Morning Report

August, 4 20168
th
Supervisor:
Dr. Sp. OG
DM Jaga:
verga, hani, nisa, silmina
• Name : Ny. Z
• Age : 27 years old
• Address : Lingsar
• Admitted : 04 th August 2018
• RM : 608157
 Case Resume

Pathologies Labor 1. G3P0A2L0 38-39 weeks S/L/IU head presentation with

inpartu laten phase of labor.

Remain Patient
 Time Subjective Objective Assessment Planning

03/08/2018 Pattient refferd from Lingsar PHC with General Status G3P0A2L0 38-39 weeks S/L/IU DM planning:
(16.30) 38-39 weeks S/L/IU inpartu laten GC : well head presentation with inpartu Diagnostic :
phase of labor. Patient pregnant GCS : CM (E4V5M6) laten phase of labor - CBC
confessed that the leage of water BP : 120/80 mmHg
from the vagina (+) since 06:00 PR : 94 x/mnt Therapy in lingsar:
(03/08/2018). Abdominal pain (+) RR : 20 x/mnt - Ampicillin 1 gr IV
since 05.00 (03/08/2018), bloody T : 37.5 C - Paracetamol 1 tablet 500 mg
discharge (-). - Obs. Progress of labor
Fetal heart rate accelerates (+). Fetal Local status - CIE : CIE mother and family
movement decrease (+). Eye : an (-/-), ict (-/-) about diagnostic planning
Pulmo : ve (+/+), rh (-/-), wh (-/-)
History of DM (-), HT in pregnancy (-), Cor : S1S2 single regular, m (-), g(-) DM co GP, GP co SPV, SPV
asthma (-), and allergy (-). Abd : scar (-), striae gravidarum (+), advice:
History of family : DM(-), HT(-), astma linea nigra (+), ballottement (+) - Sectio caesaria
(-). Ext : edema (-/-), warm acral (+/+) - Resusitation
- Drip Cefotaxime 2 grm in
LMP : 09/12/2017 Obstetric status NaCl 100 cc
EDD : 16/09/2018 L1 : breech
GW : 38-39 weeks L2 : back on the right side Co. anesthesia :
L3 : head - ACC SC
History of ANC : 12 x L4 : 4/5
Last result : BP 120/80 mmHg, GW UFH : 32 cm
36-37 weeks, UFH 29 cm, head EFW : 3255 gr
presentation. UC : 3 x 10’- 35
FHB : (-)
VT : 4 cm, eff 50 %, amnion (-), head
palpable, H1, ROA not palpable small
part and umbilical cord
 Time Subjective Objective Assessment Planning

History of USG: 5x at SPOG Lab (03/08/2018)

HB : 12.1
History of family planning: - RBC : 4.44
Next family planning: - WBC : 20.56
PLT : 198

Baby was born at 18.14, apgar

03/08/2018 score 6-8, weight : 3420 g,
(18.14) length : 43 cm, uac : 12 cm.
 Time Subjective Objective Assessment Planning

03/08/2018 Patient confessed General Status - P1A2H1 post SC day 1 - IVFD + oksitoksin
(20.00) postoperative pain GC : well - Cefadroxil 500 mg/
GCS : CM (E4V5M6) 12 j
BP : 110/70 mmHg - Analgesik
PR : 90 x/mnt - Obs. of maternal
RR : 20 x/mnt awareness
T : 36.6 C - Obs. of bleeding
UFH : two fingers below - Obs. of fluid intake
the umbilical, active and output
bleeding (+).