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MORNING REPORT

Sunday, January 31st, 2016 at 07.00 AM


Monday, February 1st, 2016 at 07.00 AM
Physiologic obstetrical patient
Pathologic obstetrical patient
Gynecological patient
Passed Away
Total patient

: 2 case
: 4 cases
: - case
: - case
: 6 cases

Obstetric ward patients


Gynecology and Oncology ward patients
ICU patient
Total Patients

: 34 patients
: 57 patients
: 3 patient
: 94 patients

OBSTETRICS
1.

30-01-16
02:00 PM

Hb : 10.4 g/dl
WBC : 9.200/mm3
PLt :
304.000/mm3
BS: 2

LSCS due to fetal distress


Mrs.
PAJ/33/UA/ARP/MAN
D/ G2P1A0 39 weeks gestational age not inlabor + PROM 2
days SLF cephalic presentation
US ER (NIS):
SLF cephalic presentation
Biometry :
BPD : 93 mm
AC : 332mm
EFW : 3190 g
HC : 334mm
FL : 72 mm
Placenta at anterior corpus of uterine
Amniotic fluid was decrease, AFI 1,3 1,6 = 6,9 cm
1,8 2,2
C/ 39 weeks gestational age SLF cephalic presentation
M/ - Observed vital sign, FHR, inlabor sign
- IVFD RL gtt xx/m
- Laboratory examination
- Ampicillin1g/6 hours iv
- Misoprostol 50mg/6 hours pv
P/ Vaginal delivery

08:00 PM
0 cm

02:00 AM
2 cm
UC 2x/10/25

06:00 AM
3 cm
UC 2x/10/25

08:30 AM

4 cm
UC 4x/10/35
FHR I: 120x/m
FHR II: 105 x/m
FHR III: 101 x/m

10.25 AM
10.30 AM
Hb : 9.1 g/dl
WBC :
15.000/mm3
PLt :
232.000/mm3

D/ G2P1A0 39 weeks gestational age not inlabor + PROM 2


days SLF cephalic presentation
M/ - Observed vital sign, FHR, inlabor sign
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Misoprostol 50mg/6 hours pv
P/ - Vaginal delivery
D/ G2P1A0 39 weeks gestational age inlabor 1st stages
laten phase + PROM 2 days SLF cephalic presentation
M/ - Observed vital sign, FHR, contraction
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Acceleration with oxytocin drip 5 IU
P/ Vaginal delivery
D/ G2P1A0 39 weeks gestational age inlabor 1st stages
laten phase + PROM 2 days SLF cephalic presentation
M/ - Observed vital sign, FHR, contraction
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Acceleration with oxytocin drip 5 IU
P/ Vaginal delivery
D/ G2P1A0 39 weeks gestational age inlabor 1st stages
laten phase + PROM 2 days SLF cephalic presentation
+ fetal distress
M/ - Observed vital sign, FHR, contraction
- IVFD RLgtt xx/m
- Acceleration oxytocin drip 5 IU stop
- O2 5L/m
- Latero position
P/ Abdominal delivery
Consult to Dr. H. Irawan Sastradinata, SpOG(K) Agree for abdominal
delivery
Male life baby was born, BW 3500 gr, BL 48 cm, AS 2/0/0 FTAGA
Placenta was delivered completely, PW 490 g, UCL: 48 cm, 19x 18cm
Mother was in good condition.

30-01-16
11.30 PM
Hb : 10.9 g/dl
WBC :
11.600/mm3
PLt :
311.000/mm3
CRP kuantitatif:
<5
CRP Kualitatif: (-)

05.30 AM

01.30 PM

05.20 PM
05.25 PM
Hb : 10.6 g/dl
WBC :

LSCS due to malpresentation

Mrs. SAL/37/RA/ARP/COR
D/ G2P1A0 40 weeks gestational age not inlabor + PROM 3 days +
secondary infertile 17 years SLF cephalic presentation
US ER (NIS):
SLF cephalic presentation
Biometry :
BPD : 94 mm
AC : 325mm
EFW : 3671 g
HC : 321mm
FL : 74 mm
Placenta at posterior corpus of uterine
Amniotic fluid was enough
C/ 40 weeks gestational age SLF cephalic presentation
M/ - Observed vital sign, FHR, inlabor sign
- IVFD RL gtt xx/m
- Laboratory examination
- Ampicillin1g/6 hours iv
- induction with misoprostol 25 mg/6 hours pv
P/ Vaginal delivery
D/ G2P1A0 40 weeks gestational age not inlabor + PROM 3 days
secondary infertile 17 years SLF cephalic presentation
M/ - Observed vital sign, FHR, inlabor sign
- IVFD RL gtt xx/m
- Misoprostol 25 mg/6 hours pv
P/ Vaginal delivery
D/ G2P1A0 40 weeks gestational age not inlabor + PROM 3 days
secondary infertile 17 years SLF cephalic presentation + failed
induction
M/ - Observed vital sign, FHR, inlabor sign
- IVFD RL gtt xx/m
P/ Abdominal delivery
Consult to Dr. H. Iskandar Zulqarnain, SpOG(K) Agree for abdominal
delivery
Male life baby was born, BW 3250 gr, BL 50 cm, AS 8/9 FTAGA
Placenta was delivered completely, PW 500 g, UCL: 49 cm, 19x
18cm
Mother was in good condition.

