Morning report 27/05/2015

Supervisor: dr H. Agus Thoriq SpOG

Koas: Dede, Nadiah, Diah,
Oriq

Cases
1. G4P3A0L3 41-42 weeks S/L/IU head
presentation with PROM < 12 hours
+ Gestasional Hypertension
(observation)
2. G1P0A0L0 A/S/L/IU head
presentation with severe pre
eclampsia ( observation )

Case 1
Name

: Mrs. M

RM

: 102175

Age

: 33 years old

Address
Admitted

: Gn. Sari, West Lombok

: May 26th 2015, at 23.05

Time

Subject

26/05/2
015
23.05

Patient referred from Gn. Sari

PHC with G4P3A0L3
42-43
weeks
S/L/IU
head
presentation with PROM < 12
hour
+
gestasional
Hypertension.
Patient
confessed water leaked out
from her womb since 19.00
(26/05/2015). Abdominal pain
(-).Blood slim (-). FM (+).
Headache (-), Blurry vision (-),
nausea (-), vomiting (-)
History of DM (-), HT (-),
asthma (-).
LMP : Forget
EDD : GW : 38-39 weeks (based on
USG result)
History ANC : 8x at PHC, last
18-04-2015
Result : BP 140/100, 33-34
w ,head presentation, UFH : 28
cm, FHB +, proteinuri (-),
History of USG : 1x at SpOG
Last 26-11-2014
Result: Fetal S/L/IU , 12-14
week AF enough, EDD: 06-062015
History of family planning:
injection 3 months
Next
family
planning:
tubectomy
Obstetric History:
1. Female/ aterm/ traditional
practitioner/ 19 y.o
2. Male/ Aterm/ traditional
practitioner/ 14 y.o

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 140/100mmHg
PR: 848x/m
RR: 20 x/m
T: 36,74C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular
M(-), G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext
uper: warm (+/+)
edema (-/-)
Ext
lower: warm (+/+)
edema (-/-)
Obstetric status
L1 : breech UFH: 34 cm
EFW : 3565
gram
L2 : back on the right side
L3 : head
L4 : 4/5
UC : FHB : 11.12.12 (140x/min)
VT : (-), consistency of
cervix average, palpation in
fornix feel like head palpable
PS : 3
Dilatation of servix : 0
Consistency of cervix
Position of cervix : 1

Assessment

Planning

G4P3A0L3
38-39
weeks S/L/IU head
presentation with
PROM < 12 hours
+
Gestasional
hypertension

Obs. Mother and

fetal well being.
CIE mother to eat,
drink and lie down
to the left side
Obs. Sign of inpartu
Inj. ampicillin 1 gr
IV/6 hours (at PHC
19.30 Wita)
DM co to GP pro
CTG, GP agree .

Time

Subject
Chronologist at Gunung sari
PHC 26-05-2015 (15.00
wita)
S :Patient confessed water
leaked out
from her womb
since 19.00
(26/05/2015).
Abdominal pain (-).Blood slim
(-). FM (+).
Headache (-),
Blurry vision (-), nausea (-),
vomiting (-)
O:
GC : well
GCS : CM (E4V5M6)
BP : 140/100 mmHg
PR : 84x/m
RR : 20 x/m
Temp : 36,7oC
Obstetric status
L1 : breech UFH: 30 cm
EFW : 2945 gram
L2 : back on the right side
L3 : head
L4 : 4/5
UC : FHB : 12.12.12 (144x/min)
VT :
(-), consistency of
cervix average, palpation in
fornix feel like head palpable
A : G4P3A0L3 42-43 weeks
head presentation mother and
fetal in well condition with
PROM < 12 hours +
gestasional hypertension.
P:

Object
Lab :
22.00
Hb: 10,8
Wbc 13,65
Plt 431
HbsAg (-) Proteinuria
Glucose: (-)

Assessment

(-),

G4P3A0L3
A/S/L/IU head
presentation with
PROM < 12 hours
+ Gestasional
hypertension

Planning

TIME

SUBJECTIVE

27/05/
2015

Mother transfer to VK Teratai

00.50

04.00

Abdominal pain (+)

06.00

Abdominal pain more frequent

OBJECTIVE

ASSESSMENT

PLANNING

GC : well
GCS : CM
BP : 140/90 mmHg
PR : 84 x/m
RR : 22 x/m
T : 36,4C
UFH : 34 cm
UC : FHB : I. 12-12-11 (140 x/m)

G4P3A0L3 A/S/L/IU
head presentation with
PROM + gestational
hypertension

Observe mother and

fetal well being.
CIE mother to eat and
drink
Injection ampicilin
1gr/IV

GC : well
GCS : CM
BP : 140/80 mmHg
PR : 80 x/m
RR : 24 x/m
T : 36,6C
UC : 3x10~35
FHB : I. 12-11-12 (136 x/m)
VT : 4 cm, eff 50%, amnion (-),
head
palpable,
denominator
sutura sagitalis melintang, H I,
impalpable small part / umbilical
cord.

