MORNING REPORT

MATARAM UNIVERSITY HOSPITAL

13th March 2021
TEAM IN CHARGE
Nada, Muara, Bagus
 PATIENT IN WARD

NO NAME AGE DIAGNOSE

G2P0A1H0 with gestational age 40-41 weeks S/A/IU with oblique lie
1. Mrs. CM 28 y.o
+ postdate
IDENTITY
NAME: Mrs. CM
AGE: 28 years old
CASE 1
ADRESS: Sandubaya, Mataram
ADMITTED: 12th March 2021
MR NUMBER: 02 77 11
 SUBJECTIVE
12/03/2021 MAIN COMPLAINT : Malposition of the baby
07.30 a.m. PRESENT MEDICAL HISTORY:
WITA
The patient G2P0A1H0 with gestational age 40-41 weeks S/A/IU came to Mataram University
VK Hospitals because she was received a schedule to sectio caesarean at 13-03-2021 with indication
oblique lie and post date.
Firstly, patient came to Mataram University Hospitals Policlinic to get ANC on Thursday, 09 March
2021 because the estimated date of delivery was imminent. In the policlinic patient was undergone
examination and the examiner found the position of the baby was oblique. Patient was advised to
go home first and come back on the estimated day of delivery (11 March 2021) to evaluate the
position of the baby.
At EDD morning (11 March 2021, 06.00 a.m.), patient felt pain in her abdomen infrequently with
characteristic cramping. There was also little bloody slime came out from her birth canal. Then
patient came to Mataram University Hospital and got examination with result the position of baby
still oblique and there’s no labour sign. The fetal movement still felt by the patient. Because of that
condition, patient was suggested to get section caesarean.
The other complaint such as fever (-), seizure (-), nausea (-), vomitting (-)
PAST MEDICAL HISTORY:
Similar complaint (-). Allergy (-), asthma (-), trauma (-), hypertension (-), DM (-)
HISTORY OF FAMILY DISEASE:
Similar complaint (-). Hypertension (-), cancer (-), DM (-).
 SUBJECTIVE
12/03/2021 OBSTETRIC HISTORY:
07.30 a.m. 1. 2019/spontaneus abortus/4 weeks/hospital
WITA
2. This pregnancy
VK
HISTORY OF CONTRACEPTION : -
NEXT FAMILY PLANNING : implant

MENARCHE: 14 y.o
HISTORY OF MENSTRUATION CYCLE: 1 x every month, 28 days cycle, reguler,
duration 6-7 days, volume +- 150 cc, no complaints

FIRST DAY OF LAST MENSTRUATION: 4 June 2020

ESTIMATED DELIVERY DATE : 11 March 2021
GESTATIONAL AGE: 40-41 weeks
26/01/2021 OBJECTIVE
12/03/2021 GENERAL STATUS: LOCAL STATUS:
07.30 a.m. GC: good Eye: anemic -/-, icteric -/-
WITA GCS: E4V5M6 Cor: S1 S2 single reguler, murmur (-), gallop (-)
VK BP: 117/70 mmHg Pulmo :Vesiculer (+/+), rhonki (-/-), wheezing (-/-)
HR: 80 bpm Abdomen: enlargement (+), scar (-)
RR: 20 x/minute - -
Temp: 36,0 C Extremity: edema - , - warm acral (+/+)
SpO2: 98 % room air

Body Weight: 59 kg
Body Height: 150 cm
BMI: 26,2 kg/m2
 OBJECTIVE
12/03/2021 OBSTETRICAL STATUS:
07.30 a.m. Abdominal examination :
WITA • Inspection: distention (+), striae gravidarum (+), scar (-), linea nigra (+)
VK • Palpation:
• Fundus height: 31 cm
• Leopold 1 : breech, oblique to the right
• Leopold 2 : back on the right side
• Leopold 3 : shoulder, head oblique to left side
• Leopold 4 : not entering the pelvic yet
• Contraction: -
• Auscultation: 12-12-12 (148x/min)
• EFW : 2. 945 grams
 OBSTETRICAL STATUS:
OBJECTIVE
12/03/2021
07.30 a.m.
Genitalia Examination:
WITA Inspection :
• Pubic area : growth hair pubic normal, excoriasi (-), inflamation (-)
VK • Vulva area : Lesion (-), mass (-), inflamation (-)
• OUE : normal
• Mayor and minor labia : inflamation (-), gland bartholin swelling (-)
• Perineum : lesion (-), scar (-)
• Vaginal introitus : Bleeding (-), clear slime (+)

