Morning Report

14 DESEMBER 2009
Supervisor : dr. Edi Prasetyo Wibowo, SpOG
Medical Student:
Helmiati
Halia
Syarif
Winda

Cases resume :
1

G1P0A1L0 37-38 W/S/L/IU with protracted active

phase first stage of labor.

G2P1A0H1 A/G/L-L/IU-IU with

. neglected 1st
stage of labor

Normal labor

Name/adress

Age
Time
16.00

Admitted
to
Hospital

: Mrs. H/Gunung sari

18 years old
Subject

Patient came to Mataram GH referred by

Gunung sari PHC with G2P0A1H0 A/S/L/IU
with
Chronologist :
Patient came to Gunung sari PHC at 04.00
(14/12/2009) confess abdominal pain (+),
bloody show (+), watery vaginal discharge (-),
fetal movement (+), history of hipertension
(-), and history of DM (-).
LMP:26/03/2009
ADD:02/01/2010
ANC : 8x at PHC, last about 2 weak
Examination in PHC:
BP: 120/70 mmHg
PR: 88 bpm
RR:18 tpm
T: 37 C
UFH : 30 cm
FHR: 12-12-12
UC: 4x10

14 Desember 2009

15.30 wita
Object
Examinaton at VK :
General condition: good
GCS : E4V5M6
BP :110/70 mmHg
PR : 84 bpm
RR : 20 tmp
Temp : 37 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/
Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :31cm
EFW : 3100 gram
FHR : 12-11-12
UC : 2x10/30
VT :CD 5 cm, eff 50,% AM (+), head
palpable, descend HI+, denominator
Frontanela minor anterior dekstra, small
part and umbilical cord wasnt palpable.

Assesment
G1P0A1L0 37-38
W/S/L/IU with
protracted active
phase first stage of
labor

Planning
Obs. Mother and fetal wellbeing
Report to supervisor:
Advice: Ampicillin, Rehidrasi, if
22.00 not born yetSC

Time

Subject

Object

04.00 WITA
VT : CD 4 cm, eff 40%, AM (+), head palpable, descend HI,
denominator frontanela minor anterior dekstra, unpapable
small organ and umbilical cord.

Lab. Examination :
Hb : 10,2 gr%
Leko : 12.800 mm3
Trombo : 258.000 mm3
Hct : 30,4 gr%
HBsAg : Pelvic evaluation
Promontorium not palpable
Spina
ischiadica
not
prominent
Os coxcy mobile
Arcus pubis > 90

08.00 WITA
VT : CD 5 cm, eff 50%, AM (+), head palpable, descend HI,
denominator frontanela minor anterior dekstra, unpapable
small organ and umbilical cord.
12.00 WITA
VT : CD 5 cm, eff 50%, AM (+), head palpable, descend HI,
denominator frontanela minor anterior dekstra, unpapable
small organ and umbilical cord.
Referred to Mataram GH at 15.00
Obstetric history:
1. Abortus
2. This pregnancy
History of contraception: injc 3 mounth
Planning contraception: injc 3 mounth

Assesment

Planning

Time

Subject

Object

Assesment

Planning

16.30

Abdominal pain>>

UC: 2wx10/30
FHR:12-12-13

Observed UC and FHR 30

minutes again

17.00

Abdominal pain>>

UC: 2x10/30
FHR:12-12-13

Observed UC and FHR 30

minutes again

17.30

Abdominal pain>>

UC: 3x10/-30
FHR:13-12-12

Observed UC and FHR 30

minutes again

18.00

Abdominal pain>>

UC: 3x10/30
FHR:12-12-12

Observed UC and FHR 30

minutes again

18.30

Abdominal pain>>>

UC: 3x10/30
FHR:12-12-13

Observed UC and FHR 30

minutes again

19.00

Abdominal pain>>>>

UC: 3x10/30
FHR:12-12-13

Observed UC and FHR 30

minutes again

19.30

Abdominal pain>>>>

UC: 3x10/30
FHR:13-12-13

Observed UC and FHR 30

minutes again

20.00

Abdominal pain>

BP :120/80 mmHg
PR : 84x/
RR : 24x/
Temp : 36,5C
UC : 3x10/30
FHR:11-12-12
L4: 4/5
VT : CD 6 cm, eff 50%, AM (+),
headpalpable,
descend
H1+,
denominator fontanella minor right
anterior, unpalpable small part of fetal
and umbilical

G1P0A1L0
37-38
W/S/L/IU
with
prolong active phase
first stage of labor

Report to supervisor
Advice:prepare for SC at 22.00

Time

Subject

Object

Assesment

Planning

20.30

Abdominal pain>>

UC: 3x10/30
FHR:12-12-13

Observed UC and FHR 30

minutes again

21.00

Abdominal pain>>

UC: 3x10/30
FHR:12-12-13

Observed UC and FHR 30

minutes again

21.30

Abdominal pain>>

UC: 3x10/-30
FHR:13-12-12

Observed UC and FHR 30

minutes again

Time
22.00

Subject

Object

SC begun

Assesment
Stage 2 of labor
Stage 3 of labor

Planning
Baby male was born, 3250 g, AS 7-9
Amniotic fluid clear
Placenta was born 5 minutes
later

24.00

Lokea (+)
BP :110/70 mmHg
PR : 80x/
RR : 20x/
Temp : 36,8C
UC : good
UFH : 2 finger below umbilicus
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm

2 hours post SC

Obs. Mother and baby well

being
Motivate to breast feeding

07.00

Lokea (+)
BP :110/80 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,5
UC: good
FUH: 2 finger below umbilicus
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm
Wound operation:good

