Morning Report

August, 18th 2015

Supervisor:
dr. Gede made punarbawa, Sp.OG
DM Jaga:
febri, rian

Morning Report
th
august 10 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G3P2A0L2 38-39 weeks S/L/IU, transverse

presentation with PROM>12 hours
LABOR

Case 1
Name : Mrs. M
Age : 33 years old
Address : Bayan
Admitted : 15-08-2015
No. RM : 56-52-38
G3P2A0L2 38-39 weeks S/L/IU,
transverse presentation + PROM >12
hours

TIME

SUBJECTIVE

11/08/2015
23.12 wita

Patient reffered from KLU GH to

NTB GH with G3P2A0L2 38-39
weeks S/L/IU transverse
presentation. Patient confessed
abdominal pain spread to the
flank (+) since 4 days ago,
water leaked out from her
womb (+) since 4 days ago,
bloody slim (-), FM (+).
History of DM (-), HT (-),
asthma (-) and allergy (-).
LMP : 07/12/2014
EDD : 14/9/2015
History of ANC : 9x at Posyandu
Last result: (06/08/2015)
BP 100/70 mmHg, GW: 37-38
weeks, UFH 32 cm, transverse
presentation, FHB (+), BW: 59
kg

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36,8C
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 : back
L2 : head on the right side
L3 : L4 : 5/5
UFH: 31 cm
EFW : - gr
UC : 1x10 ~40
FHB : 11-12-12
VT : 0 cm, eff 0%, amnion
(-), transverse presentation.

ASSESSMENT
G3P2A0L2 38-39
weeks S/L/IU,
transverse
presentation +
PROM >12 hours

PLANNING
DM planning:
CTG
Pro termination with
CS
DM co to GP co to SPV
C-section at 20.00
Inj Ceftriaxon 2gr/24
hours
CIE planning
CIE mother and
family about
diagnostic planning
and therapeutic
planning

TIME

SUBJECTIVE

OBJECTIVE

History of USG : 2x, at SpOG

Last : 15/08/2015
Result : S/L/IU, transverse GW:
38-39 weeks, EFW: 3420 gr,
amnion not clear, minimal,
placenta at fundus gr II-III, FHB
(+) 100-120x/minute
Suggestion : pro SCTP
History of family planning: Next family planning : Inj 3
month

Laboratory (11/08/2015 23.56):

HB: 10.8 g/dl
RBC: 3.49
HCT: 31.1 %
WBC: 8.53
PLT: 259
HbsAg: non reactive
BT : 310
CT : 615

Obstetric History:
I. Aterm/male/Spt/2700
gr/5
years/live
II. Aterm/female/Spt/2900 gr/3
years/live
III. This
Chronologist : at KLU GH
(15-08-2015)
12.50 WITA
S : Patient reffered form
obstetric poly with fetal
distress and PROM 5 days
transverse presentation.
Patient confessed history
of water leaked out from
her womb since 5 days
ago, fetal movement (+).
Patient confessed this is
the 3rd pregnancy. No
history of abortus. All the
baby are live. History of
severe disease (-)
LMP : 7/12/2014

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
Obstetric status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 1/5
UFH: 30 cm
AbdC : 97
EFW : 2910 gr
UC : FHB : 137x/minutes
VT : not do
A : G3P2A0L2 38 weeks S/L/IU,
transverse presentation with
PROM 5 days + fetal distress
P : co to SPV
O2 4 lpm
Infus D5 20 tpm
DC
Reffered to NTB GH
13.15
Doing 02 4 lpm
Infusion D5 20 tpm
Do DC
Skin Test ampicillin
injected at 13.30 wita
14.00 FHB (+) 124x/minute
14.05 CIE family to reffered to
NTB GH agree
15.30 patient transfereed to NTB
GH, FHB 143x/minute, D5
infusion finished, change to
RL 1st flash, VT 1 cm
dilatation

OBJECTIVE

ASSESSMENT

PLANNING

TIME
20.00

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 80 bpm
RR: 18 bpm
T: 36,7C

C-Section begin at
21.00
At 21.17 Baby was
born, male, A-S 6-8,
3000 g, BL 50 cm, HC
34 cm, anus (+)
congenital anomaly (-)

UC : 1x10 ~40
FHB : 11-12-12

Placenta was born

completely
Intraoperative finding :
bicorn uteri

22.30

GC : well
consciousness: CM
BP : 110/80 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36.4C

2 hours post CS

Observation general
condition and vital
sign
Observation UC,
UFH, and active
bleeding

UC : well
UFH : 2 fingers below umbilical
UO : 200 cc/hours
Active bleeding (-)
16/08/201
5
07.00

GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 76 bpm
RR: 20 bpm
T: 36.3C
UC : well
UFH : 2 fingers below umbilical
UO : 100 cc/hours
Lochea rubra (+)

Observation general
condition and vital
sign
Observation UC,
UFH, and lochea
CIE mother to eat and
drink
CIE mother to breast
feeding
CIE mother to
mobilization

.. Thank
You ..