Morning Report

8 NOVEMBER 2009
Supervisor : dr. Rusdhy SpOG
Medical Student:
Syarif
Winda
Helmiati
Halia

Cases resume :
1

G3P2A0L2 A/S/L/IU with APB

G1P0A0 A/S/L/IU with kala II kasep

G1P0A0 A/S/L/IU with kala II kasep + fetal

distres

Normal labor

Name
Age

: Mrs. Rasmiati/pujut
: 33 years old

Wakt
u

Subject

12.00

Patient refered by Praya GH with

G3P2A0L2 A/S/L/IU with APB + PER.
Cronologis :
Patient came Praya GH at 10.00 wita
(08/11/09) confess active vaginal
bleeding
since
09.00
(08/11/09),abdominal pain (-)
LMP : forgot
Examination in Praya GH:
BP: 140/100 mmHg
PR: 92 bpm
RR: 20 tmp
UFH : 33 cm
EFW: 3410 gram
FHR: 139 bpm
UC: 1x10-20
VT : Not done
Protein : +1
USG : plasenta previa totalis (+)
A: G3P2A0L2 A/S/L/IU with APB
PER

admite
d

Object

therapy
- inject ampicillin 1 g (at 10.00) 1
-Nifedipine oral
-RL fls I
Report to doctor the doctor wasnt
in there, the patient referred to
Mataram GH

Examination in ER
General status
General condition: good
Conciousness: CM
BP: 130/80
RR: 20x/mnt
PR :84 x/mnt
T: 36,2C
Eyes : an(-) ikt (-)
Cor -Pulmo : within normal limit
Obstetric status :
L1 : head
L2 : left back
L3 : breech
L4 : was not in pelvic inlet yet
UFH : 33 cm
EFW:3410 g
UC : 1-x10-10
FHR : 144 bpm
VT : not done
active vaginal bleeding (+)
Lab examination: UL, DL, HBsAg
Lab result :
-HBsAg (-)
-Protein (-)
-HB = 10,0 g%
-WB =15.000
-TRB = 231.000
-Hct = 33,2

Assesment
G3P2A0H2
A/S/L/IU with APB
+placenta previa
totalis

: Nov, 8th 2009

: 12.00

Planning

Report to supervisor :
Advice: pro USG at
tomorrow morning

Wakt
u

Subject
Status obstetri:
1.
aterm, spontan, polindes,
male, 9 yo
2.
Aterm, spontan, polindes,
male, 5 yo
3.
this

Object

Assesment

Planning

Wakt
u

Subject

Object

Assesment

Planning

15.00

Active vaginal bleeding (+)

General condition: good

BP : 120/80 mmHg
PR : 88 x/mnt
RR : 20 x/mnt
T : 36 C
FHR : 144 x/mnt
UC : (-)
VT : Not done

-Obs mother n baby

wellbeing
-Obs general condition &
vita sign
-Obs bleeding

16.30

Active vaginal bleeding (+) 200 cc

General condition: good

BP : 120/80 mmHg
PR : 120 x/mnt
RR : 20 x/mnt
T : 36 C
FHR : 136 x/mnt
UC : 2 x 10 ~ 10
VT : Not done

-Lab examination : 9,1 g

%
-Report to supervisor
obs 2 hours again, if
active vaginal bleeding
still (+) >> SC

18.45

Active vaginal bleeding (+) > 200 cc

Report to supervisor
SC

20.00

SC begun

Placenta was born 2

minutes before the baby
was born
The baby was born,
male 2800 g, A-S: 5-7,
amnion green.

22.00

Active vaginal bleeding (-)

General condition: good

BP : 140/70 mmHg
PR : 120 x/mnt
RR : 20 x/mnt
T : 37,9 C
UFH : at umbilicus line
UC : good

2 hour post SC

Obs. Mother and baby

well being
Motivated mother to
breast feeding
obs.
Active
vaginal
bleeding.

06.0
0(09/
11/0)

Active vaginal bleeding (-)

-General condition: good

-BP : 120/80 mmHg
-PR : 88 x/mnt
-RR : 20 x/mnt
-T : 36,8 C
-UFH : 2 finger under
umbilicus
-UC : good

1day post SC

Obs. Mother and baby well

being
obs.
Activ
vaginal
bleeding.

Name/adress

: Mrs. Nurul Aini/Selaparang Ampenan

Age

27years old

Time
14.30

Subject
Patient came to Mataram GH referred by
Tanjung Karang PHC with G1P0A0 A/S/L/IU
with prolong 2nd stage of labor
Chronologist :
Patient came to Tanjung Karang PHC at
01.00 (08/11/09) confess abdominal pain (+),
bloody show (-), watery vaginal discharge (-)
Examination in PHC:
BP: 110/70 mmHg
PR; 80 bpm
RR:18 tpm
T: 36 C
UFH : 34 cm
EFW: 3410
FHR: 132 bpm
UC: 2x10-30
VT : CD 2 cm, eff 20%, AM (+), head
palpable, descend HI,unpapable small organ
and umbilical cord.
05.00
UC: 3x10-35
FHR: 136 bpm
VT : CD 6 cm, eff 50%, AM (+), head
palpable, descend HII, unpapable small
organ and umbilical cord.
06.00
Watery vaginal discharge
VT : CD 6 cm, eff 60%, AM (-), head
palpable, descend HII, unpapable small
organ and umbilical cord.
09.00

