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Morning Report

August 30th 2014


Supervisor : dr. Agus Thoriq,
Sp.OG
Medical Students :
Santi, Ria, Ayu, Yuli
CASE RESUME
NORMAL LABOR

PATHOLOGY
LABOR

1
2
3

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


PROM > 12 hours
G1P0A0L0 38 weeks/G/L-L/IU head presentation-head
presentation with active phase of labor
G2P1A0L0 A/S/L/IU head presentation with history of CS
and asthma

CASE 1
Name : Mrs. N
Age
: 23 years old
Address : Langko-Lingsar
Admitted : 29-08-2014
No. RM
: 11-37-57
G2P1A0L1 36-37
weeks/S/L/IU head
presentation with PROM > 12
hours

Time

Subject

29-08-2014
11.20

Patient came to NTB GH


reffered
Sigerongan
PHC with G2P1A0L1 3637 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 36- Obs. Mother and


37
weeks fetal well being
/S/L/IU
head DM co to GP pro
presentation
CTG and Inj. Ampi
with PROM > 1 g/6 h, GP acc
12 hours
Doing CTG
Inj.ampi 1 gr/6h

Time

Subject

Object

History of USG :-

VT : 1 cm, eff. 0 % amnion (-)


clear, head palpable, HI, denom
History of family planning : unclear, unpalpable small part of
injection 3 months
fetus/ umbilical cord
Next family planning :
injection 3 month
PS :
Cervic dilatation 0 cm : 0
History of obstetric :
Cerviks length 4 cm: 1
1. Preterm/ 2600/ male/
cerviks consistency soft: 2
midwife/ NTB GH/ 4
Cerviks position posterior: 0
years old/ life
Station H I: 1
2. This
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 (2908-2014 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

14.00

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

Start drip oxytocin at 8 dpm

14.30

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

Oxy drip: 12 dpm

15.00

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


Conduct the labor

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

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 : Mrs. ES
Age
: 28 years old
Address : Sumbawa
Admitted : 29-08-2014
No. RM
: 11-37-38
G1P0A0L0 38 weeks/G/LL/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 (-), bloody slim (+)
29-08-14 (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.

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
History of USG : 2x at doctor UFH: 34 cm
Last : 12-08-14 : result :
gemeli, head presentationUC : 3 x 10 ~ 25
head-presentation : EFW :
FHB : I. 12-13-13 (152x/min)
2416 gram, 1808 gram.
II. 12-11-11 (140 x/min)

Assessment

Planning

G1P0A0L0 38 Obs. Mother and


weeks/G/L-L/IU fetal well being
head-head
Observation
presentation
progress of labor
with active
Obs. with partograf
phase of labor

Time

Subject

Object

History of family planning :


Next family planning :
injection 3 months

VT : 6 cm, eff. 60 % amnion (-)


clear, head palpable, HI, denom
unclear, unpalpable small part of
fetus/ umbilikal cord

History of obstetric :
I.
This

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
28-08-14 (22.00), water come out from her
vagina (-), 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 AC: 92 cm
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
Conduct mother to bearing
labor (first baby)
down

20.55

First 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 (second
baby)

Conduct mother to bearing


down
Second baby was born.
female. 2600 gram. 48 cm,
AS 5-7. Anus (+).
Congenital anomaly(-).

Time

Subject

Object

Assessment

Planning

3rd of labor

Placenta was born spontan.


Complete. 500gram.
Bleeding 400 cc

21.40

UC : well
UFH : 1 finger bellow umbilicus

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.

4
3
4
5
2
2
20

3
3
3
2
3
3
17

Bayi
pertumbuhan
janin
terhambat dan
kecil masa
kehamilan

Case Report 3
Name: Mrs. BS
RM
Age

: 545572
: 32 years old

Address : Sukadana, Bayan


Admitted : August, 29th 2014 (23.45 WITA)
Diagnose

: G2P1A0L0 A/S/L/IU head


presentation with history of CS and asthma

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

29/082
014
23.50
wita

Patient reffered from KLU GH with


G2P1A0L0 37 wks S/L/IU head
presentation with latent phase and
LMR
Patient
confessed
lower
abdominal pain that spread to
flank region since 19.30 wita
(29/08/2014), history of water
leaked out since 23.00 wita
(29/08/2014), bloody slim (+).
Fetal movement (+).
history of DM ( -), HT(-), asthma
(+) recurred 2x during pregnancy
allergy (-).

