Morning Report

24 October, 2019
th

Supervisor: dr. Edy Prasetyo W, Sp,OG

Team in Charge: Alya, Wahidah,Rosalia
 Normal labor -

Pathologies 1. G2P1A0H1 39-40 weeks S/L/IU with Neglated

labor Labor, Severe Eclampsia, history of SC, CPD

Case Resume
Remain
patient
 Name : Mrs. N
Age : 30 y.o.
Address : Tanjung, KLU
Admitted : October 23 th, 2019
CASE 1 MR Number : 047665
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
24 -10-2019 Main complaint : Abdominal pain General Status: G2P1A0H1 39-40 weeks History of treatments in
18.00 pm GC: Well S/L/IU with phase II , Tanjung Hospital:
Patient was reffered from RS GCS: CM Gestasional Hypertension, - Rehidration with
Tanjung with G2P1A0L1 39-40 BP: 140/90 mmHg history of SC, CPD IVFD RL 1000 cc 20
weeks S/L/IU head presentation PR: 90 bpm tpm at 14.35 pm
active phase with history of SC 7 RR: 20 x/min
years ago, Temp: 36,7oC
She was complaint there are W: 40 kg
abdominal pain since 06.00 am H: 145 cm
(23/10/2019). bloody slime (+), IMT: 19 kg/m2
water leakage (+) since 15.20, Fetal
movement (+).
Local Status:
No history of DM, HT, asthma, Eye: An (-/-), ict (-/-)
heart disease, and allergies Cor: S1S2 single reguler,
murmur (-), gallop (-)
Pulmo: Vesikuler (+/+),
wheezing (-/-), rhonki (-/-)
Abdomen: BU (+), timpani
(+), scar (+), tenderness (-).
Extremity: Edema (-/-), warm
acral (+/+)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

LMP: 20-01-2019 Obstetrical Status: G2P1A0H1 39-40 weeks Diagnostic:

EDD: 27-10-2019 Abdominal examination : S/L/IU with phase II , - Laboratorium
GW: 39-40 weeks Inspection : striae gravidarum Gestasional Hypertension, (complete blood count,
(+), scar (+), linea nigra (-) history of SC, CPD HBsAg, HIV, GDS,
History of ANC: 3 times at PHC and PT, APTT)
Obstretician L1: Breech - Lead to Labor
L2: Back on the rigth side
History of USG: 1 times at RS L3: Head Observation:
Tanjung. Last USG result (25-07- L4: Convergen - Observation subjective
2019). Palpation : complaint, vital sign,
UFH: 28 cm sign of dehydration,
Obstetrical History: EFW: 2635 gr FHB, HIS, decreased
1. 2012/SC/Male/BW - gr/Alive FHB: 14-14-13 (164 bpm) of fetus
2. This gestation His: 3x/10’~35”
Inspeculo: Not performed
History of Family Planning: Inspection : swollen vulva
Hormonal injection VT:
Dilatation 10 cm, swollen
Next Family Planning: Not decided portio, Amniotic sac (-)
yet meconium stained,
Presentation head, caput,
Ascending Hodge III, Not
felt small parts of the fetus /
umbilical cord
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
23-10- Heaviest abdominal pain, GS : moderate G2P1A0H1 39-40 Consul to SPV :
2019 lethargy GCS : E4V5M6 weeks S/L/IU with Advice :
19.00 pm BP : 140/90 mmHg Neglated Labor, - Pro SC
HR : 86 bpm Severe Eclampsia, - Drip ceftriaxon 2 gram
RR : 20 bpm history of SC, CPD gram iv
Temp : 36,7 C - Move to OK CITO
Local Status
Sunken eyes, dry mouth,poor skin
turgor
Urine output : low urine output
(20cc), dark yellow urine
His : 4x/10’~40”
FHB:14-14-14 (168 x/minute)
Laboratorium:
Hb 11,4 g/dl
Hct 34%
WBC 17190/Ul
RBC 4,39 jt/ul
PLT 190000/UL
GDS : 168 mg/dl
PT 14,1’’
APTT 33,1’’
HIV RAPID: non reaktif
HbsAg : non reaktif
Urinalisis :
Protein : +3
Blood : +3
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

24/10/2019 Baby was born Mother: - Eye ointment both

19.25 Vital Sign : eyes
HR : 139x/m - Injection HB0 + vit K

Bleeding durante
operation : 400cc

Baby :
A-S : 6-8, not crying,
Female
BW/BL : 2695 g / 48 cm
Abnormalities (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

24/10/2019 Fatigue General Status: P2A0L2 post SC - Observation vital sign

21.00 GCS: CM of the mother and baby,
BP: 116/78 mmHg obervation post partum
PR: 108 bpm bleeding.
RR: 20x/min - Laboratory
Temp: 36,5oC Examination ( CBC,
Bleeding: 10 cc SGOT, SGPT,
Contraction of utery: Well Ureum, Creatinin,
UFH : 3 finger above Electrolyt).
umbilical - Misoprostol 3 tabs
Urine Output : 300 cc (2hour) perrectal
- IVFD paracetamol 1
g/ 8 hours
- IVFD oxytocin 10 IU
+ RL 500 cc 20 dpm
- Tranexamat acid Inj
3x 1 amp IV
- Cefotaxime 3x1 amp
IV

- Advice anesthesi
- pro Tranfusi PRC 2
kolf
ANC
USG

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Reffered Letter
 BALLARD SCORE

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6 16

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KURVA LUBCHENCO
Foto Bayi

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Thank You