Morning report

March, 21th 2014

SUPERVISOR:
Dr. EDY P.W, SpOG
DM:
AKBAR, ARIQ, ASRI

PATIENT IDENTITY
Name
Age
Address
Admitted

: Mrs. R
: 20 yo
: Lengkot
: March, 20th 2014 at 04.30 pm

TIME

SUBJECTIVE

20/03/
2014

Patient
referred
from
Narmada PHC with G1P0A0
39 40 weeks S/L/IU with
PROM + preeclampsia.
Patient confessed water
came out from her vagina
since
11.30
pm
(19/03/2014).
Abdominal
pain (-), bloody slim (-), fetal
movement (+).

General status:
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 37,80 C

History of ANC : 9x
Last
ANC:
20/02/2014,
result: BP: 120/80 mmHg,
40-41 wk, FHB (+), UFH: 30
cm

Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 31 cm
EFW: 3100 g
UC: FHB: 12-12-13(148x/min)

04.30
pm

OBJECTIVE

Eye : anemis (-), icteric (-)

Thorax :
Cor : S1S2 single reguler,
No history of DM, HT, murmur (-), gallop (-)
asthma. No history of Pulmo : vesikuler (+/+),
allergic reaction to medicine wheezing (-/-), Ronkhi (-/-).
or food.
Abdomen : scar (-), striae (+),
linea nigra (+)
LMP : 15/06/2013
Extremity : edema (-/-), warm
EDD: 22/03/2014
acral (-/-)

ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension

PLANNING
Obs mother & fetal
well being
DM co to GP pro
induction with drip
oxy if PROM>12 h,
GP advice :
Pro CTG
Continue Antibiotic
Ampicilin inj 1 gr/
12 h
Paracetamol tab 3
x 500 mg

TIME

SUBJECTIVE
History of USG : History of Family Planning: Next
Family
Planning:
injection
History of obstetry:
1.This
Chronologist :
Narmada PHC
20/03/2014
S/
Patient confessed water
came out from her vagina
since 11,30 pm
(19/03/2014). Abdominal
pain (-), bloody slim (-), fetal
movement (+).
O/
General status:
GC: well
GCS: E4V5M6
BP: 140/100 mmHg
PR: 90 bpm
RR: 24 rpm
T: 36,50 C

OBJECTIVE
VT : 1 cm, eff 25%, amnion
(-), head presentation, denom
unclear, HI, smallest part of
fetal
or
umbilical
cord
unpalpable
PS: 6
Servic dilatatiion: 1cm (1)
Servic length:1cm (2)
Station: mid (1)
Consistency: average(1)
Potition : -2cm (1)
PE:
Promontorium
unpalpable,
spina ischiadika not prominent,
os coccygeous mobile, pubic
arch >90
Lab Result
Hb : 9,9 x 106/ L
WBC : 9,73 x 103/ L
PLT : 396 x 103/ L
HCT : 30,9%
Proteinuria (-)
HBsAg : (-) non reactive

ASSESTMENT

PLANNING

TIME

SUBJECTIVE
Status Obstetric
L1 : head
L2 : back on the left side
L3 : breech
L4 : 4/5
UFH : 31 cm
EFW : 3100 gram
FHR : 12-11-12, reguler
(140bpm)
UC : VT : 1 cm, eff 25 %, amnion (-)
clear,
head
palpable
H1,
denominator unclear, impalpable
small part and umbilical cord.
Lab examination:
Protein in urine : +1
A/
G1P0A0 39 40 weeks S/L/IU
general condition of mother and
fetus well with PROM > 12h +
preeclampsia.
P/
-KIE patient and family to referred
to GH NTB
-IVFD RL 20 tpm
-Inj. Ampicillin 1 gr/ 12h
-Referred to GH NTB

OBJECTIVE

ASSESTMENT

PLANNING

TIME
06.00
pm

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

Result of CTG:

DM co to GP result
of CTG, GP advice
rehidration
intrauterine
CTG again after
RIU

06.30

Rehidration
intrauterine IVFD
RL:Dex 5 % 2:1

TIME
08.00
pm

SUBJECTIVE
-

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12
(144x/min)

ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertention

PLANNING
Pro CTG

DM co result GP,
GP
advice
observation
4
hours, repeat CTG

TIME
12.00
pm

SUBJECTIVE
-

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 130/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12
(144x/min)

ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension

PLANNING
Pro CTG

Co to GP, CTG
normal,
observation.

TIME
21/03/
14
05.30
am

SUBJECTIVE

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12 (144x/min)

ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension

PLANNING
Obs. Mother and
fetal well being
Pro CTG

DM co to GP, GP
advice pro co to
SPV at morning.

TIME

SUBJECTIVE

08.00
am

09.30
am

OBJECTIVE
GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12 (144x/min)

ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with
PROM>12h +
gestational
hypertension

PLANNING
DM co to GP, GP
co to SPV, SPV
advice pro USG

USG result:
SPV advice drip
oxytocin
CIE
to
family
about
condition
and next planning
to drip oxytocin

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

10.00
am

BP: 140/90 mmHg

PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: FHB: 12-12-12 (144x/min)

Flash 1st
Drip oxy began 8
dpm

10.30
am

UC : FHB : 12-12-12 (144 bpm)

Drip oxy 12 dpm

11.00
am

UC : FHB : 12-12-11 (140 bpm)

Drip oxy 16 dpm

11.30
am

Abdominal pain

GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: 2x10 ~25
FHB: 12-12-12 (144x/min)
VT : 3 cm, eff 25%, amnion
(-), head presentation, denom
unclear, head HI, smallest
part of fetal or umbilical cord
unpalpable.

