Morning Report

16 November 2008

Supervisor : dr. Punarbawa, Sp.OG

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

Cases resume :
1. 1
2. 1
3. 1

1.
Wakt
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Subject Object Assesment Planning

04.00 pm
08.00 pm Lab. result:
HBsAg (-)
12.00 pm HB = 10,7
VT : 8 cm. WB = 9.700
TRB = 347.000
02.00 am (16-11-08) HMT = 33,7
VT : 8 cm.

04.00 am
VT : 8 cm.

Last menstrual period : -

History of family planning :
injection/3 months
Family planning : injection/3
months
ANC : routine in public health
center, > 4x.
Obstetric history:
1.Abortus
2.Abortus
3.Abortus
4.Male, aterm, VE, RSU, 2500 g, 1
year old.
5.Now.
Name : Mrs. Robiyatul CTH : 16 11 - 2008
Age : 33 years : 05.00 am
Address : Gunung Sari
Wakt
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Subject Object Assesment Planning

05.1 Patient refered by Gunung Sari General status : G5P1A3H1 Observation mother
0 Community Health Center General condition: well, aterm/single/life/intra and fetal well being.
am Conciousness: CM uterine with retrected Laboratory
with G5P1A3H1
aterm/single/life/intra uterine with BP: 120/70 of active fase of stage examination : DL,
RR: 20 x/mnt 1 HBsAg
retrected of active fase of stage 1. Pulse :84 x/mnt Reported to
T: 36,1 C supervisor Advice :
cronologis : Eyes : an(-) ikt (-) amniotomy, antibiotic,
Patient felt intermitten abdominal Cor -Pulmo : in normal range evaluation 2 hours
pain since 07.00 am (15-11-2008), again.
then she went to Gunung Sari Obstetric status :
Community Health Center at L1 : breech
08.00 am. Bloody show (-), water L2 : right back
discharge (-), and the fetal L3 : head
movement was active. The L4 : desend 4/5
examination in Gunung Sari Uterine Fundal Length : 32 cm
Community Health Center EFW : 3255 g
His : (+) 3x/10~35
found :
Fetal Heart Rate : 152 x/mnt
General status : well VT : 8 cm, eff 80 %, amnionic
BP : 110/70 mmHg membrane (+), descend HI+, unpalpable
Pulse =80 x/mnt small organ and umbilical cord.
RR: 20 x/mnt
Temp = 36C
UFL =
Head presentation, desend 4/5.
VT : 2 cm.

12.00 am
 Time Subject Object Assesment Planning

05. 40 Patient felt RR: 20 x/mnt G5P1A3H1 Observation mother and

am abdominal pain Pulse :90 x/mnt aterm/single/life/intra fetal well being.
His : 3X/10~30 uterine with retracted
FHR : 156x/mnt of active fase of stage
1

06.10 Patient felt RR: 20 x/mnt G5P1A3H1 Observation mother and

am abdominal pain Pulse :90 x/mnt aterm/single/life/intra fetal well being.
His : 3x/10~30 uterine with retracted
FHR : 140x/mnt of active fase of stage
1

06.40 Patient felt RR: 20 x/mnt G5P1A3H1 Observation mother and

am abdominal pain Pulse :90 x/mnt aterm/single/life/intra fetal well being.
His : 3x/10~30 uterine with retracted
FHR : 140x/mnt of active fase of stage
1

O7.15 Patient felt RR: 20 x/mnt G5P1A3H1 Reported to supervisor

am abdominal pain Pulse :90 x/mnt aterm/single/life/intra Advice : evaluation 1 hours
His : 3x/10~30 uterine with retracted again.
FHR : 140x/mnt of active fase of stage
VT : 8 cm, eff 80 %, 1
amnionic membrane (+),
descend HI+, fontanella minor
posterosinistra, unpalpable
small organ and umbilical cord.

07.45 Patient felt more RR: 20 x/mnt G5P1A3H1 Observation mother and
abdominal pain Pulse :90 x/mnt aterm/single/life/intra fetal well being.
His : 3x/10~30 uterine with retracted
FHR : 140x/mnt of active fase of stage
Waktu Subject Object Assesment Planning
08.15 Patient felt RR: 20 x/mnt G5P1A3H1 Reported to supervisor
am abdominal pain Pulse :90 x/mnt aterm/single/life/intra Advice : prepare to SC.
His : 3x/10~30 uterine with retracted -Injection of ampicillin 2
FHR : 140x/mnt of active fase of stage 1 gram
VT : 8 cm, eff 80 %, amnionic -Infuse 500 ml RL
membrane (+), descend HI+,
fontanella minor posterosinistra,
unpalpable small organ and
umbilical cord.

