MORNING REPORT

TH
24 OF DECEMBER
2013
Supervisor: dr. Doddy Aryo
Kumboyo, SpOG
DM: Titin, Sandi, Armand, Rara

PATIENT IDENTITY

Name : Mrs. S
Age : 20 yo
Address :Kayangan
Addmitted :December 23th 2013
RM :529250
G1P0A0L0 42-43 weeks S/L/IU
head presentation

TIME

SUBJECTIVE

23/1
2/20
13

Patient came to Pregnancy

Policlinic NTB GH referred
from Kayangan PHC with
G1P0A0L0 42 weeks S/L/IU
with serotinus. Abdominal
pain (-) history rupture of
membrane (-), bloody slim
(-), FM (+).
No history of DM, HT,
asthma.

11.3
0
WIT
A

LMP : 28/02/2013
EDD : 05/12/2013
History ANC : > 7x at PHC
Last ANC : 21/12/2013
USG : 1x at NTB GH.
Result : placenta grade III,
BPD 92, AC 30, FL 74,
Amnion sufficient turbid,
EFW 2700.
History of family planning :
(-)
Next family planning :
Injection 3 months
History of Obstetric :
1. This

OBJECTIVE
General Status :
GC : well
BP : 120/80 mmHg
PR : 88 bpm
RR : 20 bpm
Temp : 36,7oC
Eye : palor (-/-), icteric
(-/-)
Cor : S1S2 single
reguler, murmur (-),
gallop (-).
Pulmo : vesikuler (+/
+), wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-),
striae (+), linea nigra
(+).
Extremity : edema
(-/-), warm acral (+/
+).
Obstetric Status :
L1 : breech
L2 : back on the right
side
L3 : head
L4 : 4/5
UFH : 30 cm
EFW : 2945 gram

ASSESSMENT

PLANNING

G1P0A0L0 4243 weeks

S/L/IU head
presentation

Observation
mother & fetal
well being.
CTG
DM co to SPV Pro
Induction of labor
with oxytocin drip,
SPV
advice:
induction with drip
oxytocin

TIME

SUBJECTIVE

23/1
2/20
13

@ Kayangan PHC
Subjective : 9 months
pregnant woman confessed
abdominal pain since
21/12/2013 at 08.00
WITA,LMP 28/02/2013, EDD
07/12/2013.
Objective:
General condition : Well
GCS: CM
BP : 110/70 mmHg
PR : 82 x/m
RR : 22 x/m
Temp : 36,5 C
UFH: 30 cm, breech
palpable in fundus, back of
right side,
FHR: (+), regular,12-11-12
(140x/m), UC (-), VT not
doing.
Assesment:
G1P0A0L0
42
weeks
S/L/IU head presentation
with serotinus.

OBJECTIVE
PS: 6
Dilatation Servix 1
Eff 1
Station 1
Consistency 2
Position 1
PE: seem normal
Spina ischiadica not
prominent
Arcus pubis > 900
Os Coxygeus mobile
Lab Result:
Hb : 11,4 gr/dl
HCT : 34,5%
RBC : 4,81M/uL
PLT : 320 K/uL
WBC : 14,53 K/uL

ASSESSMENT

PLANNING

TIME
14.0
0

SUBJECTIVE
-

OBJECTIVE

ASSESTMENT

GC: well
BP: 120/80 mmHg
PR: 82 bpm
RR: 20
T: 36,8

PLANNING
Drip oxy began 8
dpm flash I

UC: FHR: 11-11-12 (136)

14.3
0

UC: FHR: 11-11-11 (132)

Drip oxy 12 dpm

15.0
0

UC: 2x/10 ~ 25
FHR: 12-11-12 (140)

Drip oxy 16 dpm

15.3
0

Abdominal pain came

and relieved

UC: 3x/10 ~ 30
FHR: 11-12-12 (140)

Drip oxy 20 dpm

16.0
0

Abdominal pain came

and relieved

UC: 3x/10 ~ 35
FHR: 11-11-11 (132)
VT: 3 cm, eff 25%,
amnion (+), head
palpable HI, impalpable
small part / umbilical
cord.

G1P0A0L0 4243 weeks S/L/IU

head
presentation
with latent
phase of labor

Drip oxy 24 dpm

16.3
0

Abdominal pain came

and relieved

UC: 3x/10 ~ 35
FHR: 12-11-11 (136)

Drip oxy 28 dpm

17.0
0

Abdominal pain came

and relieved

UC: 3x/10 ~ 35
FHR: 11-11-11 (132)

Drip oxy 32 dpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

17.3
0

Abdominal pain came

and relieved

UC: 3x/10 ~ 35
FHR: 12-11-12 (140)

Drip oxy 36 dpm

18.0
0

Abdominal pain came

and relieved

UC: 3x/10 ~ 35
FHR: 11-11-12 (136)

Drip oxy 40 dpm

18.3
0

Abdominal pain came

and relieved

UC: 4x/10 ~ 40
FHR: 12-12-12 (144)

Drip oxy 40 dpm

19.0
0

Abdominal pain came

and relieved

UC: 4x/10 ~ 40
FHR: 12-12-12 (144)

Drip oxy 40 dpm

19.3
0

Abdominal pain came

and relieved

UC: 4x/10 ~ 40
FHR: 12-11-12 (140)

Drip oxy 40 dpm

20.0
0

Abdominal pain came

and relieved

UC: 4x/10 ~ 40
FHR: 12-12-12 (144)
VT: 8 cm, eff 75%,
amnion (+), head
palpable HII, impalpable
small part / umbilical cord

G1P0A0L0 4243 weeks S/L/IU

head
presentation
with active
phase of labor

Drip oxy 40 dpm

Flash II

20.3
0

UC: 4x/10 ~ 40
FHR: 12-12-12 (144)

Drip oxy 40 dpm

21.0
0

UC: 4x/10 ~ 40
FHR: 12-12-12 (144)

Drip oxy 40 dpm

TIME

SUBJECTIVE

OBJECTIVE

21.3
0

Abdominal pain came

and relieved

UC: 4x/10 ~ 40
FHR: 12-11-12 (140)

22.0
0

Mother want to bearing

down

Inspection: Crowning

ASSESTME
NT

PLANNING
Drip oxy 40 dpm

2nd stage of
labor

Conduct Labor
Baby was born, at
22.05, female, BW
2900 gram, BL 54cm,
A-S 7-9, sign of
postmature stage I,
congenital anomali (-)
Placenta born
spontan, complete,
500 gram
Active bleeding (-)

TIME

SUBJECTIVE

24.00

OBJECTIVE

General condition : well

BP: 120/80
PR : 80 x / m
RR : 20x/m
T: 36,8

ASSESTMEN
T

P1A0L1 2
hours post
partum

PLANNING

Obs mother well

being
Obs for VS and
bleeding, uterine
contraction

UFH: 2 finger below

umbilicus
UC: (+) well
Active bleeding (-)
24/12/20
13
07.00

General condition : well

P1A0L1 1st
BP: 120/80
day post
PR : 80 x / m
partum
RR : 20x/m
T: 36,8
UFH: 2 finger below
umbilicus
UC: (+) well
Active bleeding (-)
Babies in Rooming
PR: 148 bpm
RR: 50 x/m
Temp :36,6 C

Obs. Mother and

baby well being
CIE: explanation
about result of
examination,
drink n eat, ASI
exclusive, and
mobilization

Skin Exfoliate

Long
Nail