MORNING REPORT

October 26th, 2012

Supervisor : dr. Made Widya

Mahayasa, Sp.OG
Medical Students :
Diah, Rani, Dini, Rifka, Era, Vera, Farid,
Wawan
CASES RESUME

NORMAL LABOR

PATHOLOGY LABOR

1. G3P2A0L2 40-41 weeks S/L/IU head presentation with

postdate and failed drip 2nd serial
2. G1P0A0L0 A/S/L/IU with eclampsia + Susp. Macrosomia +
2nd Stage of Labor neglected.

Case report
Name

: Mrs.F

Age

: 23 years old

Address : Kr. Bucu, Labuapi

Admitted : October 26th 2012, 14.50 WITA

Time

Subject
Chronologist (26/10/2012,
in Gerung GH):
S: Patient pregnant 9
months, came to PHC
confessed Abdominal pain
since 02.00
(26/20/2012), rupture of
membrane since 06.00
(26/10/2012). Blur vision
(-), vomiting (-), nausea
(-). Patient suddenly
convulsion 2 times at
13.30 and 14.20
(26/10/2012)
O:
GC: weak
BP: 190/110
PR: 94 x/min
RR: 24x/min
T: 39,6c
FHR : 14-14-14
UC : 2x/10 ~25
UFH: 38cm
EFW : 3875 gram
VT : complete, eff 100%,
amnion (-), head palpable
HI, caput (+),
impalpable small part and
umbilical cord.,
A:
G1P0A0L0 A/S/L/IU head
presentation + eklampsia
+ big baby + 2nd Stage of
Labor + Febris

Object
Lab:
Hb = 12,2g/dl
Rbc = 4,40
WBC : 31,81
Plt = 314
Hct = 37,8%
HbSAg = (-)
Protein urine : +3
SGOT : 102
SGPT : 50

Assessment

Planning

TIME

SUBJECTIVE
P:
- Observed mother and
fetal well being.
-Observed impanding
eclampsia
-Coo Sp.OG Out of
Town
-O2 5 Lpm
-Ceftriaxon 1 gr/ IV
(13.30)
-Nifedipin 10 mg
(13.30)
-Drip MgSO4 40% g gr
28 tpm (13.30)
-Bolus MgSO4 40% 4
gr/IV
-Referred to NTB GH

OBJECTIVE

ASSESSMENT

PLANNING

TIME
17.00

SUBJECTIVE

OBJECTIVE

ASSESSMENT

CTG Patient

G1P0A0L0
A/S/L/IU with
eclampsia +
Susp.
Macrosomia +
2nd Stage of
Labor neglected
+ Fetal distress

19.15

PLANNING
DM Coo Result CTG
Advice: CS 18.00
Preoperation:
Inj. Ceftriaxone 1 gr

CS began
Amnion fluid: meconeal
Baby was born (19.20).
male. 3100 g. AS 3-5.
Anus (+). Congenital
anomaly (-).
Placenta was born.
Manually. Complete.
500 gram.
Bleeding 300cc

21.30

GC : weak
BP : 120/80mmHg
PR : 88x/minute
RR : 20x/minute
T : 37,1C
UC: (+)
UFH : 2 finger
umbilicus
UT: 550 cc/6 h
Lochea: (+)

2 hours post CS

below

Mother in ICU
mother
Observation
and baby well being.
Observation : vital
sign, bleeding, uterus
contraction,
urine
output.

TIME
23.00

SUBJECTIVE

OBJECTIVE
GC : well
BP : 120/80 mmHg
PR : 81 bpm
RR : 24 bpm
T : 36.2C
Urine : 500 cc
UFH : 2 fingers below
the umbilicus
Lochea rubra : +

01.00

GC : well
BP : 120/80 mmHg
PR : 81 bpm
RR : 24 bpm
T : 36.2C
Urine : 500 cc

03.00

GC : well
BP : 120/80 mmHg
PR : 88 bpm
RR : 24 bpm
T : 36.2C
Urine : 500 cc

27/10
/2012

GC : well
BP : 130/80 mmHg
PR : 89 bpm
RR : 24 bpm
T : 36.2C
UFH : 2 fingers below
the umbilicus
Lochea rubra : (+)
Baby in NICU :
GC : well
PR : 120 bpm
RR : 52 bpm
T : 36,4oC

07.00

ASSESSMENT

PLANNING
Ceftriaxone 1
hour
Ranitidine 1
hours
Kaltrofen Sup
Diazepam iif
Konvulsion
Check CBC post
BG

1st day post CS

gr/ 12
A/

12

patient
Op and

Observe mother and

baby well being.
CBC Result :
Hb : 9,8 g/dL
WBC : 21,7 x 103 /uL
RBC : 3,69 X 10
PLT : 185 X 10
BG : 93
Observation : vital sign,
bleeding,
uterus
contraction,
urine
output.

TIME

SUBJECTIVE

OBJECTIVE

11.30

GC : well
BP : 130/90 mmHg
PR : 76 bpm
RR : 20 bpm
T : 36.C
UFH : 2 fingers below
the umbilicus
Lochea rubra : +

28/10
/12
07.00

GC : well
BP : 120/80 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36.2C
UFH : 2 fingers below
the umbilicus
Lochea rubra : (+)
Baby in NICU :
GC : well
PR : 120 bpm
RR : 52 bpm
T : 36,4oC

ASSESSMENT

PLANNING
Observe mother and
baby well being.
Anestethist suggest to
move at Melati Room
Observe mother and
baby well being.
Observation : vital sign,
bleeding,
uterus
contraction,
urine
output.

2nd day post SC

Observe mother and

baby well being.
Observation : vital sign,
bleeding,
uterus
contraction,
urine
output.