Morning Report

July 4th 2017

Supervisor : dr.
Medical Students :
Rosid, Haviz, Neneng

Cases Resume
Normal Labor -
Pathologic Labor -

Remain Patient 1. G1P0A0L0 41 -42 weeks S/L/IU head presentation

Case Report
Name : Mrs. AFD
Age : 18 years old
RM : 139134
Address : ?
Admitted to Hospital : July 3rd 2017
 Time Subject Object Assessment Planning
3/7/2017 Patient referred from poly obtetric General status G1P0A0L0 41 -42 Termination
13.15 west nusa tenggara hospital with GC : well weeks S/L/IU head CBC, HbsAg, CTG
G1P0A0L0 UK 41- 42 wk S/L/IU GCS: CM (E4V5M6) presentation Observation mother
head presentation. Patient confessed BP : 120/90mmHg subjective and fetal well
the pregnancy more than to EDD. PR: 88 x/m being
water leaked out (-). Abdominal RR: 20 x/m CIE mother to eat, drink
pain (-). Blood slime (-). FM (+). T: 36,5C and lie down to the left
History of DM (-), HT (-), asthma side
(-). Local status Pro consul SPV
LMP : forget Eye : an (-/-), ict (-/-)
EDD : 25-6-2017 (USG) Pulmo: ves (+/+), rh (-/-), wh (-/-)
Cor : S1S2 single regular M(-),
History ANC : 15x at PHC and west G(-)
nusa tenggara hospital, last 3-7-2017 Abd : striae gravidarum (+), linea
Result : BP 110/70, 41-42 week nigra (+), scar (-)
,head presentation, UFH : 32 cm, Ext upper: warm (+/+) edema (-
FHB + 11-11-11, edema - /-)
History of USG : 2x at RSUP NTB Ext lower: warm (+/+) edema (-
last 3/7/2017 : Fetal single, Life/IU, /-)
Head Presentation, little bit
amniotic, plasenta at fundus 41-42 Obstetric status
wk, EFW 3132 gr L1 : Breach
History of family planning: - L2 : back on the left side
Next family planning: - L3 : head
L4 : 4/5
Obstetric History: UC : --
1. This UFH: 30 cm
EFW : 2945 gram
FHB : 11/12/11 (136x/min)

VT : 0 cm, leght of cervix 3

cm, concistency of cervix soft,
position of cervix posterior ,
position of fetal head of spina
ischiadica >3cm on top
Time Subject Object Assessment Planning

Chronologist at poly obstetric RSUP

NTB 3/7/2017
S :Patient control her obstetric and
confessed the pregnancy more
than EDD
O:
GC : well
GCS : CM (E4V5M6)
BP : 110/70 mmHg
FHB : 11-11-11
UFH : 32 cm

A : G1P0A0L0 41-42 wk S/L/IU

head presentation

P: MRS, CTG, planning partus

pervaginam, CIE dangerous sign,
counceling KB
 TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

14.00 - FHR: 12-12-12 G1P0A0L0 41 -42 weeks Advanced planning

S/L/IU head presentation

15.00 - FHR: 12-11-12 G1P0A0L0 41 -42 weeks Co to SPV for the result of
Lab: S/L/IU head presentation CTG, advice:
HGB: 12,5 g% observation + insertion
WBC:11,44x103 uL misoprostol 1/8 tab
PLT: 351x103 uL intravagina at 02.00
HbsAg - (4/7/2017)
20.00 Patient fell anxious FHR: 11-11-10 G1P0A0L0 41 -42 weeks CIE mother and fetal
BP: 130/70 mmHg S/L/IU head presentation condition
HR: 92 bpm + anxious CIE mothet to eat,
RR: 20 bpm drink, lie down to left
Temp : 36,6 C side
4/7/2017 - - G1P0A0L0 41 -42 weeks Insertion of misoprostol
02.00 S/L/IU head presentation 1/8 tab
CIE patient to take rest
Observation PS
06.00 FHR: 12-11-12 G1P0A0L0 41 -42 weeks Observation mother
VT: 1cm, eff 10%, portio medial S/L/IU head presentation in and fetal well being
with concistency soft and lenght 3 cm, induction of misoprostol CIE mother and fetal
amnion +, head palpable H1, condition
denominator unclear, impalpable small
part of fetal & umbilical cord

PS:5