemeli, head presentationhead-presentation : EFW :
2416 gram, 1808 gram.

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 120/100 mmHg
HR: 88 x/m
RR: 22 x/m
T: 36,8 C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular, M(-),
G(-)
Abd : striae gravidarum (+), linea
nigra (+), scar (-)
Ext : edema (+/+), warm (+/+)
Obstetric status
L1 : breech, breech
L2 : back on the left and right side
L3 : head
L4 : 4/5
UFH: 34 cm
UC : 3 x 10 ~ 25
FHB : I. 12-13-13 (152x/min)
II. 12-11-11 (140 x/min)

Assessment

Planning

G1P0A0L0 38
weeks/G/LL/IU head
presentation
head head
presentation
with active
phase of labor

Obs. Mother and

fetal well being
Observation progress
of labor
Obs. with partograf

Time

Subject
History of USG : 1 times
Last USG: 30 Juli 2014
Result: G1P0A0L0 gemeli.
History of family planning :
Next family planning :
injection 3 months
History of obstetric :
I.
This

Object
VT : 6 cm, eff. 60 % amnion (-)
clear, head palpable, HI, denom
unclear, unpalpable small part of
fetus/ umbilikal cord
Pelvic examination:
Promontorium unpalpable
Spina ischiadica not prominent
Os coccygeus mobile
Arcus pubic > 90 degree
PS :
Cervic dilatation 5 cm : 2
Cerviks length 3 cm: 1
Cerviks consistency mild : 1
Cerviks position posterior: 0
Station H I: 1
Total: 5
Lab:
HGB = 12.4 g/dl
RBC = 4,20 K/ul
WBC = 13.74 M/ul
HCT : 30=7.0 %
PLT = 269 M/ul
HBsAg = (-)

Assessment

Planning

Time

Subject
Chronologist : at Brangrea PHC (29-082014 02.00)
S : Patient confessed abdominal pain since 2808-14 (22.00), water come out from her vagina
(-) since 14-08-2014 (01.00), bloody slim (+)
29-08-14 (03.00), and FM (+).
O : GC : well
Cons : CM
BP : 110/70mmHg
HR : 84x/m
RR : 20x/m
T : 36,5
L1 : breech, breech
L2 : back on the left and right side
L3 : head
L4 : 4/5
UFH : 33cm
EFW : 3630 gram
FHR 1: 140x/m
FHR 2: 126 x/m
UC : 3x10-20
VT : 1cm, eff 10%, amnion (-), head
palpable, HII, unpalpable small part of
fetus/ umbilikal cord.
A : G1P0A0L0 +/- 39 weeks G/L-L/IU
P : Obs. Mother and etal well being, RL 20
tpm, refferd to NTB GH

Object

Assessment

Planning

Time

Subject

Object

Assessment

Planning

14.30

Abdominal pain

UC : 3x 10 ~ 30
FHB : I 13-12-13 ( 148/min)
II 11-11-12 (136x/min)
VT : 8cm, eff 75%, amnion (-),
head palpable, HI, unpalpable
small part of fetus/ umbilikal cord.

Prolong active phase

-Obs. Mother and fetal well

being
-DM pro CTG, GP acc, CTG
result is reactive GP co to
SPV, SPV advice :
acceleration
-Obs. Proggest of labor

16.30

UC : 3x 10 ~ 30
FHB : I 12-12-12 ( 144x/min)
II 12-11-11 (136x/min)

-Start drip oxytocin at 8 dpm

17.00

UC : 4 x 10 ~ 30
FHB : I 12-12-13 ( 148x/min)
II 11-12-12 (140x/min)

Oxy drip: 12 dpm

17.30

UC : 4 x 10 ~ 30
FHB : I 12-12-12 ( 144x/min)
II 12-12-11 (140x/min)

Oxy drip: 16 dpm

18.00

UC : 4 x 10 ~ 30
FHB : I 12-12-12 ( 144x/min)
II 12-12-11 (140x/min)

Oxy drip: 20 dpm

18.30

UC : 4 x 10 ~ 40
FHB : I 12-12-12 ( 144x/min)
II 12-12-11 (140x/min)
VT : 9 cm, eff 80%, amnion(-),
head palpable, HII, unpalpable
small part of fetus/ umbilikal cord.

Prolong active phase

Oxy drip: 24 dpm

Time

Subject

19.30

20.30

Object

Assessment

UC : 4 x 10 ~ 40
FHB : I 11-12-13 ( 144x/min)
II 12-13-12 (148x/min)
Mother wont to
bearing down

UC : 4 x 10 ~ 40
FHB : I 11-12-11 ( 136x/min)
II 12-12-12 (144x/min)
Inspection : opening of vulva,
bulging of perineum, pressure of
anus

Planning
Oxy drip: 24 dpm

2nd stage of labor

20.55

Conduct mother to bearing

down

Fist baby was born. female.

1500 gram. 44 cm, AS 4-6.
Anus (+). Congenital
anomaly(-).
UFH : 1 finger above umbillicus
UC : 4 x 10 ~ 40
FHB : I 11-12-11 ( 136x/min)
VT : 9cm, eff 90%, amnion (-),
head palpable, HII, unpalpable
small part of fetus/ umbilikal cord.

21.20

21.30

Mother wont to
bearing down

Inspection : opening of vulva,

bulging of perineum, pressure of
anus

2nd stage of labor

Conduct mother to bearing

down
Second baby was born.
female. 2600 gram. 48 cm, AS
5-. Anus (+). Congenital
anomaly(-).

Time

Subject

19.30

20.30

Object

Assessment

UC : 4 x 10 ~ 40
FHB : I 11-12-13 ( 144x/min)
II 12-13-12 (148x/min)
Mother wont to
bearing down

UC : 4 x 10 ~ 40
FHB : I 11-12-11 ( 136x/min)
II 12-12-12 (144x/min)
Inspection : opening of vulva,
bulging of perineum, pressure of
anus

Planning
Oxy drip: 24 dpm

2nd stage of labor

20.55

Conduct mother to bearing

down

Fist baby was born. female.

1500 gram. 44 cm, AS 4-6.
Anus (+). Congenital
anomaly(-).
UFH : 1 finger above umbillicus
UC : 4 x 10 ~ 40
FHB : I 11-12-11 ( 136x/min)
VT : 9cm, eff 90%, amnion (-),
head palpable, HII, unpalpable
small part of fetus/ umbilikal cord.
Second baby was born.
female. 1500 gram. 40 cm, AS
7-9. Anus (+). Congenital
anomaly(-).

14.05

UC : well
UFH : 2 finger bellow umbilicus

3rd of labor

Placenta was born spontan.

Complete. 500gram.
Bleeding 400 cc

Time

Subject

Object
UC : well
UFH : 1 finger bellow umbilicus

Assessment

Planning

3rd of labor

Placenta was born spontan.

Complete. 500gram.
Bleeding 400 cc

23.30

GC: well cons:E4V5M6

BP: 100/70 mmHg
PR: 92x/m
RR: 20x/m
T: 36,6 0C
UC: (+) well
UFH: 1 fingers below umbilicus
Bleeding (+)

2 hours post partum

Observation mother
Suggest mother to eat and drink
Suggest mother to mobilitation

30-082014
07.00

GC: well cons:E4V5M6

BP: 110/70 mmHg
PR: 84x/m
RR: 18x/m
T: 36,4 0C
UC: (+) well
UFH: 1 fingers below umbilicus
Active bleeding: (-)
Lokea rubra +

1 day post post partu

Observed mother
Suggest mother to eat and drink
suggest mother to breast feeding
Suggest mother to mobilisation.

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4
2
2
2
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3
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