G1P0A0 39
40 weeks
S/L/IU head
presentation
with history
ROM + laten
phase 1st stage
of labor +
gestational
hypertension

Drip oxy 20 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

12.00
am

Abdominal pain

UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)

Drip oxy 24 dpm

12.30
pm

Abdominal pain

UC : 3x10 ~25
FHB : 12-11-12 (144 bpm)

Drip oxy 28 dpm

01.00
pm

Abdominal pain

UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)

Drip oxy 32 dpm

01.30
pm

Abdominal pain

UC : 3x10 ~25
FHB : 12-11-12 (144 bpm)

Drip oxy 36 dpm

02.00
pm

Abdominal pain

UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)

Drip oxy 40 dpm

02.30
pm

Abdominal pain

UC : 3x10 ~25
FHB : 12-11-12 (144 bpm)

Drip oxy 40 dpm

03.00
pm

Abdominal pain

UC : 3x10 ~25
FHB : 12-12-12 (144 bpm)

Drip oxy 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT
G1P0A0 39
40 weeks
S/L/IU head
presentation
with history
ROM + active
phase 1st stage
of labor +
gestational
hypertension

PLANNING

03.30
pm

Abdominal pain

GC: well
GCS: E4V5M6
BP: 140/90 mmHg
PR: 88 bpm
RR: 22 rpm
T: 36,70 C
UC: 3x 10~35
FHB: 12-12-12 (144x/min)
VT : 6 cm, eff 75%, amnion
(-), head presentation, HII,
denom unclear, smallest part
of fetal or umbilical cord
unpalpable

Drip oxy 40 dpm

04.00
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min)

Stop flash 1st

change to flash 2nd

04.30
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min

Drip oxy 40 dpm

05.00
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min

Drip oxy 40 dpm

05.30
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min

Drip oxy 40 dpm

06.00
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min

Drip oxy 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

06.30
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min)

Drip oxy 40 dpm

07.00
pm

Abdominal pain

UC: 3x 10~35
FHB: 12-12-12 (144x/min)

Drip oxy 40 dpm

07.30
pm

Abdominal pain increased

UC : 4x10 ~40
FHB : 12-12-12 (144 bpm)
VT: complete, eff 100%,
amnion (-), head presentation,
HII, denom unclear, smallest
part of fetal or umbilical cord
unpalpable.

08.10
pm

Abdominal pain increase,

mother want to bearing
down

Inspection:
Bulging of perineum, opening
vulva, anus presure

G1P0A0 39
40 weeks
S/L/IU head
presentation
with 2nd stage of
labor +
gestational
hypertension

Obs. Sign of labor

Conduct labor

08.20
pm

Baby was born,

male, AS: 7-9,
BW/BL = 3350/50,
anus +, anomaly
kongenital -

08.30
pm

MAK III

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

08.45
pm

Placenta wasnt born

UC flacid
Bleeding active
BP: 110/80 mmHg

Retentio uteri

Inj oxy 1 amp

Manual placenta
KBI 5 minutes
Drip oxy 2 amp in
RL 40 tpm

08.50
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg

Post Partum

Obs. Mother well

being
Obs. Bleeding and
VS

09.05
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg

15 minutes PP

Obs. Mother well

being
Obs. Bleeding and
VS

09.20
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg

30 minutes PP

Obs. Mother well

being
Obs. Bleeding and
VS

09.35
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 110/80 mmHg

45 minutes PP

Obs. Mother well

being
Obs. Bleeding and
VS

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

09.50
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 120/80 mmHg

1 hour PP

Obs. Mother well

being
Obs. Bleeding and
VS

10.20
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 120/80 mmHg

1 hour 30
minutes PP

Obs. Mother well

being
Obs. Bleeding and
VS

10.50
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding +
BP: 110/80 mmHg

2 hours PP +
HPP ec Rest
placenta

Exploration uteri
Continue drip oxy 2
amp

30 minutes post
HPP

Obs. Mother well

being
Obs. Bleeding and
VS
Breast feeding
Suggest mother to
eat and drink

VT: palpable rest amnion and

placenta
11.30
pm

UC well
UFH 2 finger bellow umbilical
Active bleeding BP: 120/80 mmHg
Lab Result
Hb : 9,7 x 106/ L
WBC : 26,92x 103/ L

TIME
07.00
pm

SUBJECTIVE
-

OBJECTIVE
Cons: well
GCS: CM
BP: 120/80 mmHg
PR: 84 bpm
RR: 20 rpm
T: 37,30 C
UC: (+) well
UFH: 2 finger below umbiliccal
Bleeding
Baby rooming in is normal.
HR : 148 bpm
RR : 54 bpm
Temp : 36,70C

ASSESTMENT
1 day post
partum

PLANNING
Obseation Mother
and baby well
being
Suggest mother eat
and drink
Suggest mother to
breast feeding.

Thank you