MORNING REPORT

th
30 November 2014
Supervisor : dr. H. Agus Thoriq, SpOG
Medical Students:
Anies, Ida, Aan

Case 2

Name : Ny. E
Age
: 17 yo
Adress : Gunung sari
No. RM : 550768
Admitted :30th November 2014, 01.00
am
Diagnose : G1P0A0L0 S/L/IU 34-35
weeks breech presentation with second
phase of labor

Time

Subjective

Objective

Assesment

Planning

30/11
/2014

Patient reffered from Gunung sari PHC

with G1P0A0L0 S/L/IU 34-35 weeks
breech presentation with second phase of
labor. Patient confess abdominal pain
spread to her flank since 19.30 wita
(29/11/14), water leaked out from her
vagina (-), bloody slim (-), FM (+).

General status :
GC: well
BP: 130/60 mmHg
RR: 24x/mnt
P: 88x/mnt
T: 36,5 C
Eyes : an (-/-) ikt (-/-)
Cor : S1S2 Reg Single M
(-) G (-)
Pulmo: ves +/+.wh -/-, ro
-/Abdomen: scar (-), striae
(+)
Extremity:
warm(+),
oedema (-)

G1P0A0L0 S/L/IU 34-35

weeks breech presentation
second phase of labor

Obs. mother and

fetal well being

01.00
wita

History of DM (-), HT (-) and Asthma (-)

LMP : 4-4-2014
EDD : 11-1-2014
History of ANC :8x at Polindes
Last ANC : (14-11-2014)
Result : BP =100/60, PR=? T=37,6 RR=?
History of USG: -.
History of family planning : Next family planning : Obstetry History:
1.This

Obstetric status :
L1 : breech
L2 : head on right side
L3 :head
L4 : 5/5
UFH : 13cm,
EFW : 155 gr
UC : 4x/10-25
FHR : 14-13-13 (160 bpm)
VT:: complete, eff. 100
%, Amnion (+), brech
palpable HII,
denominator unclear,
palpable small part of
fetal (the hands)

DM consult to GP co
to SPV: observation
of labor
Observation
progress of labor
Motivation mother
to eat and drink

Time

Subjective

Objective

Chronologist : at Gunung sari PHC:

S/ patient 9 month pregnant confess
abdominal pain since 17.00 wita
(29/11/14), water leaked out from her
vagina (-), bloody slim (-), FM (+).
O/
GC: well,
BP: 110/70, P: 81 bpm, RR:21 bpm, T:
36,7 C
L1 : breech
L2: back on the right side
L3 : Head
L4 : 4/5
UFH : 25cm, EFW : 2170 gr, FHB : 1211-12 (140bpm), UC: 5x/10-35
VT: complete, eff. 100 %, Amnion
(+), brech palpable HII,
denominator unclear, palpable
small part of fetal (the hands)
A/G1P0A0L0 S/L/IU 30-31 weeks breech
presentation with inpartu sign
second phase of labor
P/ inform consent and reffered to NTB
GH

Lab:
HGB: 11,3
Hct: 33
RBC: 4,27
WBC: 15,17
Plt: 191
BT:200
CT:500
HbsAg: (-)

Assesment

Planning

Time

01.20

Patient confessed abdominal pain more

UC : 4x/10-40
FHR : 12-12-13 (148bpm)

Second phase of labor

- Obs mother and fetal

wellbeing
- Observation progress
of labor
- Motivation mother to
eat and drink

01.40

Mother want to bearing down

On inspection:
Pressure of anus, bulging of
perineum, opening of vulva

01.50

03.50

GC: welll
BP : 120/80 mmHg
PR : 88x/minute
RR : 20x/minute
T : 36,7C
UFH : 3 finger below
umbilicus
UC : good
Bleeding : 30cc

Second phase of labor

Conduct labor
(01.44) Baby was born
spt bracht, female,
BW : 2250 gram, BL: 47
cm, A-S : 5-7, anus (+),
congenital anomaly (-)

Third phase of labor

Plasenta
was
complite
Bleeding 150cc
Perineum intak

2 hours post partum

Observation general
status and vital sign
mother
Motivation mother to
breast feeding
Motivation mother to
eat and drink

born

S
01-122014
07.00

GC: well
BP: 110/80 mmHg
PR: 92x/minute
RR: 20x/minute
T: 36,5C
UC: good
UFH:
3
finger
umbilicus
Active bleeding (-)

1st day post partum

Observation general
status and vital sign
mother
Motivation mother to
breast feeding
Motivation mother to
eat and drink
Motivation mother to
walking

Baby in NICU:
PR: 138x/minute
RR: 40x/minute
T; 37C

below

 CONTOH PADA BAYI LAIN

2
0
2
2
1
1
8

Posture (3)

Square window (0)

Arm recoil (3)

Popliteal angle (4)

Scarf sign (3)

Hell to ear (2)

Skin (1)

Lanugo (1)

Plantar surface (0)

Breast (2)

Eye/ Ear (3)

Genitals (2)

1
1
0
2
3
2