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MORNING REPORT

June 25th, 2012

Supervisor: dr. A. Rusdhy A.H., Sp.OG


Medical Students :
Yan, Wiwid, Novi, Sapto, Ika, Ira, Lani

CASE RESUME
NORMAL LABOR 2

PATHOLOGIES LABOR 1. G1P0A0L0 39-40 weeks S/L/IU with prologed 2nd stage of
labor + mild pre-eclampsia + history of rupture membrane.
2. G1P0A0L0 37-38 weeks S/L/IU with PROM and fetal
distress.
3. G3P2A0H2, 41 weeks, S/L/IU, breech presentation, laten
phase 1st stage of labor + history rupture of membrane.
Case Report
Name : Mrs. NH
Age : 26 years old
Address : Narmada, Lombok Barat
Admitted : June, 23th 2012 at 20.30

G1P0A0L0 39-40 weeks S/L/IU with prologed 2nd stage


of labor + mild pre-eclampsia + history of rupture
membrane.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

23/06/ Patient referred from Narmada PHC General Status : G1P0A0L0 39-40 Obs mother & fetal well
2012 with G1P0A0L0 39-40 weeks GC : well weeks S/L/IU with being.
S/L/IU mother & fetal well with BP : 150/90 mmHg prolonged 2nd Rehydration (RL : D5 =
20.30
prolonged 2nd stage of labor. Patient PR : 84 bpm stage of labor + 2 : 1).
confessed abdominal pain since RR : 22 bpm mild pre-eclampsia DM co to SPV : pro CS;
03.00 (23/06/2012) and water T : 36,8OC + history of rupture advice : Acc CS.
came out from her womb since Eye : anemis (-), icteric (-) membrane. Prepare CS :
05.00 (23/06/2012). Bloody slim - Insert DC
Cor : S1S2 single regular, murmur (-),
(+), FM (+). - Skin test (-), Inject.
gallop (-).
No history of DM, HT, asthma. Ceftriaxone 2 g/IV.
Pulmo : vesicular (+/+), wheezing (-/-),
- CIE patient & family
ronkhi (-/-).
LMP : 24/09/2011 Abdomen : scar (-), striae gravidarum
EDD : 01/07/2012 (+), linea nigra (+).
Upper Extremity : edema (-/-), warm
History of ANC : > 4x at PHC acral (+/+).
Last ANC : 12/06/2012
Lower Extremity : edema (+/+), warm
History of USG : 2x acral (+/+).
Last USG : 02/04/2012
Obstetrical Status :
History of family planning : (-) L1 : breech
Next family planning : Inj. 3 months L2 : back on the right side
L3 : head
Obstetrical History : L4 : 3/5
I. This UFH : 32 cm
EFW : 3255 g
UC : 4x10 ~ 35
FHB : 12-12-11 (140 bpm)
VT : complete, amnion (-), head
palpable H-II, denominator unclear,
caput (+), impalpable small part and
umbilical cord.
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
Chronologist : PE :
Spina ischiadica not prominent
23/06/2012 (06.20)
Os coccygeus mobile
S : Mother came with pregnancy 9 months that
Arcus pubis > 90O
confessed abdominal pain since 03.00
(23/06/2012), bloody show (+), history of
Lab Examination :
rupture membrane (+), FM (+).
HB : 13,1 g/dl
O:
GC : well RBC : 4,45 M/dl
HCT : 39,1 %
BP : 120/70 mmHg
WBC : 21,23 K/dl
PR : 84 bpm
PLT : 265 K/dl
RR : 22 bpm
HbSAg : (-)
T : 36,2oC
BT : 2,00
Head presentation, back on the right, 4/5
CT : 6,00
UFH : 31 cm
Proteinuria : +1
EFW : 3100 gram
UC : 3 x 10 ~ 30
FHB : 11-12-11 (136 bpm)
VT : 1 cm, eff 25%, amnion (-) clear, head
palpable HI, denominator unclear, impalpable
small part /umbilical cord.
A:
G1P0A0L0 39-40 weeks S/L/IU head
presentation, mother & fetal well, with inpartu
1st stage of labor
P:
Obs mother & fetal well being
Obs progress of labor
Suggest mother to eat and drink
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
14.00
S : Patient confessed abdominal pain that spread to
the frank frequently.
O:
GC : well
BP : 120/70 mmHg PR : 80 bpm
RR : 20 bpm T : 36,6oC
UC : 3 x 10 ~ 45 FHB : 11-12-11 (136 bpm)
VT : 2 cm, eff 25%, amnion (-) clear, head palpable
HI, denominator unclear, impalpable small part
/umbilical cord.
A : G1P0A0L0 39-40 weeks S/L/IU mother & fetal
well with laten phase 1st stage of labor.
P:
Obs mother & fetal well being
Obs progress of labor
Suggest mother to eat and drink
Skin test (-), injection Ampicillin 1 g/IV at 15.00
(23/06/2012).

17.30
S : Patient wants to bearing down
O:
GC : well
BP : 120/90 mmHg PR : 82 bpm
RR : 20 bpm T : 36,6oC
UC : 4 x 10 ~ 50 FHB : 11-12-12 (140 bpm)
VT : 10 cm, eff 100%, amnion (+), head palpable
H-III, denominator LOA, impalpable small part
/umbilical cord.
A : 2nd stage of labor
P:
Suggest mother to eat and drink
Suggest mother to squatting down
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
18.30
S : (-)
O:
UC : 4 x 10 ~ 50
FHB : 12-12-11 (140 bpm)
A : Prolonged 2nd stage of labor
P:
Suggest mother to the left sideways
Infuse RL 500 cc
Refer to NTB GH at 19.30 (23/06/2012)

23/06/ CS began :
2012 Baby was born, female, BW
23.00 3700 gram, BL 51 cm, AS 7-9,
anus (+), congenital anomaly (-).
Plasenta was born manually,
complete, bleeding 200 cc.
Diagnosis Post Operative :
Prolonged 2nd stage of labor et
causa CPD.

24/06/ Patient confessed wound pain GC : well 2 hours post CS Observed mother well being
2012 BP : 110/70 mmHg Observed active bleeding and
01.20 HR : 80 bpm vital sign.
RR : 20 bpm Suggest mother to eat, drink,
T : 36,2oC and rest.
UC : (+)
UFH : at umbilicus
UO : 800 cc
Lochea rubra : (+)
TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING
25/06/ Patient confessed wound pain GC : well 1 day post CS Observed mother well being
2012 BP : 110/80 mmHg Suggest mother to
07.00 HR : 84 bpm mobilization, eat, drink, and
RR : 20 bpm medication.
T : 36,4OC Breast feeding
UFH : 1 finger below umbilicus
UC : (+)
Lochea rubra : (+)

Baby rooming in :
GC : well
PR : 140 bpm
RR : 44 bpm
T : 36,7OC