08.45 BP = 110/80 G5P1A3H1 Sent the patient to the

am RR: 20 x/mnt aterm/single/life/intra operation room.
Pulse :90 x/mnt uterine with retracted
His : 3x/10~30 of active fase of stage 1
FHR : 140x/mnt
09.50 stage 2 of labor Baby was born with
am SC, male, 2800 g,
body length 48 cm,
AS = 6-8.
stage 3 of labor Placenta was born
manuallly, complete.
Bleeding : 300 cc
11.00 am RR= 20 x/mnt stage IV of labor Observation maternal
Tax = 36,8 well being
Pulse = 80 x/mnt Observation for
Uterus contraction : well, hemorrhage sign
Fundal uterine length = 2
finger below umbilical
Bleeding = -, lochia (+)
Waktu Subject Object Assesment Planning
11.15 am RR= 20 x/mnt stage IV of labor Observation maternal well
Tax = 36,8 being
Pulse = 80 x/mnt Observation for hemorrhage
Uterus contraction : well, Fundal sign
uterine length = 2 finger below
umbilical
Bleeding = -, lochia (+)

11.30 pm BP = 110/80 stage IV of labor Observation maternal well

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

11.45 pm RR= 20 x/mnt stage IV of labor Observation maternal well

Tax = 36,8 being
Pulse = 80 x/mnt Observation for hemorrhage
Uterus contraction : well, Fundal sign
uterine length = 2 finger below
umbilical

12.00 pm BP = 110/80 stage IV of labor Observation maternal well

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

12.30 am BP = 110/80 1 daay post labor Observation maternal well

RR= 20 x/mnt being
Tax = 36,8 Observation for hemorrhage
Pulse = 80 x/mnt sign
Uterus contraction : well, Fundal
uterine length = 2 finger below
umbilical
Bleeding = -
Lochia rubra (+)
Waktu Subject Object Assesment Planning
01.00 pm BP = 110/80 stage IV of labor Observation maternal well
RR= 20 x/mnt being
Pulse = 80 x/mnt Observation for hemorrhage
Uterus contraction : sign
well, Fundal uterine
length = 2 finger below
umbilical
05.00 pm BP = 110/80 stage IV of labor Observation maternal well
RR= 20 x/mnt being
Tax = 36,8 Observation for hemorrhage
Pulse = 80 x/mnt sign
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
09.00 pm BP = 110/80 stage IV of labor Observation maternal well
RR= 20 x/mnt being
Tax = 36,8 Observation for hemorrhage
Pulse = 80 x/mnt sign
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
06.00 am BP = 110/80 1 daay post labor Observation maternal well
RR= 20 x/mnt being
Tax = 36,8 Observation for hemorrhage
Pulse = 80 x/mnt sign
Uterus contraction :
well, Fundal uterine
length = 2 finger below
umbilical
Bleeding = -
Lochia rubra (+)
Name : Mrs. Sumiati CTH : 15 11 - 2008
Age : 33 years : 02.10 pm
Address : Gunung Sari
Wakt
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Subject Object Assesment Planning

02.2 Patient refered by Pamenang General status : G4P3A0H3 Observation mother

0 Community Health Center General condition: well, aterm/single/life/ intra and fetal well being.
pm Conciousness: CM uterine + mild pre- Laboratory
with G4P3A0H3
postterm/single/life/ intra uterine + BP: 140/90 mmHg eclampsi. examination : DL, UL,
RR: 20 x/mnt HBsAg
mild pre-eclampsi. Pulse :84 x/mnt Reported to
T: 36,8 C supervisor Advice :
cronologis : Eyes : an(-) ikt (-) observation of inpartu
Patient went to
Pamenang Cor -Pulmo : in normal range sign.
Community Health Center at
08.00 am (15-11-08) for Obstetric status :
routine control. bAbdominal L1 : breech
pain (-), loody show (-), water L2 : right back
discharge (-), and the fetal L3 : head
movement was active. The L4 : desend 4/5
examination in Pamenang Uterine Fundal Length : 32 cm
Community Health Center EFW : 3255 g
found : His : (-)
Fetal Heart Rate : 144 x/mnt
General status : well
VT : 1 cm eff 10 %, amnionic
BP : 150/80 mmHg membrane (+), descend HI+, unpalpable
Pulse =88 x/mnt small organ and umbilical cord.
RR: 24 x/mnt
Temp = 36C
Extremitas = oedem (+)
UFL = 42 cm
Head presentation, desend 4/5.
Then the Pamenang CHC sent this
patient to Mataram Hospital.
Wakt
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Subject Object Assesment Planning

