MORNING REPORT 7

2014
Abdi, yid

TH

JULY

 Name : Mrs. R
Age : 35 yo
Admitted : 05/07/2014

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

05/07/
2014
10.24

Patient referred from PHC

Gunung Sari with G3P2A0L3 3637 week S/L/IU head
presentation with mother and fetal
well being latent phase of labor
with Severe Pre-eclampsia.
Patient confessed Abdominal pain
since 04.00 (04-07-14). Water
Leaked out from her vagina (-),
Bloody slim (+), FM (+).

General status:
GC: well
BP: 160/90 mmHg
PR: 82 bpm
RR: 22
T: 36,4 C
Eye : anemis (-), icteric (-)
Thorax :
Cor : S1S2 single reguler (murmur
-), (gallop -)
Pulmo : vesikuler (+/+), wheezing
(-/-), Ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+)
Extremity : edema (+/+), warm acral
(+/+)

G3P3A0L3 36-37
weeks/S/L/IU with
head presentation
active phase of
labor + Severe
pre-eclampsia

- Obs. Mother fetal

and well being
- Obs progress of
labor with partograf
- Continue drip
MgSO4 from PHC
- Bolus MgSO4 40% 6
gr
- DC

No history of DM, asthma, HT

LMP: 25-10-2013
EDD: 04-07-2014
History of ANC: > 4x in PHC
History of USG: History of family planning: inj. 3
month
Next family planning: inj. 3 month
Obstetrical history:
I. Aterm/female-female/15001700/GH NTB/14
yo/Life(Gemeli)
II. Aterm/Female/3500/Polindes/
7yo/Life
III. This

Obstetrical status:
L1: hard to evaluate
L2: hard to evaluate
L3: head
L4: 4/5
UFH: 45 cm
EFW: 5270 g
UC: 3 x10 ~ 40
FHB: 11-12-11 (136 x/min)
VT: 6 cm, eff 50%, amnion (+),
head palpable HI, denom unclear,
impalpable small part / umbilical
cord.

TIME

SUBJECTIVE
Chronologist:
09.05 (05-07-2014)
S:
Patient 9 month confess abdominal pain
and spread to waist. Bloody slim (+).
O:
GC: well
BP: 150/110 mmHg
PR: 88 bpms
RR: 16
T: 36,6 C
UFH: EFW: UC: 3x10 ~ 35
FHB: 136x/min
VT : 2 cm, eff 50%, amnion (+), head
palpable, H I.
Lab:
Protein: +3
A: G3P2A0L3 36-37 week S/L/IU head
presentation with mother and fetal well
being latent phase of labor with Severe
Pre-eclampsia
P:
-infus RL
-Inj. MgSO4 40% 4 gr bolus and drip 6 gr
-Patient refer to NTB GH

OBJECTIVE
Lab:
HB: 11.6 g/dl
RBC: 4.22 M/dl
HCT: 34.6 %
WBC: 11.56 K/dl
PLT: 243 K/dl
HbSAg: (-)
Proteinuria: +3
BT: 330
CT: 615
Blood Glucose: 84
SGOT: 18
SGPT: 10

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

11.30

Mother confess water came out from her

vagina

VT: 7 cm, eff 50%, amnion

(-) clear, head palpable HI,
denom unclear, impalpable
small part / umbilical cord.

DM co to SPV advice
observation
Vaginal birth delivery

11.58

Mother wants to bearing down

GC: well
BP: 170/100 mmHg
PR: 80 bpms
RR: 20
T: 36 C

Baby was born

spontan, female, W :
2300 gram, head
diameter 31 , body
length 45 , A-S 7-9,
caput (-), amnion clear
Congenital anomali (-),
anus (+)

12.00

Mother feel nausea and headache

FUH: 2 fingger upper

umbilicus
VT: complete, amnion (+),
head palpable HI,
impalpable small part /
umbilical cord.

Gemeli

Do amniotomi
DM co to SPV advice:
Severe pre-eclampsia
management
Accelerate second
stage of labor with
vacum extraction
CIE mother and
family about result of
examination and
medical planning

TIME
12.30

SUBJECTIVE
Mother wants to bearing
down

12.35

OBJECTIVE
GC: well
BP: 150/100 mmHg
PR: 80 bpms
RR: 20
T: 36 C
UC: 4x10~ 45
When we will do VE, head of baby was
came out

ASSESTMENT
second baby
retension

UFH: same level as umbilicus

PLANNING
Lead vaginal birth
delivery

Second baby was

born spontan, female,
W : 2600 gram, head
diameter 32 , body
length 45 ,A-S 7-9,
caput (-), amnion clear
Congenital anomali (-),
anus (+)
Active management
3rd phase of labor
Inj oxytosin 1 amp

12.50

13.05

mother felt abdominal pain

Active management
3rd phase of labor
Inj oxytosin 1 amp
(2nd amp)
Placenta wasnt born

Retensio
plasenta

Manual placenta

UFH: same level as umbilicus

13.15

UFH: 2 fingger bellow umbilicus

UC: (+)

Placenta was born,

bleeding + 200cc,
Perineum intact

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

15.05

GC: well
BP: 160/90 mmHg
PR: 82 bpm
RR: 22
T: 36,4 C
UFH: same level as umbilicus
Lochea rubra: 30cc
UO: 100cc/hour

2 hours post
partum

Drip mgso4 40% 28

tpm
Obs mother and baby
well being
Suggest eat and drink
Early mobilization

06-072014
08.30

GC: well
BP: 120/90 mmHg
PR: 88 bpm
RR: 22
T: 36,7 C
UFH: 2 finger bellow
umbilicus
Lochea rubra: (+)
UO : 200 cc/hour

1 day post
partum

Obs mother and baby

well being
Suggest eat and drink
Early mobilization