Active phase 1st stage

of labor with ROM +
gestational
hypertension

GC : well
GCS : CM
BP : 140/90 mmHg
PR : 88 x/m
RR : 22 x/m
T : 36,8C
UC : 3x10~35
FHB : I. 12-12-13 (148 x/m)

Observe mother and

fetal well being.
CIE mother to eat and
drink
CIE mother to lie down
on the left side
Observation progress
of labor

Observation mother
and fetal well being
DM co to GP, advice:
observation progress
of labor

Case 2

Name
RM
Age
Address
Admitted

: Mrs. DF
: 561062
: 37 years old
: Seteluk, West sumbawa
: May 27th 2015, at 03.55

Time

Subject

27/05/2
015
03.55

Patient referred from KSB GH

with G1P0A0L0 41 weeks
S/L/IU head presentation with
severe pre eklampsia. Patient
confessed water leaked out
from her womb (-). Abdominal
pain (-).Blood slim (-). FM (+).
Headache (-), Blurry vision (-),
nausea (-), vomiting (-)
History of DM (-), HT (-),
asthma (-).
LMP : ?/8/2014
EDD : ?/5/2015
History ANC : 11x at PHC, last
24-05-2015
Result : BP 140/100, 38-39
w ,head presentation, UFH : 36
cm, FHB +, proteinuri (+),
History of USG : 1x at SpOG
Last 26-05-2015
Result: Fetal S/L/IU , AF
enough, EFW: 3120 gr EDD:
13-06-2015
History of family planning: Next family planning: Obstetric History:
1. this

Object
General status
GC : well
GCS: CM (E4V5M6)
BP : 160/100mmHg
PR: 96 x/m
RR: 20 x/m
T: 36,74C
Local status
Eye : an (-/-), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular
M(-), G(-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext
uper: warm (+/+)
edema (-/-)
Ext
lower: warm (+/+)
edema (-/-)
Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 32 cm
EFW : 3255 gram
UC : FHB : 11.12.12 (140x/min)
VT : (-), consistency of
cervix average, palpation in
fornix feel like head palpable
PS : 4
Dilatation of servix : 0
Consistency of cervix : 1
Position of cervix : 1

Assessment

Planning

G1P0A0L0 A/S/L/IU
head presentation
with severe pre
eclampsia

Obs. Mother and

fetal well being.
CIE mother to eat,
drink and lie down
to the left side
Cervical
rippening
with misoprostol 50
mcg / 8 hour
Pro
termination
oxytocin drip when
PS > 5
Ctg
Bolus
MgSO4
4
gram IV
Drip MgSO4 in RL
500 cc 28 dpm
DM co to GP , GP co
to spv, advice: pro
termination
with
induction.
Give
MgSO4 for severe
pre-eclampsia. First
(bolus 4gr cont
drip 6 gr in RL
500cc),
after
2
hours,
start
induction
with
oxytocin drip No
need misoprostol.

Time

Subject

Object

Chronologist at KSB GH 26-052015 (23.30 wita)

S :Patient confessed water
leaked out from her womb (-),
Abdominal pain (-).Blood slim
(-). FM (+).
Headache (+),
Blurry vision (-), nausea (+),
vomiting (-)
O:
GC : well
GCS : CM (E4V5M6)
BP : 160/100 mmHg
PR : 96 x/m
RR : 20 x/m
Temp : 36,7oC
Obstetric status
L1 : breech UFH: 32 cm
EFW : 3255 gram
L2 : back on the right side
L3 : head
L4 : 4/5
UC : FHB : 12.12.12 (144x/min)
VT : -

Lab :
(04.00)
Hb: 11,8
Wbc 15,97
Plt 281
HbsAg (-) Proteinuria (+1),
Glucose: (-)

A : G1P0A0L0 A/ S/L/IU head

presentation mother and fetal
in well condition with severe
pre eclampsia
P:
- IVFD RL 20 dpm
- referred to NTB GH

Assessment

Planning

TIME
27/05/
2015
06.00

06.10

SUBJECTIVE

OBJECTIVE
GC : well
GCS : CM
BP : 160/90 mmHg
PR : 84 x/m
RR : 22 x/m
T : 36,4C
UC : FHB :12-12-11 (140 x/m)

ASSESSMENT

PLANNING

G4P3A0L3 A/S/L/IU
head presentation with
PROM + gestational
hypertension

Observe mother and

fetal well being.
CIE mother to eat and
drink
MgSO4 40% 4gr iv in
10 minutes

Start drip MgSO4 40%

6 gr, 2 hours later start
induction of oxytocin
drip 5 IU in D5%
500cc 8 dpm
double line.