Morning Report

13 November 2008

Supervisor : dr. Edi P.W., Sp.OG

Dokter Muda Jaga:
1.Nasrullah
2.Sulistiawati
3.Zikrul Haikal
Cases resume :
1.

2.

3.

4.

1.

5.

6.

Name

: Mrs. Muli

Age

: 32 years

Address

: Narmada
Subject

Wakt
u

04.4
5
pm

Patient

refered

by

Narmada

with
G1P0A0H0
aterm/single/life/intra uterine with
prolong of stage 1.
cronologis :
Patient felt intermitten abdominal
pain since 00.30 am (13-11-2008),
then she went to Narmada
Community Health Center as
soon, bloody show (-), and the

fetal movement was active.

Rupture of amnion membrane at
01.00 pm (13-11-08),
The last examination in Narmada
Health

Center

found :
General status : well
BP : 110/70 mmHg
Pulse =80 x/mnt
RR: 20 x/mnt
Temp = 36C
UFL = 2 finger under xyphoideus
procesus.
Head presentation, desend 2/5.
VT : completed.

: 13 11 - 2008
: 04.30 pm

Object

Community Health Center

Community

CTH

General status :
General condition: well,
Conciousness: CM
BP: 150/90
RR: 20 x/mnt
Pulse :88 x/mnt
T: 37,2 C
Eyes : an(-) ikt (-)
Cor -Pulmo : in normal range
Obstetric status :
L1 : breech
L2 : right back
L3 : head
L4 : desend 2/5
Uterine Fundal Length : 34 cm
EFW : 3565 g
His : (+) 3x/10~35
Fetal Heart Rate : 152 x/mnt
VT : completed, eff 100 %, amnionic
membrane (-), amniotic fluid (-)
meconeal, fontanella minor, descend
HIII, moulage (+1), small organ and
umbilical cord havent clear.

Assesment

Planning

G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK

Observation
mother
and fetal well being.
Laboratory
examination : DL, UL,
HBsAg
Resusitation :
Reported
supervisor :
Advice : VE

to

Wakt
u

Subject

Last menstrual period : 12-02-08

EDD : 19-11-08
History of family planning : Family planning : IUD
ANC : routine in public health
center, > 4x.
Obstetric history: now

Object

Lab. result:
HBsAg (-)
HB = 11,6
WB = 26.800
TRB = 356.000
HMT = 35,1
Proteinuri (-)

Assesment

Planning

Time

Subject

05. 15
pm

Patient want
bearing down

to

RR: 20 x/mnt
Pulse :90 x/mnt
His : 4X/10~30
FHR : 156x/mnt

G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK

Observation mother
fetal well being.
Prepare the VE set.

05.40
pm

Patient want
bearing down

to

BP: 150/90
RR: 20 x/mnt
Pulse :90 x/mnt
His : 4x/10~30
FHR : 140x/mnt

G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK

Observation mother and

fetal well being.
Conduct the patient to
bearing down when she has
abdominal pain.

Patient want
bearing down

to

RR: 20 x/mnt
Pulse :90 x/mnt
His : 4x/10~30
FHR : 140x/mnt

G1P0A0H0
aterm/single/life/intra
uterine + neglected of
stage 2 +HDK

Baby was born with

VE, female, 3250 g,
body length 48 cm,
AS = 6-8.

05.50
pm

Object

Assesment

O6.00
pm

06.15 pm

Planning

Placenta was born

spontaneously,
complete, 500 g.
BP = 120/80
RR= 20 x/mnt
Tax = 36,7
Pulse = 87 x/mnt
Uterus contraction : well,
Fundal uterine length = in
umbilical line
Urine : 180 cc

stage IV of labor

Observation mother and

fetal well being.

and

Waktu

Subject

Object

Assesment

Planning

06.30 pm

RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Bleeding = -, lochia (+)

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

06.45 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

07.15 pm

RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

07.45 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Lochia rubra (+)

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

06.00 am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Bleeding = Lochia rubra (+)

1 daay post labor

Observation maternal well

being
Observation for hemorrhage
sign

Waktu

Subject

Object

Assesment

Planning

05.15 pm

BP = 110/80
RR= 20 x/mnt
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

05.30 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

05.45 pm

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical

stage IV of labor

Observation maternal well

being
Observation for hemorrhage
sign

06.00 am

BP = 110/80
RR= 20 x/mnt
Tax = 36,8
Pulse = 80 x/mnt
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = Lochia rubra (+)

1 daay post labor

Observation maternal well

being
Observation for hemorrhage
sign