MORNING REPORT

22-10-2009
Supervisor : dr. Agus Thoriq, Sp.OG
Medical student :
1.Idham
2.Holis
3.Halida

Cases report
1.

G1P0A0. A/T/H with neglected 2nd stage of

labor

Normal Labor

2.
3.

1.

Name

: Mrs. S

CTH

: 22-10-2009

Age

: 38 years

Time

: 13.00 am

Adress

: Teniga Tanjung
Subject

Object

Assesment

Planning

Patient refered by Tanjung Public Health

Center with G3P2A0H2 Posterm/S/L/IU
prolong of stage 1 active phase + PER .

General states :
GC : moderate, CM
BP : 160/110 mmHg
HR : 92x/mnt
RR : 20x/mnt
T : 370C,
Eye : an(-/-) ikt (-/-)
Cor pulmo : in normal ranges.

G3P2A0H2 H.
A/T/H with
protracted
active phase +
Suspect PER

Lab test :
DL,
HbsAg, UL
Observation
mother and fetal
well being
Conduct mother to
eat and drink

Time

13.0
0
am

Cronologist :
Patient said that she went to Tanjung
PHC at 01.00 pm (21-10-2009) with
G3P2A0H2 42 weeks, single, live,
intrauterine + intermitten abdominal
pain in the past (21-10-09) at 13.00 am,
without membrane rupture or bleeding.

General status : well

BP : 140/90 mmHg
Pulse = 84 x/mnt
RR: Temp = 36.8C
Head presentation, FHL in 3 cm under the
navel.
FEW: 3720

Obstetric state :

L1 : breech
L2 : left back
L3 : head, entered pelvic inlet yet.
Uterine Fundal Length : 35 cm
EFW : 3720 g
His : (+) 1x/10~15
Fetal Heart Rate : 136 x/mnt
VT : 6 cm, eff 75 %, amniotic
membrane (-),clear, palpation of head
descend HI, small organ and
umbilical cord havent clear.

Auscultation: cor (+), 11-11-11 =132

x/menit
VT :
Pkl. 01.30: 4 cm, eff 40 %, membran of
amnion fluid (+), desend H1.
Pkl: 05.30: 5 cm, eff 50 %, membran of
amnion fluid (+), desend H1.
Pkl. 09.30, 6 cm, eff 70 %, membran of
amnion fluid (+), desend H1.

UL: + 1

Lab. result:
Hb: 7,8 gr%
HbsAg (+)

Subject

Object

Assesment

Planning

14.40 pm

GC : moderate, CM
BP : 170/110 mmHg
HR : 84x/menit
RR : 20x/menit
T : 37,30C
CU : 1-2x ~10 (15)
FHR: 140x/menit
Lab. Result:
Hb: 11,2
Lekosit: 13.300
Trombosit: 295.000
Hematokrit: 34,6
HBsAg: +
Protein -

16.00

GC : moderate, CM
BP : 170/110 mmHg
HR : 84x/menit
RR : 20x/menit
T : 37,30C
CU : 1-2x ~10 (15)
FHR: 140x/menit

- Drip oxytosin 5 IU in D5 (from 6 dpm)

-Observation UC and FHR 30 minute again

16.30

UC: 2x10~20
FHR:134x/minute

Observation UC and FHR 30 minute again

17.00

UC: 2x10~30
FHR:137x/minute

Observation UC and FHR 30 minute again

17.30

UC adekuat
UC: 4x10~40
FHR:134x/minute

-Maintenance 20 dpm
-VT 2 hours later

G3P2A0H2 H. A/T/H with

protracted active phase
+ HDK

-Mother Resusitation (RL:D5 = 2:1)

-CTG

Subject

Object

Assesment

Planning

19.30 pm

GC : CM
BP : 170/110 mmHg
HR : 84x/menit
RR : 28x/menit
T : 380C
FHR: 136x/minute
VT: 10 cm, amniotic
membrane
(-),clear,
palpation of head ,
denominator fontanella
minor, descend HII, ,
small organ and umbilical
cord havent palpable.