Last menstrual period : -

History of family planning : Lab. result:
HBsAg (-)
injection/3 months and pil. HB = 13,6
Family planning : IUD ? WB = 10.200
ANC : routine in public health TRB = 261.000
center, 7x. HMT = 38,5
Obstetric history: Proteinuri (+1)
1.Female, aterm, spontan, dukun,
16 years old.
2.Male, aterm, spontan, hospital,
16 years old.
3.Male, aterm, spontan, hospital,
16 years old.
4.Now.
 Time Subject Object Assesment Planning

03. 00 RR: 20 x/mnt G4P3A0H3 Observation mother and

pm Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : - uterine + mild pre-
FHR : 156x/mnt eclampsi.

04.00 BP: 140/90 mmHg G4P3A0H3 Observation mother and

pm RR: 20 x/mnt aterm/single/life/ intra fetal well being.
Pulse :90 x/mnt uterine + mild pre-
His : - eclampsi.
FHR : 140x/mnt

05.00 RR: 20 x/mnt G4P3A0H3 Observation mother and

pm Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : - uterine + mild pre-
FHR : 140x/mnt eclampsi.
O6.00 BP: 140/90 mmHg G4P3A0H3 Reported to supervisor
pm RR: 20 x/mnt aterm/single/life/ intra Advice : evaluation 1 hours
Pulse :90 x/mnt uterine + mild pre- again.
His : - eclampsi.
FHR : 140x/mnt

07.00 pm RR: 20 x/mnt G4P3A0H3 Observation mother and

Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : - uterine + mild pre-
FHR : 140x/mnt eclampsi.

08.00 pm BP: 140/90 mmHg G4P3A0H3 Sent the patient to the Nifas
RR: 20 x/mnt aterm/single/life/ intra room.
Pulse :90 x/mnt uterine + mild pre-
His : - eclampsi.
FHR : 140x/mnt
 Time Subject Object Assesment Planning

11.30 Patient refered RR: 20 x/mnt G4P3A0H3 Reported to supervisor :

am by Nifas room Pulse :90 x/mnt aterm/single/life/ intra advice
with pro His : 1x/10~15 uterine + mild pre-
oxytocin drip FHR : 156x/mnt eclampsi.
VT : 2 cm eff 25 %,
amnionic membrane (+),
descend HI+, unpalpable small
organ and umbilical cord.

12.30 BP: 140/90 mmHg G4P3A0H3 Oxytocin drips 5

am RR: 20 x/mnt aterm/single/life/ intra units in 500 ml
Pulse :90 x/mnt uterine + mild pre- Ringers lactate,
His : 1x/10~15 eclampsi. start at 8
FHR : 140x/mnt drops/mnt.
01.00 RR: 20 x/mnt G4P3A0H3 Observation mother and
pm Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : 1x/10~15 uterine + mild pre- Oxytocin drip 12 drops/mnt
FHR : 140x/mnt eclampsi.

01.30 BP: 140/90 mmHg G4P3A0H3 Observation mother and

pm RR: 20 x/mnt aterm/single/life/ intra fetal well being.
Pulse :90 x/mnt uterine + mild pre- Oxytocin drip 16 drops/mnt
His : 1x/10~15 eclampsi.
FHR : 140x/mnt

02.00 pm RR: 20 x/mnt G4P3A0H3 Observation mother and

Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : 1x/10~20 uterine + mild pre- Oxytocin drip 20 drops/mnt
FHR : 140x/mnt eclampsi.
 Time Subject Object Assesment Planning

03.00 RR: 20 x/mnt G4P3A0H3 Observation mother and

pm Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : 1x/10~20 uterine + mild pre- Oxytocin drip 28 drops/mnt
FHR : 156x/mnt eclampsi.
03.30 BP: 140/90 mmHg G4P3A0H3 Observation mother and
pm RR: 20 x/mnt aterm/single/life/ intra fetal well being.
Pulse :90 x/mnt uterine + mild pre- Oxytocin drip 32 drops/mnt
His : 1x/10~20 eclampsi.
FHR : 140x/mnt

04.00 Patient felt RR: 20 x/mnt G4P3A0H3 Observation mother and

pm abdominal pain Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
His : 2x/10~25 uterine + mild pre- Oxytocin drip 36 drops/mnt
FHR : 140x/mnt eclampsi.