VT :
• Cervix dilatation: -
• Effacement: -
• Amnion: can’t evaluated
• Lowerst part: can’t evaluated
• Denominator: can’t evaluated
• Hodge: -
• Smallest part/umbilical cord: can’t evaluated
Laboratory (11 March 2021, 10.31 a.m )
Parameter Nilai Nilai rujukan

Hematology
HGB 13.4 11,5-16,5
WBC 8.080 4000-10000
RBC 4.99 3,5-5,5
PLT 207.000 150000-400000
HCT 42.0 36 - 48
MCV 84.2 80,0-100,0
MCH 26.9 26,0-34,0
MCHC 31.9 32,0-36,0
Hemostatic
BT 2 1-6 menit
CT 9 6-14 menit
Laboratory (11 March 2021, 10.31 a.m )
Parameter Nilai Nilai rujukan

Blood Glucose
GDS 84 70-140
Serology
HBsAg Rapid Non reaktif
Anti HIV Non reaktif
Antigen Covid-19 Negatif
USG (24-09-2020,
13.51 WITA )
Single/alive/intrauterin/male
BPD : 3.14 cm
GA : 15w5d
EDD : 13-03-2021
EFW : 135.5 grams
Placenta in corpus posterior
Amnion adequate, clear
USG (26/11/2020), 12.06 WITA )

Single/alive/intrauterin/breech
presentation/male
BPD : 25/26
AC : 24/25
Placenta in corpus posterior
Amnion adequate, clear
USG (18/02/2021), 12.29 a.m WITA )

Single/alive/intrauterin/oblique
lie/male
BPD : 35w5d
AC : 34w2d
EDD : 20/03/2021
EFW : 2.528 grams
Placenta in corpus posterior
Amnion adequate, clear
USG 09 March 2021, 18.52 p.m WITA

Single/alive/intrauterin/oblique
lie/male
EDD : 28-03-2021
EFW : 2.800 grams
Placenta in corpus posterior
Amnion adequate/clear
 CTG:

Interpretation :
Baseline : 150 bpm
Variability : 5 – 25
Acceleration : -
Deceleration : -
Conclusion : category 1
KIA book
 ASSESMENT
12/03/2021 G2P0A1H0 Gestasional Age 40-41 weeks S/A/IU oblique lie + postdate
07.30 a.m.
WITA
VK

PLANNING
Planning Therapy: Planning monitoring:
• Pro delivery with sectio caesarean Monitoring sign of labor
Pre medication : Monitoring Maternal and Fetal Condition (CTG)
• IVFD RL 20 dpm
• DC catether
• Cefazoline injection 2 gram IV
• Ondancetron injection 8 mg IV
Operation
Report :
Diagnose pra operation : G2P0A1H0 GA 40-41
weeks S/A/IU oblique lie + posdate + BOH
Procedures :
1. Incision abdomen +- 12 cm
2. Performed LSCS :
 Incision of lower uterine segment. Amnion
membran ruptured : amnion clear.
 Baby was born with vacuum extraction :
male/3.100 grams/48 cm/A-S 7-9
 Hecting the LUS
 Wash abdominal cavity
 Close the operation field
Diagnose post operation : P1A1H1 post SC
 BABY BORN 12/03/2021, 09.40 a.m
Cry spontaneuosly,
A-S: 7-9
Gender : male
Birth Weight : 3.125 grams
Body Length : 48 cm
Head Circumference : 34 cm
Chest Circumference : 35 cm
Upper Arm Circumference : 12 cm
Anus : +
BALLARD SCORE:
39
LUBCHENCHO
CHART
Follow up 2 hours after delivery :
S : minimal pain in operation wound P:
O : GC : good GCS : E4V5M6 • Ondancetron injection (if needed)
BP : 118/70 mmHg HR : 89x/m,
• Cefixime 2 x 200 mg P.O
RR : 20x/m, T : 36.4 C SpO2 : 98% RA
• Analtram 3 x 1 tab P.O
Contraction (+)
Fundus height : 1 finger below • Multivitamin (caviplex) 2 x 1 tab P.O
umbilicus • Aff DC at 00.40
bleeding : +- 5 cc Monitoring :
UO : +- 700 cc
• Bleeding
A : P1A1H1 post partum perabdominal 2
hours • Vital sign
DISCUSSION
THANK YOU