1 day post SC

Obs. Mother and baby well

being
Motivate to breast feeding

Name/adress

: Mrs. N/ Praya

Age
Time

25years old
Subject

18.00

Patient came to Mataram GH referred by

Praya GH with G2P1A0 A/G/L/IU observation
of inpartu
LMP: Forgot
Chronologist :
Patient came to Praya GH at 15.10
(14/12/09) referred by PHC Mujur with
G2P1A0H1 A/G/H with PRoM, confess
abdominal pain (+), watery vaginal discharge
(+) since 12.00 (14/12/09). History of
Hipertention (-), DM (-), asma (-).
Examination in Praya GH:
15.10
General condition : good
BP: 140/100 mmHg
PR; 84 bpm
UC (+)
UFH : 40 cm
FHR: 136 bpm & 133 bpm
VT : CD 4 cm, eff 40%, AM (-), head
palpable, descend HI.
Therapy:
Inj ampicillin 1 g (13.30)
Infus RL fls I 20 tts
ANC 8 x,at PHC, last 26 nov 2009
Obstetric history
1. aterm, female,11 th, midwife, normal, 2500
g
2.This pregnant
Contraception history: implant (1,5 year),
inject 3 month
Contraception planing: inject 3 month

Admitted
to
Hospital

Object
Examinaton at Mataram GH:
General condition: good
GCS : CM
BP :120/80 mmHg
PR : 100 bpm
RR : 24 tmp
Temp : 39,2 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech-breech
L2 : fetal back on the right n left side
L3 : head-head
L4 : was in pelvic inlet 4/5
UFH :46cm
EFW : FHR : 186 bpm-190 bpm
UC :3x10-35
VT :CD 4 cm, efff 40%, portio odem, AM
(-), greenish, head palpable, descend
HI+, denom unclear, small part and
umbilical cord wasnt palpable.
Lab. Examination :
Hb : 12,1 gr%
Leko : 16.500 mm3
Trombo : 170.000 mm3
Hct : 32,8 gr%
HBsAg : -

Assesment
G2P1A0L1 A/G/LL/IU with neglected
active phase 1st
stage of labor.

14 desember 2009

18.00 wita

Planning

Obs. Mother and fetal wellbeing

Inject cefotaxim 1g IV, skin test
(-)
Resusitation
KIE patient & family
Lab examination
Report to supervisor:
Propose :SC
Advice : preparing to SC at
22.00

Time

Subject

Object

Assesment

Planning

18.30

Abdominal pain >>

PR : 100 bpm
UC : 3 x10- 35
FHR : 186/180 bpm

Observed PR, UC and FHR 30

minutes again

19.00

Abdominal pain >>

PR : 100bpm
UC : 3 x10- 35
FHR : 160/161 bpm

Observed PR, UC and FHR 30

minutes again

19.30

Abdominal pain >>

PR : 100bpm
UC : 3 x10- 35
FHR : 159/158 bpm

Observed PR, UC and FHR 30

minutes again

20.00

Abdominal pain >>

PR : 100bpm
UC : 3 x10- 35
FHR : 156/159 bpm
T: 38 C

Observed PR, UC, temp and FHR

30 minutes again

20.30

Abdominal pain >>

PR : 100bpm
UC : 3 x10- 35
FHR : 155/155 bpm

Observed PR, UC and FHR 30

minutes again

21.00

Abdominal pain >>

PR : 98bpm
UC : 3 x10- 35
FHR : 156/156 bpm

Observed PR, UC and FHR 30

minutes again

21.30

Abdominal pain >>

PR : 98bpm
UC : 3 x10- 35
FHR : 155/169 bpm

Observed VS, UC, VT and FHR 30

minutes again

22.00

Abdominal pain >>

BP :120/80 mmHg
RR : 24 tmp
PR : 98bpm
UC : 3 x10- 35
FHR : 186/186 bpm
T: 37,5 C
L4: was in pelvic inlet 4/5
VT :CD 4 cm, efff 40%, portio
odem, AM (-), greenish,
head
palpable, denom unclear, descend
HI+, small part and umbilical cord
wasnt palpable.

G2P1A0L1 A/G/L-L/IU
with neglected active
phase 1st stage of
labor.

Preparing to SC

Time
22.20

24.20
(15/12/
09)

Subject

Object

Assesment

SC begun

Planning
Baby was born male-male,
2600-2500 gram, AS 7-9/7-9,
amniotic fluid greenish.
Placenta was born 1 minutes
letter, complete.

-General condition: good

-BP : 120/80 mmHg
-PR : 80 x/mnt
-RR : 20 x/mnt
-T : 37 C
-UFH :2 finger under umbilicus
-UC : good
-Lokea (+)
-Wound of operation : good

2 hours post SC

Obs. Mother and baby well

being
Motivated to breast feeding

1 day post SC

Obs. Mother and baby well

being
Motivated to breast feeding
Motivated to drink n eat

Baby:
T:36,6 C 37 C
RR: 36 tpm - 38 tpm
HR : 120 bpm 120 bpm
06.00

-General condition: good

-BP : 120/80 mmHg
-PR : 80 x/mnt
-RR : 20 x/mnt
-T : 36,8 C
-UFH :2 finger under umbilicus
-UC : good
-Lokea (+)
-Wound of operation : good

Baby:
T:36,6 C 37 C
RR: 36 tpm - 38 tpm
HR : 120 bpm 120 bpm