04.30 Patient felt BP: 140/90 mmHg G4P3A0H3 Observation mother and
pm abdominal pain RR: 20 x/mnt aterm/single/life/ intra fetal well being.
Pulse :90 x/mnt uterine + mild pre- Oxytocin drip 40 drops/mnt
His : 2x/10~30 eclampsi.
FHR : 140x/mnt

05.00 pm Patient said RR: 20 x/mnt G4P3A0H3 Observation mother and

that there was Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
water out from His : 2x/10~30 uterine + laten fase of Oxytocin drip 40 drops/mnt
her vagina FHR : 140x/mnt stage 1 of labor+ mild
VT : 3 cm eff 50 %, pre-eclampsi.
amnionic membrane (-),
amniotic fluid (+) jernih,
descend HI+, fontanella minor
horizontal, unpalpable small
organ and umbilical cord.
Waktu Subject Object Assesment Planning
06.00 Patient felt BP: 130/90 mmHg G4P3A0H3 Observation mother and
pm abdominal RR: 20 x/mnt aterm/single/life/ intra fetal well being.
pain Pulse :90 x/mnt uterine + mild pre- Oxytocin drip 36 drops/
His : 3x/10~35 eclampsi. mnt
FHR : 140x/mnt

06.30 Patient felt His : 3x/10~40 G4P3A0H3 Observation mother and

pm abdominal FHR : 140x/mnt aterm/single/life/ intra fetal well being.
pain Inspeksi : bloody show. uterine + active fase of Oxytocin drip 28 drops/
VT : 6 cm eff 80 %, amnionic stage 1 of labor + mild mnt
membrane (-), amniotic fluid (+) pre-eclampsi.
jernih, descend HI+, fontanella
minor horizontal, unpalpable small
organ and umbilical cord.

07.00 Patient felt RR: 20 x/mnt G4P3A0H3 Observation mother and

pm abdominal Pulse :90 x/mnt aterm/single/life/ intra fetal well being.
pain His : 3-4x/10~45 uterine + + active fase Oxytocin drip 20 drops/
FHR : 140x/mnt of stage 1 of labor + mnt
mild pre-eclampsi.

07.20 Patient Inspeksi : doran teknus perjol Stage 2 of labor Condact the mother to
pm want to vulka. bearing down.
bearing
down
07.25 pm Baby was born
spontanously,
female, 3600 g,
body length 51 cm,
AS = 7-9.
07.30 pm stage 3 of labor Placenta was born
 Waktu Subject Object Assesment Planning

07.45 pm BP = 140/90 stage IV of labor Observation maternal

RR= 20 x/mnt well being
Tax = 36,8 Observation for
Pulse = 80 x/mnt hemorrhage sign
Uterus contraction : well,
FUL = 2 finger below
umbilical
08.00 pm RR= 20 x/mnt stage IV of labor Observation maternal
Tax = 36,8 well being
Pulse = 80 x/mnt Observation for
Uterus contraction : well, hemorrhage sign
FUL = 2 finger below
umbilical
08.15 pm RR= 20 x/mnt stage IV of labor Observation maternal
Tax = 36,8 well being
Pulse = 80 x/mnt Observation for
Uterus contraction : well, hemorrhage sign
FUL = 2 finger below
umbilical
08.30 pm BP = 130/80 stage IV of labor Observation maternal
RR= 20 x/mnt well being
Tax = 36,8 Observation for
Pulse = 80 x/mnt hemorrhage sign
Uterus contraction : well,
FUL = 2 finger below
umbilical
Lochia rubra (+), bleeding
(-)
09.00 pm RR= 20 x/mnt 1 daay post labor Observation maternal
Waktu Subject Object Assesment Planning

09.30 BP = 120/80 stage IV of labor Observation maternal

pm RR= 20 x/mnt well being
Tax = 36,8 Observation for
Pulse = 80 x/mnt hemorrhage sign
Uterus contraction :
well,
FUL = 2 finger below
umbilical
Lochia rubra (+),
bleeding (-)
06.00 BP = 110/80 1 day post labor Observation maternal
am RR= 20 x/mnt well being
Tax = 36,8 Observation for
Pulse = 80 x/mnt hemorrhage sign
Uterus contraction :
well, Fundal uterine
length = 2 finger
below umbilical
Bleeding = -
Lochia rubra (+)

Baby well being

T : 36,7, RR :
40x/mnt, ASI