Admitted
to
Hospital

Object

Examinaton at VK :
General condition: weak
GCS : E4V5M6
BP :100/70 mmHg
PR : 88 bpm
RR : 18 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 3/5
UFH :34cm
EFW : 3410 gr
FHR : 148 bpm
UC :3x10-35
VT :CD complete, AM (-), clear, head
palpable, caput (+) descend HII,
moulage grade II, small part and
umbilical cord wasnt palpable.
Lab. Examination :
Hb : 9,1 gr%
Leko : 14.700 mm3
Trombo : 243.000 mm3
Hct : 29,3 gr%
HBsAg : -

8 November 2009

14.30 wita
Assesment

Planning

G1P0A0L0 A/S/L/IU
with neglected 2th
stage of labor.

Obs. Mother and fetal wellbeing

Inject cefo 1 g IV
Report to supervisor:
Advice: SC

Time

Subject

Object

Assesment

Planning

09.00
VT : CD 7 cm, eff 70%, AM (-), head
palpable, descend HII,unpapable small organ
and umbilical cord.
Report to doctor infus RL, obs. 1 hour letter
10.00.
UC: 3x1040
FHR: 144 bpm
VT : CD complete, AM (-), head palpable,
descend HII ,unpapable small organ and
umbilical cord.
Report to the doctor: obs. 2 hour, if nothing
progres refered to mataram GH
12.00
nothing progressrefered to mataram GH
Therapy: RL 28 dpm
Obstetric history
1.This
15.00

SC begun

Baby was born female, 2800

gram, AS 7-9, amniotic fluid
green.
Placenta was born 1 minuts
letter.

17.00

Active vaginal bleeding (-)

-General condition: good

-BP : 110/80 mmHg
-PR : 88 x/mnt
-RR : 20 x/mnt
-T : 36,8 C
-UFH : 1 finger under umbilicus
-UC : good

2 hour post SC

Obs. Mother and baby well

being
Motivated to breast feeding

06.00

Active vaginal bleeding (-)

-General condition: good

-BP : 110/80 mmHg
-PR : 84 x/mnt
-RR : 16 x/mnt
-T : 36 C
-UFH :1 finger under umbilicus
-UC : good

1 day post SC

Obs. Mother and baby well

being
Motivated to breast feeding

Name/adress

: Mrs. Z/Kediri

Age

25years old

Time
23.00

Subject
Patient came to Mataram GH referred by
Gerung GH with G1P0A0 A/S/L/IU with
negleted 2nd stage of labor and fetal distress
Chronologist :
Patient came to Gerung PHC at 16.30.
confess abdominal pain (+), bloody show (+),
watery vaginal discharge since 21.00 (7-112009).
LMP: Forgot
Examination in Gerung GH:
BP: 130/90 mmHg
PR; 84 bpm
RR:20 tpm
T: 36,7 C
UFH : 31 cm
EFW: 3100 gram
FHR: 108 bpm, ireguler.
UC: 2x10-20
VT : CD complete, AM (-), caput (+), head
palpable, descend HI, caput +, denominator
fontanella minor anterior, unpapable small
organ and umbilical cord.
Patologis restriction (+)
Report to SpOG advice refered to
Bayangkhara GH but the capacyty was full
than patien refered to mataram GH
Theraphy:
Motivied mother to eat and drink
Rehidration RL : D5% = 2:1
Inject ampicilin 1 gram IV
O2 5 lpm
Obstetric status
1. This

Admitted
to
Hospital

Object

Examinaton at ER :
General condition: weak
GCS : E4V5M6
BP :130/90 mmHg
PR : 96 bpm
RR : 20 tmp
Temp : 37,8 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 :30cm
EFW : 2945 gr
FHR : 66 bpm
UC :3x10-40
VT :CD complete, AM (-), green, head
palpable, descend HI+, caput (+),
small part and umbilical cord wasnt
palpable.
Lab. Examination :
Hb : 11,3 gr%
Leko : 19.000 mm3
Trombo : 240.000 mm3
Hct : 30,3 gr%
HBsAg :-

8 November 2009

23.00 wita
Assesment

Planning

G1P0A0L0 A/S/L/IU
with neglected 2th
stage of labor and
fetal distress

Report to supervisor:
Advice :resucitation, inject cefo
1 gram IV

Time

Subject

Object

Assesment

UC: 3x1040
FHR: 168

Planning

00.00

Abdomial pain >>>

Report to supervisor
Advice: SC

01.00

SC begun

03.00

Active vaginal bleeding (-)

-General condition: good

-BP : 110/80 mmHg
-PR : 88 x/mnt
-RR : 20 x/mnt
-T : 36,8 C
-UFH : 1 finger under umbilicus
-UC : good

2 hour post SC

Obs. Mother well being

06.00

Active vaginal bleeding (-)

-General condition: good

-BP : 110/80 mmHg
-PR : 84 x/mnt
-RR : 16 x/mnt
-T : 36 C
-UFH :1 finger under umbilicus
-UC : good

1 day post SC

Obs. Mother well being

Baby was death

Placenta was born 1 minuts
letter.