Morning Report

December 4th 2012

Supervisor : dr. Edi Prasetyo

W., Sp.OG
Medical Students :
Indah, Subi, Faried, Era, Adit,
Weni
CASES RESUME

NORMAL LABOR

PATHOLOGY
LABOR

1. G1P0A0L0 A/G/L-L/IU Head presentation-breech

Presentation, latent phase 1st stage of labour.
2. G1P0A0H0
43-44
weeks
S/L/IU
head
presentation with arrested active phase 1st
stage of labor.
3. G2P1A0L1 A/S/L/IU with Transversal Presentation

Name : Mrs. M
Age
: 18 yo
Adress : Gunung Sari, Lombok Barat
Admitted: December, 4th 2012 at 10.30

TIME

SUBJECTIVE

4/12/
2012

Patient referred from Penimbung

PHC with G1P0A0H0 42-43
weeks S/L/IU head presentation
with arrested active phase 1st
stage of labor.
Patient confessed abdominal
pain that spread to waist since
13.00 (03/12/2012). No histrory
water leaked from her womb.
Bloody slim (-), FM (+).
No history of DM, HT, asthma.

10.30

LMP : 03/02/2012
EDD : 10/11/2012
History of ANC : >4x at Posyandu
Last ANC : 08/11/2012
History of USG : never
History of family planning : (-)
Next family planning : Injection 3
months.
Obstetrical History :
I.This

OBJECTIVE
General Status
GC : well
Consciusness : CM
BP : 120/70 mmHg
PR : 96 bpm
RR : 24 bpm
T : 37oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single reguler, M (-), G (-)
Pulmo : vesikuler (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral
(+/+)
Obstetrical Status
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 32 cm
EFW : 3255 g
UC :3x/10 ~ 35
FHB : 11-11-11 (132 bpm)
VT : 3 cm, eff 50%, amnion (+),
head palpable H I +, denominator
unclear, impalpable small part /
umbilical cord.

ASSESSMENT

PLANNING

G1P0A0H0 43-44
weeks S/L/IU
head presentation
with latent phase
1st stage of labor.

Observe mother and

fetal well being.
Observe progress of
labor.
DM co GP; GP consult
to SPV. Advice :
observation and
evaluation at 14.30
WITA.

TIME

SUBJECTIVE
Chronologist at Penimbung PHC :
05.00 (04/12/2012)
S : Abdominal pain spread to frank since
13.00 (3/12/2012). History rupture of
membrane (-), bloody slim (-),FM (+).
O : GC : well
BP : 120/80 mmHg
PR : 84 bpm
RR : 24 bpm
T : 36,5oC
L1 : breech
L2 : back on the left side
L3 : head
L4 : 4/5
UFH : 32 cm
UC : 3x/10~35
FHB : 11-11-12 (136 bpm)
VT : 4 cm, eff 50%, amnion (+), head
palpable HI , denom unclear,
unpalpable small part / umbilical cord.
A : G1P0A0H0 42-43 weeks S/L/IU head
presentation with active phase 1st
stage of labor.
P:
Suggest mother lay to the sideways,
eat, and drink.
Observe mother and fetal well being

OBJECTIVE
Pelvic Evaluation :
Spina ischiadica not prominent
Os coccigeous mobile
Pubic arch > 900
Lab Evaluation
HB : 11,8 g/dl
RBC : 3,67 M/dl
HCT : 39,9 %
WBC : 13,9 K/dl
PLT : 241 K/dl
HbSAg : (-)

ASSESSMENT

PLANNING

TIME

SUBJECTIVE
09.00
S : abdominal pain +
O : GC well
BP : 110/70 mmHg
PR : 80 bpm
RR : 20 bpm
T : 36oC
UC : 3x/10~35
FHB : 11-12-11 (136 bpm)
VT : 4 cm, eff 50%, amnion (+), head
palpable HI , denom unclear,
unpalpable small part / umbilical cord.
A : G1P0A0H0 42-43 weeks S/L/IU head
presentation with arrested active
phase 1st stage of labor.
P:
CIE patient and family
Referred to NTB GH

OBJECTIVE

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

04/12/
2012

Abdominal pain came and

relieved

GC : well
UC :3x/10 ~ 35
FHB : 12-12-12 (144 bpm)
VT : 4 cm, eff 50%, amnion (+),
head palpable H I +,
denominator unclear, impalpable
small part / umbilical cord.

G1P0A0H0 43-44
weeks S/L/IU head
presentation with
active phase 1st stage
of labor.

18.30

Abdominal pain came and

relieved

GC : well
UC :3x/10 ~ 35
FHB : 12-12-13 (148 bpm)
VT : 6 cm, eff 50%, amnion (+),
head palpable H I +,
denominator unclear, impalpable
small part / umbilical cord.

G1P0A0H0 43-44
weeks S/L/IU head
presentation with
prolonged active
phase 1st stage of
labor.
.

Observe mother and

fetal well being.
Dm consult to SPV pro
acceleration with
amniotomi. SPV
Advice : Rehydration
and observation until 2
hours

20.30

Abdominal pain came and

relieved

GC : well
UC :3x/10 ~ 35
FHB : 12-12-12 (144 bpm)
VT : 6 cm, eff 50%, amnion (+),
head palpable H I +,
denominator unclear, impalpable
small part / umbilical cord.

G1P0A0H0 43-44
weeks S/L/IU head
presentation with
arrested active phase
1st stage of labor.
.

Observe mother and

fetal well being.
Dm consult to SPV pro
CS. SPV Advice : CS
at 22.00 WITA.

14.30

21.00

PLANNING
Observe mother and
fetal well being.
Observe progress of
labor with partograf
Evaluation 18.30

Prepare for CS
CIE patient and family

TIME
22.00

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING
C-section began
Baby was born : Male, AS: 7-9, BL: 52
cm, BW: 3200 gram.
Amnion (+) clear, 500 cc
Placenta was born manually, complete,
bleeding 300 cc. Placenta weight :
500 gram
Anus (+), congenital anomaly (-),
amnion (-).
C-section finished.

TIME

SUBJECTIVE

05/12/
2012

Patient confessed wound pain.

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 280 cc/2 h
Operation wound good

Patient confessed wound pain

GC : well
BP : 110/80 mmHg
PR : 72 bpm
RR : 24 bpm
T : 36,5oC
UFH : 2 finger below umbilicus
UC : (+)
Active bleeding : (-)
Urine output : 350 cc
Operation wound good

00.00

05/12/
2012
07.00

OBJECTIVE

Baby in NICU
GC : well
PR : 124 bpm
RR : 54 bpm
T : 36,5oC

ASSESTMENT

PLANNING

2 hours post CS

Observe mother well

being.
CIE mother to take a
rest.
Medication :
Infuse RL 20 tpm
Injection Ampicillin 1
gram IV
Inj. Ketorolak

One day post CS

Observed mother and

baby well being
Suggest mother to
mobilisation, eat, and
drink, medication.