G3P2A0H2 H. A/T/H
inpartu 2nd stage +
HDK

Observation mother and fetal well being

Conduct mother to squoting position
Conduct mother to eat and drink

20.25 pm

Perdarahan +_ 400
cc,
TFU:
1finger
upper umbilicus

HPP cause atonia uteri

- Baby was born spontaneously, A-S: 6-8, weight:

3800, length: 52 cm, head circumference: 32 cm
-Placenta was born spontaneously, complete, UC:
not good.
--> Massage, KBI, drip Oxytocin 1 ampul

20.40 pm

GC: CM
HR: 130/100 mmHg
Bleeding (-)
UC: good
TFU: 2 finger below
umbilicus

HPP cause atonia uteri

- Observation 2 hours post partum

22.30
Patient felt headache

GC : weak
BP : 140/70 mmHg
HR : 120x/menit
Patient sweaty
UC : not good
UFH : as high as

HPP cause atonia uteri

+pre shock

-Double infuss with maximal drop

-Lab examination
-Internal Compression Bimanual (KBI)
-Injection oxytocin
-Misoprostol 3 tab per rectal

Subject

Object

Assesment

Planning
-Report to supervisor
to
transfusion
2
kolf,
-Proposed
proposed agreed
-Advice ; injection metergin 1 ampul/IV

23.00

23.15

UC : not good
Bleeding + 200cc
BP : 87/53 mmHg
HR : 135x/mnt

23.25

GC : weak
BP : 120/50 mmHg
HR : 130x/menit

23.30

BP : 160/80
HR : 130x/mnt
Tranfusion 1 kolf of WB

00.00
00.25

BP : 159/76 mmHg
HR : 125x/mnt

-Transfusion 1
continue with RL

kolf

fininshed

00.30

BP : 130/76 mmHg
HR : 125x/mnt

- Transfusion kolf 2 of WB started

01.00

UC : good
Bleeding + 50 cc

05.00

BP : 144/84 mmHg
HR : 118x/mnt
UC : good
Bleeding : + 50 cc

-Injection ampicillin 1 gr/IV

-Observation continue

and

Name

: Mrs. I

CTH

: 22-10-2009

Age

: 21 years

Time

: 18.00 am

Adress

: Abian Tubuh

Time

Subject

Object

Assesment

Planning

18.0
0

Patient refered by Abian Tubuh public

Health Center with G1P0A0 Aterm/S/L/IU
prolong 2nd stage of labor.

General states :
GC : CM
BP : 140/90 mmHg
HR : 84x/mnt
RR : 20x/mnt
T : 370C,
Eye : an(-/-) ikt (-/-)
Cor pulmo : in normal ranges.

G1P0A0. A/T/H
with neglected
2nd stage of
labor

Lab test :
DL,
HbsAg
Observation
mother and fetal
well being
Intrauterine
resusitation
Cefotaxime 2gr IV
Report
to
supervisor
Advice observation
1hour later

Cronologis :
Patient came to Abian tubuh PHC at
04.00
(22-10-2009) she confess
abdominal
pain,
history
watery
discharge (-), bloody show (-).

General status : well

Vital sign : not mention it
UFH: 29 cm
VT: CD 2cm, eff 20%, AM +, head
palpable H1, small organ and umbilical
cord unpalpable.
08.00
VT : CD 4 cm, eff 40 %, AM +, head
palpable H1, small organ and umbilical
cord unpalpable.
FHB : 144x/mnt
12.00
VT : CD 6 cm, eff 60%, AM +, head
palpable descend H1+, small organ and
umbilical cord unpalpable.
16.00
VT : CD completed, eff 100%, AM -,
Amniotomi +, head palpable descend H III,
small organ and umbilical cors unpalpable.

Obstetric state :

L1 : breech
L2 : left back
L3 : head,
L4 : 3/5.
UFH : 35 cm
EFW : 3720 g
His : (+) 3x/10~35
Fetal Heart Rate : 152 x/mnt
Vulva oedema
VT : completed, eff 100 %,
amniotic
membrane
(-),clear,
palpation of head descend HII, caput
+, small organ and umbilical cord
unpalpable.

Name

: Mrs. S

CTH

: 22-10-2009

Age

: 38 years

Time

: 13.00 am

Adress

: Teniga Tanjung

Time

Subject

16.00
Patien conduct to bearing down
17.00
Os refered to NTB prov GH.
Therapy in PHC
RL : D5 = 2:1

Object

Assesment

Planning

Subject
19.00
Abdominal pain >>>

Object

Assesment

GC : moderate, CM
BP : 130/80 mmHg
HR : 80x/menit
RR : 24x/menit
T : 370C
VT: not progress

20.15

07.00 (23 10 2009)

G1P0A0. A/T/H with

neglected 2nd stage of
labor

Planning
- report to supervisor
-Advice SC Agreed

SC begun
Female baby born, 3500 gr, AS 7-9 at 20.30
Amnion fluid was green.
Plasenta complete 20.40
Mother and
well being

baby

Baby and mother rooming in

Motivation breast feeding