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Morning Report

20 DESEMBER 2009
Supervisor : dr. G.M Punarbawa, SpOG
Medical Student:
Helmiati
Halia

Cases resume :
1

G1P0A0L0 39-40 w/S/L/IU breech


presentation with PRoM < 12
hours.
.

2
3

1
Normal labor

Name/adress

Age
Time
11.30

Admitted
to
Hospital

: Mrs. A/ Presak-Praya

24 years old
Subject

Object

Patient came to Mataram GH referred by


Praya GH with G1P0A0 with breech
presentation.
LMP: 18 march 2009
EDD: 25 december 2009
Chronologist :
Patient came to Praya GH at 08.00
(20/12/09) referred by PHC Mujur. Confess,
watery vaginal discharge (+) since 06.00
(20/12/09), abdominal pain (-). History of
Hipertention (-), DM (-), asma (-).

Examinaton at Mataram GH:


General condition: good
GCS : CM
BP :120/70 mmHg
PR : 88 bpm
RR : 18 tmp
Temp : 37,8 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/-

Therapy:
Infus RL fls I 20 tts

Obstetric status :
L1 : head
L2 : fetal back on the right side
L3 : breech
L4 : was in pelvic inlet 5/5
UFH :33 cm
Abdominal diameter: 96 cm
EFW : 3168 g
FHR : 148 bpm
UC : VT :CD 1 cm, efff 10%, AM (-), clear,
breech palpable, descend HI, denom
unclear, small part and umbilical cord
wasnt palpable.

ANC 10 x,at Polindes, last 21 nov 2009


Obstetric history
1.This pregnant
Contraception history: Contraception planing: inject 3 month

Lab. Examination :
Hb : 11,1 gr%
Leko : 14.200 mm3
Trombo : 336.000 mm3
Hct : 32,8 gr%
HBsAg : -

Assesment
G1P0A0L0 39-40
w/S/L/IU breech
presentation with
PRoM < 12 hours.

20 desember 2009

11.30 wita

Planning

Obs. Mother and fetal wellbeing


KIE patient & family
Lab examination
Report to supervisor:
Propose :SC
Advice : antibiotik, SC at
afternoon

Time

Subject

Object
ZA score: 1
Paritas: primi = 0
History : tno = 0
EDD: 3168 = 1
Uk: 39-40 = 0
Station: HI = 0
CD: 1 cm = 0

Assesment

Planning

Time

Subject

Object

Assesment

Planning

12.00

Abdominal pain >

PR : 88 bpm
UC : 1 x10- 20
FHR : 144 bpm

Observed PR, UC and FHR 30


minutes again

12.30

Abdominal pain >

PR : 88 bpm
UC : 1 x10- 20
FHR : 144 bpm

Observed PR, UC and FHR 30


minutes again

13.00

Abdominal pain >

PR : 88 bpm
UC : 1 x10- 20
FHR : 144 bpm

Observed PR, UC and FHR 30


minutes again

13.30

Abdominal pain >>

PR : 90 bpm
UC : 1 x10- 20
FHR : 146 bpm
T: 37,8 C

Observed PR, UC, temp and FHR


30 minutes again

14.00

Abdominal pain >>

PR : 90 bpm
UC : 2 x10- 25
FHR : 146 bpm

Observed PR, UC and FHR 30


minutes again

14.30

Abdominal pain >>

PR : 98bpm
UC : 2 x10- 25
FHR : 146 bpm

Observed PR, UC and FHR 30


minutes again

15.00

Abdominal pain >>

PR : 98bpm
UC : 3 x10- 25
FHR : 144 bpm

Observed VS, UC, and FHR 30


minutes again

15.30

Abdominal pain >>>

BP :120/80 mmHg
RR : 24 tmp
PR : 98bpm
T: 37,5 C
UC : 3 x10- 40
FHR : 146 bpm

Observed PR, UC, and FHR 30


minutes again
Observed VT 2 hours again

Time

Subject

Object

Assesment

Planning

16.00

Abdominal pain >>>

PR : 98 bpm
UC : 3 x10- 40
FHR : 144 bpm

Observed PR, UC and FHR 30


minutes again

16.30

Abdominal pain >>>

PR : 98 bpm
UC : 3 x10- 45
FHR : 144 bpm

Observed PR, UC and FHR 30


minutes again
Call supervisor to fix the time of SC
the telephone is not up

17.00

Abdominal pain >>>

PR : 98 bpm
UC : 3 x10- 45
FHR : 144 bpm

Observed PR, temp, VT, UC and


FHR 30 minutes again

17.30

Abdominal pain >>>

PR : 98 bpm
UC : 3 x10- 45
FHR : 146 bpm
T: 37,8 C
VT :CD 1 cm, efff 10%, AM (-),
clear, breech palpable, descend
HI, denom unclear, small part and
umbilical cord wasnt palpable.

Observed PR, UC, and FHR 30


minutes again

18.00

Abdominal pain >>>

PR : 98 bpm
UC : 3 x10- 45
FHR : 146 bpm

Observed PR, UC and FHR 30


minutes again
Call back supervisor
Propose : SC
Advice : SC at 19.00

18.30

Abdominal pain >>>

PR : 98bpm
UC : 3 x10- 45
FHR : 146 bpm

Prepared to SC

19.32

SC begun

Babywas born female, 3750 g, A-S


7-8, amniotic fluid clear n little
Placenta was born 1 minute letter

Time
21.32

Subject

Object
-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

Assesment

Planning

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:37 C
RR: 38 tpm
HR : 120 bpm
(21/12/0
9)
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:37 C
RR: 38 tpm
HR : 120 bpm

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