MORNING REPORT

30th June, 2019

Supervisor: dr. Ario Danianto, Sp.OG

Team in Charge: Putri, Arlita, Wulan, Shupy

 Case Resume
Normal Labor

Pathologies Labor 1. G2P1A0H1 37 - 38 weeks S/L/IU head presentation + susp. CHF

2. G1P0A0H0 32 - 33 weeks S/L/IU head presentation + premature rupture of
membrane <12 hour
3. G1P0A0H0 29 - 30 weeks S/L/IU head presentation PK 1 laten phase

Remain Patient
Case I
Name : Mrs. SF
Age : 31 years old
Address : Bima
Admitted : 30h June, 2019
MR Number : 035025
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-19 Main complaint: bloody slime General Status: G2P1A0H1 39-40 weeks S/L/IU
head presentation + susp. CHF
07.00 am GC: well
Patient came to the emergency room GCS: CM
with 37 - 38 weeks pregnant with BP: 1300/72 mmHg
bloody slime since 02.30 am yesterday. HR: 115 bpm
The volume -/+ 100cc. RR: 23 x/min
The patient feel palpitation, there was Temp: 36.8 oC
blood (+) and slime (+) and fetal SpO2: 98%
movement is still felt active (+)
Weight : 58 kg
Height : 152 cm
There are no history of hypertension (-),
diabetes melitus (-), asthma (-), allergic
(-) in patient, Hepatitis B (+) Local Status:
Eye : anemic -/-, icteric -/-
There are also no history of Cor : S1S2 single reguler, murmur
hypertension (-), asthma (-), allergic (-)
in the family. diabetes melitus (+) (-), gallop (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-)
Abdomen : BU (+), scar (-),
tenderness (-)
Extremity : pitting edema (-/-),
warm acral (+/+)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
LMP : 29 – 09 - 18 Obstetrical Status: G2P1A0H1 39-40 weeks Observation:
EDD : 6 – 7 - 19 Abdominal examination : S/L/IU head presentation - Observation subjective
GW : 39-40 weeks Inspection : striae gravidarum (+), scar + susp. CHF complaint and vital sign
(-), linea nigra (+)
GP co to SPV advice :
History of ANC: 4x at posyandu, 2x at Palpation: UFH 31 cm, head -Observation mother and
SPOG, Last ANC at 28-06-2019, result presentation/ breech presentation, His (-) fetal well being
BP 120/80, GW 37-38 weeks, UFH 12-12-11 (140x/minutes)
-Move to vk teratai
sepusat, head presentation.
Genitalia examination :
Inspection : active bleeding (-)
History of USG: 2x at Sp.Obsgyn. Last Palpation labia : tenderness (-)
USG 13-06-2019, result S/L/IU, GW 37 VT : not evaluated
weeks, head presentation, EDD 15-07-
2019. EFW : 2.721gr Inspeculo: no indication

History of family planning: - Lab examination :

HB 12.0 g/dl
WBC 11750 /uL
Next family planning: - RBC 4,73 x 10-6/uL
PLT 280000/uL
Obstetrical History: HCT 368%
1. 2018/P/spontan GDS 87 mg/dL
2. this HBsAg Rapid reactive
Hiv rapid non-reaktif
Natrium 140 mmol/L
Kalium 2.9 mmol/L
Klorida 102 mmol/L
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-2019 No complaint General Status: G2P1A0H1 39-40 weeks Observation:
12.10 GC: well S/L/IU head presentation + - Observation subjective
Shortness of breathing (-) GCS: CM
BP: 115/82 mmHg
susp. CHF complaint and vital sign
HR: 109 bpm
RR: 22 x/min SPV (dr.Sp.JP advice)
Temp: 36.7oC - PRO Echocardiografi (1-
SpO2: 97% without O2 NK 07-2019)
- Drip KCl 25mcg dalam
Local Status:
NaCl 500 cc (24h)
UFH 29cm - Aspar K 3X1
FHB 12-11-12 (140x/m)
EFW 2635 gr
His: (-)
VT: not evaluated

