MORNING

REPORT
FEBRUARY 23TH, 2014

Supervisor : dr. Agus Thoriq,

Sp.OG
Medical Students :
Akbar, Nugraha, Asri
CASE RESUME
Pathology
labor

1. G1P0A0L0 40-41 wk S/L/IU with PROM>12h +

Oligohidramnion + CPD

CASE 1

TIME

SUBJECT

OBJECT

22/02/2
014

Patient referred from

Meninting PHC with
G1P0A0L0 40 41
weeks S/L/IU general
condition of mother
and fetus well with
PROM.
Patient
confessed water came
out from her vagina
since
11.00
pm
(16/02/2014).
Abdominal pain (-),
bloody slim (-), fetal
movement (+).
No history of DM, HT,
asthma.
No history of allergic
reaction to medicine or
food.
LMP : 09/05/2013
EDD: 16/02/2014

General Status
GC : well
GCS: E4V5M6
BP : 120/70 mmHg
PR : 88 bpm
RR : 24 bpm
T : 36,5oC

12.00
am

Eye : anemis (-/-),

icteric (-/-)
Cor : S1S2 single
reguler, M (-), G (-)
Pulmo : vesikuler
(+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar
(+), striae (+), linea
nigra (+).
Extremity : edema
(-/-), warm acral (+/
+)

ASSESMENT

PLANNING

G1P0A0L0
Obs.
40-41 wk
Mother and
S/L/IU
fetal well
PROM>12 h + being
Oligohidramni CTG
on
DM co to
GP, GP co
to SPV
advice:
resusitation
intra uterine
(O2 + Inf.
RL:Dex 5
% 2:1)
Oxytocin
drip
CTG
repeat if
inpartu

TIME

SUBJECT

OBJECT

22/02/2
014

History of ANC : 13x

Last ANC: 18/02/2014,
result: BP: 120/80
mmHg, 39 40 wk,
FHB (+), PROM > 12
h, oligohidramnion
Suggest: SC cito

Obstetrical Status
L1 : breech
L2 : back on the
right side
L3 : head
L4 : 4/5
UFH : 29 cm
EFW : 2790 gr
UC : FHB : 12-12-11
(140 bpm)
VT : - cm, fornix
palpable head
impression, Pelvic
score: 3
Cervix dilatation: 0
Cervix length: 0
Cervix consistency:
1
Cervix position: 1
Head position: 1

12.00
am

History
of
Family
Planning: Next Family Planning:
injection
History of obstetry:
1.This
Chronologist :
S:
Patient
came
tomeninting PHC with
history
rupture
of
membran since 11.00
pm(16/02/2014),FM(+).

ASSESMENT

PLANNING

TIME
22/02/2
014
12.00
am

SUBJECT
A : G1P0A0L0 40-41
wk /S/L/IU with
PROM>12 h
+oligohidramnion
P:
Refereed to NTB GH

OBJECT

ASSESMENT

PLANNING

TIME

SUBJECT

OBJECT

ASSESMENT

PLANNING

02.00
pm

General status
GC : well
GCS: E4V5M6
BP : 100/70 mmHg
PR: 88 ppm
RR: 24 rpm
T: 36,5C
UC : FHB : 12.11.12
(140 bpm)
VT: not doing

G1P0A0L0
Pro CTG
40-41 wk
S/L/IU
PROM>12 h +
Oligohidramni
on

02.30
pm

G1P0A0L0
DM co to
40-41 wk
GP result
S/L/IU
CTG,
PROM>12 h +
advice
Oligohidramni
observatio
on
n.

CTG RESULT (02.20 PM)

TIME
06.00
pm

SUBJECT
-

OBJECT
General status
GC : well
GCS: E4V5M6
BP : 130/90 mmHg
PR: 80 ppm
RR: 18 rpm
T: 36,8C
UC : FHB : 150 bpm
VT: not doing

ASSESMENT

PLANNING

Obs.
G1P0A0L0
40-41 wk
Mother
S/L/IU
and fetal
PROM>12 h + well being
Oligohidramni CTG
on + Fetal
suspicius,
Distress
DM co to
GP, GP co
to SPV,
advice
prepare
SC

TIME

SUBJECT

OBJECT

ASSESMENT

PLANNING

09.20
pm

SC began
G1P0A0L0 4041 wk S/L/IU
PROM>12 h +
Oligohidramnion
+ Fetal Distress

09.28
pm

G1P0A0L0 40 Baby was born,

41 wk S/L/IU
male, A-S : 7-9,
PROM>12 h +
Birth Weight :
Oligohidramnion
2.600 gram, Birth
+ Fetal Distress
Lenght 47 cm.
+ CPD
Anus (+), anomaly
kongenital (-),
head
circumference : 31
cm

09.33
pm

G1P0A0L0 40 Placenta was

41 wk S/L/IU
born,manual,
PROM>12 h +
complete, 500 gr,
Oligohidramnion
bleeding 500 cc
+ Fetal Distress
+ CPD

TIME
11.30
pm

23/02/
2014
07.00
am

SUBJECT
-

OBJECT

ASSESMENT

PLANNING

General condition : Well

GCS : E4V5M6
BP : 110/70 mmHg
PR : 80 x / m
RR : 20x/m
Temp : 36,0 C
UFH : 2 finger bellow umbilical
UC : + well
Active bleeding (-)

P1A0L1 2
hours post
partum

Obs. General
Condition,
Vital sign
Obs. Mother
and baby well
being

General condition : well

BP : 120/80 mmHg
PR : 80 x / m
RR : 20x/m
Temp : 36,8 C
UFH : 2 finger below umbilical
UC : + well
Active bleeding (-)

1st day post

partum

Obs. Mother
and baby well
being
CIE:
explanation
about result
of
examination,
drink n eat,
breast
feeding, and
mobilization

Babies rooming
PR: 160 bpm
RR: 50 x/m
Temp :36,6 C