General Status :
GC : moderate GCS : E4V5M6
BP : 140/90 mmHg
PR : 84 bpm
RR : 20 bpm
T : 36,5oC
Eye : anemis (-), icteric (-)
Cor : S1S2 single regular, murmur
(-), gallop (-).
Pulmo : vesicular (+/+), wheezing
(-/-), rhonchi (-/-).
Abdomen : scar (+), stria
gravidarum (+), linea nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

G2P1A0L0
A/S/L/IU Head
presentation with
active phase +
gestasional HT +
history of asthma
and CS 1,5 years
ago

Observation mother &


fetal well being.
Lab exam

LMP : forgotten
EDD : unknown
History of ANC : 2 times at
Malaysia and PHC
Last result: 27/08/2014
BP:130/90, 36 wks, UFH 30 cm,
head presentation, FHB (+)
History of USG : 1 time at
Malaysia
Last result: normal range
History of family planning : Next family planning : IUD
Obstetrical History :
I. Aterm/male/Malaysia/SCTP/
2600 g/ dead
II. This

Obstetrical Status :
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 25 cm
EFW : 2480gram
UC : 3 x/10~ 35
FHB : 12-13-13 (152 bpm)
VT : 4cm, eff. 50%, Amnion (-),
clear, head palpable, HI, denom
unclear, impalpable small part of
fetus or umbilical cord .

DM co to GP pro
observation, GP co to
SPV pro CS and SPV
advice : Observation
Progress of labor, if
there is asthma
exacerbation co to
interna
Documentation of
partograph

TIME

SUBJECTIVE
Chronologist at RSUD KLU:
21.00 wita (29/08/2014)
S/ Patient referred from Bayan
PHC confessed lower abdominal
pain that spread to flank region
since 19.30 wita (29/08/2014),
water leaked out (-), bloody slim
(+). Fetal movement (+). history of
CS 1,5 years ago
O/
BP : 140 / 90 mmHg
HR: 84 bpm
RR: 21
T: 36,5
UFH: 27 cm , 4/5
FHB : 12-12-12 (144 x/minute)
EFW :2480 gr
UC: (+) 2x10~25
VT : 2 cm, eff. 25%, amnion
(+), head palpable, HI, denom
unclear, impalpable small part /
umbilical cord.
A/ G2P1A0L0 37 wks S/L/IU
head presentation, with latent
phase of labor and LMR
P/
IVFD RL flash 1 - 20 dpm
Co to SPV advice: Refer to NTB
GH with CIE family

OBJECTIVE
PE :
Spina ischiadica not prominent,
Os coccygeus mobile,
Arcus pubis > 900
Lab Examination :
HB : 11 g/dl
RBC : 4.62 x 106/L
HCT : 35.1 %
WBC: 14.17 x 103/L
PLT : 245 x 103/L
HbSAg : (-)
Proteinuria (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

30/08/2014
03.50 wita

Mother confessed water


leaked out

GC : well
GCS : E4V5M6
BP : 140980 mmHg
PR : 84 bpm
RR : 20 bpm
UC : 3x10~35
FHB : 12-13-12 (148 bpm)
VT : 6 cm, eff. 60%, Amnion (-),
clear, head palpable, caput (+), HII,
impalpable small part of fetus or
umbilical cord

Prolonged active
phase

Co to GP pro observation
mother and fetal well
being
Suggest mother to eat
and drink

04.30 wita

Mother want to bearing


down

UC: 4x/10 ~ 35
FHB: 12-12-12
Inspection: opening vulva (+),
bulging of perineum (+), pressure of
anus (+)

2nd stage of labor

04.55

05.00

Conduct labor

Baby was born, female,


BW 2500 gr, BL 51 cm,
AS 7-9 , anus (+),
congenital anomaly (-)
3rd stage of labor

Placenta delivered
completed, bleeding 150
cc.

TIME
07.00
wita

SUBJECTIVE

OBJECTIVE
General condition: Good
BP : 120/80 mmHg
HR : 84 bpm
RR : 22 tpm
T : 36,7oC
UFH : 1 finger below umbilical
UC : (+) well
Lochea rubra +
Active bleeding (- )
Baby is rooming in
HR : 128 bpm
RR : 50
T : 37,0

ASSESSMENT

PLANNING

2 hours Post
partum

Observation 4th stage


of labor
Observation mother
and baby well being
Suggest mother to eat
and drink
Suggest mother to
mobilization
Suggest mother to
early breastfeeding

THANK YOU