MORNING REPORT

April, 20th 2015

Supervisor :
dr. Edi Prasetyo Sp.OG
Medical Students :
Arif, Gde, Ryan, Jihan, Santya, Sinta, Yulisa, Ryan, Adi, Yuvita

CASE RESUME

NORMAL LABOR

PATHOLOGIC LABOR
G3P2A0L2 42 43 weeks S/L/IU head presentation
with Severe Preeklampsia + susp. Pulmonary
Oedema + fetal distress

CASE REPORT
Name
: Mrs. S
Age
: 33 years old
Address : Sigerongan, Lingsar, West
Lombok
Admitted: April,20th 2015 (07.48)

Time
April
20th
2015
(07.48)

Subject
Patient came to NTB GH reffered
from Sigerongan PHC with
G3P2A0L2 42 weeks S/L/IU with
impending eclampsia with susp.
Pulmonary oedema. Patient
confessed breathlless since 05.00
am, headache (+), blurred vision (-),
vomitted (-), epigastric pain (-),
seizure (-). Patient also confessed
Abdominal pain (+) since 20.00 pm
(19-04-2015). Bloody slim (-) water
leaked out from her womb (+) since
04.00 (20-04-2015), Fetal
movement (+)
No history of DM, HT, Asthma
LMP : 27-06-2014
EDD : 04-04-2015
History ANC : 7x at posyandu
Last: 23/3/2015
Result : BP : 150/100mmHg, Head
Presentation, pro USG
History of USG: 1x at Sp.OG
Last: 23-3-2014
Result : single/alive//IU, Head
Presentation, 38-39 weeks, EFW :
2770 gr, sex : female, amnion clear.
History of family planning: Injection
3 months
Next family planning: IUD
Obstetric History:
I.Aterm/male/midwife/3000gr/sponta
n/alive/14th
II.Aterm/male/midwife/3000gr/spont
an/alive/6th
III. This

Object
General status
GC : weak
GCS: E4V4M6
BP : 180/120mmHg
PR: 96 bpm
RR: 36 bpm
T: 36 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
acral (+/+).
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 34 cm
EFW : 3410 gram
UC : 2x10~30
FHB : 8-8-8x(96x/min)
VT : 3 cm, eff. 50 %,
Amnion (+), HI, head
palpable, denominator
unclear, unpalpable small
part of fetal & umbilical cord.

Assessment

Planning

G3P2A0L2 42 43
weeks S/L/IU head
presentation latent
phase 1st stage of
Labor with
Severe Preeklampsia
+ susp. Pulmonary
Oedema + fetal
distress

DM planning
Diagnostic:
Laboratorium
examination (CBC, BT
CT, HBSAg, SGOT,
SGPT, RFT, urine
examination)
Pro CTG
Monitoring:
Obs. Mother and fetal
well being
Resucitation
Intrauterine:
-set O2 mask 10 lpm
- Drip MgSO4 40% 6 gr
on 500cc RL 28 dpm
- nifedipin tab 10 mg
3x1
- Pro termination
perabdominal
- Furosemid 10 mg/8
hours
- Set to dower catheter
- Advise mother
laydown to the left side
- Pro ECG
- CO to internist

TIME

SUBJECTIVE
Chronology in Sigerongan PHC:
(20/04/2015)
S: patient came to Sigerongan PHC
with abdominal pain spread to flank
since 20.00 (19-04-2015) and water
lake out from her womb (+) since
04.00 (20-4-2015), fetal movement
(+), cough (+) , breathlless (+)
O:
GC : well
BP : 140/90 mmHG
PR : 88x/m
RR : 40x/m
T : 37 C
UFH : 36cm
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
Laboratorium :
Proteinuria : +3
A: G3P2A0L2 42 weeks S/L/IU with
impending eclampsia with susp.
Pulmonary oedema.
P:
- IVFD RL 500cc
- Set to DC
- Bolus MgSO4 40% 4 gr
- Drip MgSO4 40% 6 gr on RL 28 dpm
- Prepare to reffered to RSUP GH

OBJECTIVE
Laboratorium 20/04/2015 :
HB : 15,3 g/dL
RBC : 4,41 uL
HCT : 42,9 %
PLT : 182 uL
WBC : 18,41
Proteinuria : + 3

ASSESTMENT

PLANNING
DM co to GP pro
Teraphy:
Drip MgSO4 40% 6
gr on RL 28 dpm
Set to dower
catheter
pro ECG
Set O2 mask 10 lpm
GP co to SPV:
Advice:
Co to Internist
Internist advice :
-Amlodipin tab 10 mg
1x1
- Furosemid 10 mg/ 8
h
- Co to cardiologist
CIE :
Tell the result of
examination and
condition to mother
and her family

TIME
09.00

SUBJECTIVE
Breathless , abdominal pain
(+)

OBJECTIVE

ASSESTMENT

GC: weak
BP: 190/140 mmHg
PR: 110 x/m
RR: 38 x/m
T: 35,8 C
Sianosis lower extremity (+)
UC: 2x10~35
FHB : +

PLANNING
DM co to GP, GP co to
SPV, SPV advice co
to anesthesiologist ,
anestesiologist advice:
-Obs. Mother and fetal
well being
Drip Ceftriaxon 2gr
on RL 500cc (Skin
test)
check BGA
Inj. Furosemid 10mg
(extra)
CIE and inform
consent mother and
her family
Obs mother and fetal
well being
continue observation

09.30

Breathless , abdominal pain

(+) , water lake out (+)

GC: weak
BP: 190/140 mmHg
PR: 108x/m
RR: 38 x/m
T: 35,8 C
UC: 2x10~35
FHB : +
VT : 4cm eff : 50%, Amnion (-),
HI, head palpable, denominator
unclear, unpalpable small part of
fetal & umbilical cord.

active phase of labor

DM co to GP, GP co to
SPV, advice : SC
and co to
anestesiologist,
- Anastessiologist acc
SC
- CIE patient and
family
- prepare to SC cito

TIME
10.00

10.07

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING
SC begin

- Baby was born

female, 2800 gram,
BL 48 cm, HC 33 cm,
anus (+), congenital
anomaly (-), AS 3-5

10.10

- Placenta was born

manually : complete,
500 gr, bleeding 250
cc
- Monitoring :
observation 2 hours
post partum (vital
sign, active bleeding,
UFH, UC)

10.25

- Patient tranfser to
ICU and baby
transfer to NICU

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

12.00

GCS : E2VxM2
BP : 150/100 mmHg
PR : 100 bpm
RR : 24 bpm
T : 36,7OC
UC : (+) well
UFH : 2 fingers below
umbilicus
Active bleeding : (-)
UO : 100 cc/hours
Operation wound good

2 hours post SC

Observed mother well being

Observed bleeding & VS mother

21/04/
2015

GCS : E1VxM2
BP : 100/70 mmHg
PR : 98 bpm
RR : 14 bpm
UC : (+) well
UFH : 2 fingers below
umbilicus
Operation wound good

1st day post CS

Observed mother well being

Observed bleeding & VS mother

07.00

Baby in NICU :
GC : well
PR : 128 bpm
RR : 44 bpm
T : 36,8OC

4
3
4
4
3
4
22

Parchment
deep
cracking no
vessels

Full areola
5-10 mm
bud

Formed &
firrm instant
recoil

Yellow
umbilical
cord

Majora
large
minora
small

Mostly bald

Creases
over entire
sole

4
4
4
4
4

4
24

Lubchenco Curve

Thank you