30-06-2019 NO COMPLAINT General Status: G2P1A0H1 39-40 weeks Observation:

14.00 GC: well S/L/IU head presentation + - Observation subjective
GCS: CM susp. CHF complaint and vital sign
BP: 130/82 mmHg
HR: 113 bpm
RR: 22 x/min
Temp: 36.5oC
SpO2: 97% without O2 NK

HIS (-)
FHB 148x/menit
VT not evaluated
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-2019 No complaint General Status: G2P1A0H1 39-40 weeks Observation:
18.00 GC: well S/L/IU head presentation + - Observation subjective
GCS: CM susp. CHF complaint and vital sign
BP: 122/77 mmHg
HR: 93 bpm
RR: 20x/min
Temp: 36.7oC
SpO2: 97% without O2 NK

Local Status:
His (-)
PPV (-)
FHB 148x/m
VT not evalatued

01-07-2019 Bloody leakage from canal birth at General Status: G2P1A0H1 39-40 weeks Pro-Echocardiografi
06.00 GC: well S/L/IU head presentation +
03.00 am. GCS: CM
BP: 115/75 mmHg
susp. CHF
HR: 93 bpm
RR: 20x/min
Temp: 36.7oC
SpO2: 97% without O2 NK

Local Status:
His (-)
PPV (-)
FHB 148x/m
VT not evalatued
CTG Result
EKG
Child and Mother’s Health Book
USG
Case II
Name : Mrs. HS
Age : 18 years old
Address : Sakra
Admitted : 30th June, 2019
MR Number : 035038
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-19 Main complaint: water leakage General Status: G1P0A0H0 32 - 33 weeks
16.00 WITA GC: well S/L/IU head presentation +
Patient came to the emergency room GCS: CM premature rupture of
with 32 - 33 weeks pregnant with water BP: 130/78 mmHg membrane <12hour
lekeage since 04.30 am yesterday. The HR: 96 bpm
volume -/+ 100cc RR: 24 x/min
blood (-) and slime (+) and fetal Temp: 36.7 oC
movement is still felt active (+) SpO2: 98%
Weight : 49 kg
There are no history of hypertension (-), Height : 155 cm
diabetes melitus (-), asthma (-), allergic
(-) in patient.
Local Status:
There are also no history of Eye : anemic -/-, icteric -/-
hypertension (-), diabetes melitus (-), Cor : S1S2 single reguler, murmur
asthma (-), allergic (-) in the family.
(-), gallop (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-)
Abdomen : BU (+), scar (-),
tenderness (-)
Extremity : pitting edema (-/-),
warm acral (+/+)
TIME SUBJECTIVE
LMP : 15-11-2018
EDD : 22-08-2019
GW : 32- 33 weeks
History of ANC: 1x at posyandu, Last
ANC at 2 mont ago, result BP 110/80,
GW 36-37 weeks, UFH sepusat, head
presentation.
History of USG: 1x at Sp.Obsgyn. Last
USG 30-06-2019, result S/L/IU, GW 33
weeks, head presentation, EDD 18-08-
2019. EFW : 1.684 gr
OBJECTIVE ASSESSMENT PLANNING
Obstetrical Status: G1P0A0H0 32 - 33 weeks Observation:
Abdominal examination : S/L/IU head presentation + - Observation subjective
Inspection : striae gravidarum (-), scar premature rupture of complaint and vital sign
(-), linea nigra (+) membrane <12hour
GP co to SPV advice :
Palpation: UFH 28 cm, head - Observation mother and
presentation/ breech presentation, His fetal well being
(-), fetal heart rate 13-12-12
- Observation for signs of
(148x/minutes) labor progress
Genitalia examination : - Inj. Ampisilin 1gr/IM
- Inj. Dexametason 6
Inspection : active bleeding (-)
Palpation labia : tenderness (-) mg/IM (for two days)
VT : ø (-) , portio tenderness (+), - Move to teratai
palpable posterior fornix, H˅1

