Morning Report

September, 1th 2015

Supervisor:
dr. Gede made punarbawa, Sp.OG(K)
DM Jaga:
rian

Morning Report
th
september 1 2015
Case Resume
NORMAL
LABOR

PATHOLOGIES 1. G4P3A0L3 38-39 weeks S/L/IU, head

st
presentation
with
1
stage of labor latent
LABOR

phase and history of C Section 10 years ago

2. G1P0A0L0 27-28 weeks S/L/IU head
presentation

Case 1
Name : Mrs. Nurhayani
Age : 41 years old
Address : Ampenan
Admitted : 31-08-2015
No. RM : 56-60-74
G4P3A0L3 38-39 weeks S/L/IU, head
presentation with 1stst stage of labor
latent phase and history of C Section 10
years ago

TIME

SUBJECTIVE

31/08/201
5
05.35 wita

Patient came to emergency

department of NTB GH
confessed about abdominal
pain spread to the flank (+)
since 03.00 (31/08/2015), water
leaked out from her womb (-)
bloody slim(+), FM (+).

General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 88 bpm
RR: 20 bpm
T: 36,6C

History of DM (-), HT (-),

asthma (-) and allergy (-).

Local status
Eye : an (-/-), ict (-/-)
Pulmo : ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular, m
(-), g (-)
Abd : striae gravidarum (+),
linea nigra (+), scar (-)
Ext : edema (-/-), warm acral
(+/+).

LMP : forget
EDD : History of ANC : 6x at SpOG
Last result: (08/08/2015)
BP unclear
History of USG : 6x, at SpOG
Last : 08/08/2015
Result : EDD 07/09/2015
History of family planning:
Injection 3 months
Next family planning : MOW
Obstetric History:
I. Aterm/Polindes/midwife/37
00 g/15 years/male/live
II. Aterm/NTB
GH/SC/3700
g/10 years/female/live
III. Aterm/NTB
GH/midwife/3700
g/4
years/female/live
IV. This

OBJECTIVE

Obstetric status
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH: 30 cm
EFW : 2945 gr
UC : 1x10 ~20
FHB : 11-12-12
VT : 2 cm, eff 50%, amnion
(+), head presentation, HI,
denominator unclear, not
palpable small part &
umbilical cord

ASSESSMENT

PLANNING

G4P3A0L3 38-39
weeks S/L/IU, head
presentation with 1st
stage of labor latent
phase and history of
C Section 10 years
ago

DM planning:
Diagnostic : CBC,
HbsAg, BT, CT
Therapy :
Monitoring : VS mother,
UC, FHB, observation
progress of labor
CIE : CIE mother and
family about
diagnostic planning
and therapeutic
planning
08.00
DM co to GP co to SPV
Observation progress
of labor

TIME

SUBJECTIVE

OBJECTIVE
Laboratory (31/08/2015 05.57):
HB: 10.7 g/dl
RBC: 3.57
HCT: 32.5 %
WBC: 8.87
PLT: 219
HbsAg: non reactive
BT : 145
CT : 500

ASSESSMENT

PLANNING

TIME
09.35

SUBJECTIVE
Mother confessed about
abdominal pain

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36,8C

ASSESSMENT

PLANNING

G4P3A0L3 38-39
weeks S/L/IU,
head presentation
with 1st stage of
labor active phase
and history of C
Section 10 years
ago

DM planning:
Diagnostic : Therapy :
Monitoring : VS mother,
UC, FHB, observation
progress of labor with
partograph
CIE : suggest mother
to laydown at the left
side

G4P3A0L3 38-39
weeks S/L/IU,
head presentation
with prolonged 1st
stage of labor
active phase and
history of C
Section 10 years
ago

DM planning:
Diagnostic : CTG
Therapy : pro
amniotomy
Monitoring : VS mother,
UC, FHB, CIE :
suggest mother to
laydown at the left
side

UC : 3x10 ~35
FHB : 12-12-13
VT : 4 cm, eff 50%, amnion
(+), head presentation, HI,
denominator ROA, not palpable
small part & umbilical cord
13.35

Mother confessed about

abdominal pain

General status
GC : well
consciousness: CM
BP : 100/70 mmHg
PR: 92 bpm
RR: 21 bpm
T: 36,7C
UC : 3x10 ~30
FHB : 10-10-11
VT : 5 cm, eff 50%, amnion
(+), head presentation, HI,
denominator ROA, not palpable
small part & umbilical cord

DM co to GP co to SPV
Advice : amniotomy,
rehidration
Amniotomy was done
at 13,45
Rehidration with RL :
D5 2: 1

TIME
14.55

SUBJECTIVE
Mother want to bearing down

OBJECTIVE
General status
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 92 bpm
RR: 20 bpm
T: 36,7C

ASSESSMENT

PLANNING

G4P3A0L3 38-39
weeks S/L/IU,
head presentation
with 2nd stage of
labor and history of
C Section 10 years
ago

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, FHB
CIE : suggest mother
to bearing down

UC : 4x10 ~45
FHB : 12-12-13

Conduct mother to
bearing down

Sign of 2nd stage of labor (+) :

crowning, anus pressure,
opening of vulva, bulging of
perineum

At 15.00 Baby was

born, female, A-S 7-9,
3000 g, BL 51 cm, HC
34 cm, anus (+)
congenital anomaly (-)
Baby rooming in

VT : not perform

Placenta was born

completely at 15.25
Do the management of
4th stage of labor

17.30

GC : well
consciousness: CM
BP : 130/90 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.4C
UC : well
UFH : 2 fingers below umbilical
UO : not measured
Active bleeding (-)

2 hours post
partum

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink

TIME
01/09/201
5
07.00

SUBJECTIVE

OBJECTIVE
GC : well
consciousness: CM
BP : 110/70 mmHg
PR: 84 bpm
RR: 20 bpm
T: 36.2C
UC : well
UFH : 2 fingers below umbilical
UO : not measured
Active bleeding (-)

ASSESSMENT

PLANNING

1 day post partum

DM planning:
Diagnostic : Therapy : Monitoring : VS mother,
UC, UFH
CIE : suggest mother
to eat and drink

.. Thank
You ..