Inspeculo: no indication
History of family planning: -
Lab examination :
Next family planning: - HB 10,6 g/dl
WBC 12000 /uL
RBC 3,87 x 10-6/uL
Obstetrical History: PLT 466000/uL
1. This. HCT 33%
GDS 107 mg/dL
HBsAg Rapid non-reactive
Hiv rapid non-reaktif
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-2019 Complains that there is still water General Status: G1P0A0H0 32 - 33 weeks Observation:
17.00 GC: well S/L/IU head presentation + - Observation subjective
leakage (+) from the birth canal GCS: CM
BP: 120/80 mmHg
premature rupture of complaint and vital sign
HR: 88 bpm membrane < 12hour
RR: 20 x/min SPV (dr.Sp.JP advice)
Temp: 36.6oC - PRO Echocardiografi (1-
07-2019)
Local Status: - Drip KCl 25mcg dalam
UFH 27cm, head presentation, 4/5 NaCl 500 cc (24h)
FHB 12-12-12 (148x/m)
EFW 2480 gr - Aspar K 3X1
His: (-)
VT: not evaluated

RL drip MgSO4 flash 1 28tpm

30-06-2019 No complaint General Status: G1P0A0H0 32 - 33 weeks Observation:

20.00 GC: well S/L/IU head presentation + - Observation subjective
GCS: CM premature rupture of complaint and vital sign
BP: 130/82 mmHg
HR: 113 bpm membrane < 12hour
RR: 22 x/min
Temp: 36.5oC
SpO2: 97% without O2 NK

HIS (-)
FHB 148x/menit
VT not evaluated
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
01-07-2019 Complain (-) General Status: G1P0A0H0 32 - 33 weeks Observation:
06.00 GC: well S/L/IU head presentation + - Observation subjective
GCS: CM premature rupture of complaint and vital sign
BP: 120/80 mmHg
HR: 88 bpm membrane < 12hour
RR: 20 x/min
Temp: 36.6oC

Local Status:
UFH 27cm, head presentation, 4/5
FHB 12-12-12 (148x/m)
EFW 2480 gr
His: (-)
VT: not evaluated

RL drip MgSO4 flash 1 28tpm

CTG Result
 Child and Mother’s Health Book

History of ANC 1 times when the gestational age 7 month.

The child and mothers health book not ring to the hospital
USG
Refferal form
Case III
Name : Mrs. NL
Age : 20 years old
Address : Batu layar
Admitted : 30th June, 2019
MR Number : 035044
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-19 Main complaint: water leakage General Status: G1P0A0H0 29 - 30 weeks
19.00 WITA GC: well S/L/IU head presentation,
Patient came to the emergency room GCS: CM PK 1 laten phase
with 29 - 30 weeks pregnant with water BP: 122/86 mmHg
lekeage since 05.00 pm yesterday. HR: 95 bpm
blood (+) and slime (+) and fetal RR: 22 x/min
movement is still felt active (+) Temp: 36.8 oC
Patient complain of abdominal pain SpO2: 99%
since 02.00 am yesterday
Weight : 52 kg
Height : 155 cm
There are no history of hypertension (-), IMT 21,67
diabetes melitus (-), asthma (-), allergic
(+) in patient.
Local Status:
There are also no history of Eye : anemic -/-, icteric -/-
hypertension (-), diabetes melitus (-),
asthma (-), allergic (-) in the family. Cor : S1S2 single reguler, murmur
(-), gallop (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-)
Abdomen : BU (+), scar (-),
tenderness (-)
Extremity : pitting edema (-/-),
warm acral (+/+)
TIME SUBJECTIVE
LMP : 07-12-2018
EDD : 14-09-2019
GW : 32- 33 weeks
History of ANC: 1x at posyandu, Last
ANC at 2 mont ago, result BP 110/80,
GW 36-37 weeks, UFH sepusat, head
presentation.
History of USG: 1x at Sp.Obsgyn. Last
USG 30-06-2019, result S/L/IU, GW 33
weeks, head presentation, EDD 18-08-
2019. EFW : 1.684 gr
OBJECTIVE ASSESSMENT PLANNING
Obstetrical Status: G1P0A0H0 29 - 30 weeks
Abdominal examination : S/L/IU head presentation Observation:
Inspection : striae gravidarum (+), scar PK 1 laten phase - Observation subjective
(-), linea nigra (+) complaint and vital sign
Palpation: UFH 22 cm, head GP co to SPV advice :
presentation 3/5, His (+) 4x/10m.40, - Observation mother and
fetal heart rate 12-12-12 (148x/minutes) fetal well being
- Observation for signs of
Genitalia examination :
Inspection : active bleeding (-)
labor progress
- Move to teratai
Palpation labia : tenderness (-)
VT : ø 3cm , eff 25%, amnion (-), ↓HII,
impalpable small part of fetal &
umbilical cord,

History of family planning: - Lab examination :

HB 12.5 g/dl
WBC 29780 /uL
Next family planning: - RBC 4.39 x 10-6/uL
PLT 357000/uL
Obstetrical History: HCT 38%
1. This. GDS 95 mg/dL
HBsAg Rapid non-reactive
Hiv rapid non-reaktif
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-2019 Abdominal pain become General Status: G1P0A0H0 29 - 30 weeks Observation:
20.00 heavier GC: well S/L/IU head presentation - Observation mother and
Fetal movement still (+) GCS: CM kala 1 acthive phase fetal well being
BP: 100/70 mmHg - Observation for signs of
HR: 88 bpm labor progress
RR: 18 x/min
Temp: 36.8oC

Local Status:
UFH 22cm, head presentation, 4/5
FHB 12-12-12 (148x/m)
EFW 1550 gr
His: 4x10’ – 40’’
VT: ø 5cm, eff 75%, amnion (-), ↓HII, impalpable
small part of fetal & umbilical cord,

30-06-2019 Pasien complain she want to General Status: G1P0A0H0 32 - 33 weeks - Lead the APN
20.55 strangle and defecate GC: well S/L/IU head presentation
GCS: CM + PK 2
BP: 100/70 mmHg Baby was born with AS 5-7
HR: 80 bpm BW 1300gr and BL 39cm
RR: 20 x/min Amnion clear
Temp: 36.8oC Baby move to NICU

HIS 4x10’ – 45’’

FHB 12-12-11 (140x/menit)
There is teknus, vulka, perjol
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-2019 Abdominal pain (+) General Status: G1P0A0H0 29 - 30 weeks - MAK III (inj. Oxytocin
21.02 GC: well S/L/IU head presentation 1amp, PTT, masase uteri)
GCS: CM PK 3
There is blood leakage (+), elongated umbilical - Placenta was born
cord (+) complete
- UFH 2 finger below
umbilicak, bleeding +-
150cc, perineum intac

30-06-2019 Abdominal pain (+) General Status: G1P0A0H0 32 - 33 weeks - Observation 2hour post
21.10 GC: well S/L/IU head presentation PP (vital sign, bleeding,
GCS: CM + PK 4 uterus contraction, urine
BP: 110/70 mmHg output)
HR: 80 bpm
RR: 20 x/min
Temp: 36.7oC

UFH 2 finger below umbilical

Active bleeding (-)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
30-06-2019 COMPLAIN (-) General Status: P1A0H1 dengan post PP - Observation mothers
22.55 GC: well day1 condition
GCS: CM
BP: 90/60 mmHg
HR: 80 bpm
RR: 20 x/min
Temp: 36.5oC

UFH 2 finger below umbilical

Active bleeding (-), lokhea (+) 5cc
01-07-2019 Complain (-) General Status: P1A0H1 dengan post PP - Observation mothers
06.00 GC: well day 2 condition
GCS: CM
BP: 90/60 mmHg
HR: 76 bpm
RR: 18 x/min
Temp: 36.7oC

UFH 2 finger below umbilical

Active bleeding (-), lokhea (+) 5cc
Uterus Contraction well
CTG Result
Partograf
Child and Mother’s Health Book
Refferal form
Refferal Form
Thank you ☺