22.700/mm3
PLt :
297.000/mm3

3.

31-01-16
01:00 AM

Hb : 10.0 g/dl
WBC :
10.300/mm3
PLT :
235.000/mm3
CRP kuantitatif:
<5
CRP Kualitatif: (-)

05:00 AM

09:00 AM
2 cm
UC 2x/10/25

LSCS due to malpresentation


Mrs.
NUR/19/UA/ ARP/CGH
D/ G1P0A0 40 weeks gestational age not inlabor with
PROM 6 hours + SLF cephalic presentation
US ER (NIS):
SLF cephalic presentation
Biometry :
BPD : 94 mm
AC : 325 mm
EFW : 3147 g
HC : 320 mm
FL : 75 mm
Placenta at anterior corpus of uterine
Amniotic fluid was decrease, AFI: 0,4 1,5 = 6,1 cm
1,9 2,2
C/ 40 weeks gestational age SLF cephalic presentation
M/ - Observed vital sign, FHR
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Laboratory examination
- Oxytocin drip 5 IU
P/ Vaginal delivery
D/ G1P0A0 40 weeks gestational age not inlabor with
PROM 10 hours + SLF cephalic presentation
M/ - Observed vital sign, FHR
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Oxytocin drip 5 IU
P/ Vaginal delivery
D/ G1P0A0 40 weeks gestational age inlabor 1st stages
laten phase with PROM 14 hours + SLF cephalic
presentation
M/ - Observed vital sign, FHR
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Oxytocin drip 5 IU

01:00 PM
2 cm
UC 2x/10/25

05:00 PM
2 cm
UC 2x/10/25

11:05 PM
11:08 PM
Hb : 10.6 g/dl
WBC :
22.700/mm3
PLt :
297.000/mm3

4.

31-01-16
07:00 AM

Hb : g/dl
WBC : /mm3
PLt : /mm3

P/ Vaginal delivery
D/ G1P0A0 40 weeks gestational age inlabor 1st stages
laten phase with PROM 18 hours + SLF cephalic
presentation
M/ - Observed vital sign, FHR
- IVFD RLgtt xx/m
- Ampicillin1g/6 hours iv
- Oxytocin drip 5 IU
P/ Vaginal delivery
D/ G1P0A0 40 weeks gestational age inlabor 1st stages with
prolong laten phase + PROM 22 hours + SLF cephalic
presentation
M/ - Observed vital sign, FHR
- IVFD RLgtt xx/m
P/ Abdominal delivery
Consult to Dr. H. Irawan Sastradinata, SpOG(K) Agree for abdominal
delivery
Female life baby was born, BW 2900 gr, BL 47 cm, AS 8/9 FTAGA
Placenta was delivered completely, PW 500 g, UCL: 49 cm, 19x 18cm
Mother was in good condition.

LSCS due to total placenta previa


Mrs.
EUI/34/RA/ ARP/RIC
D/ G4P3A0 35 weeks gestational age not inlabor with APH
cb total placenta previa + recurrent bleeding + SLF
cephalic presentation
US ER (FOR):
SLF cephalic presentation
Biometry :
BPD : 80 mm
AC : 316 mm
EFW : 2550 g
HC : 311 mm
FL : 63 mm
Placenta at posterior corpus expand to OUI
Amniotic fluid was enough
C/ 35 weeks gestational age SLF cephalic presentation +

01:05 PM
01:08 PM
Hb : g/dl
WBC : /mm3
PLt : /mm3

5.

31-01-16
01:30 PM
Hb : g/dl
WBC : /mm3
PLt : /mm3

Hb : g/dl
WBC : /mm3
PLt : /mm3

31-01-16
04.00 PM

Hb : 11,1 g/dl
WBC :
13.700/mm3
PLt :
242.000/mm3

T3 total:
0,51ng/mL
T4 total: 1,88
mg/dL
Free T4:
0,68ng/dL

total placenta previa


M/ - Observed vital sign, FHR, contraction
- IVFD RLgtt xx/m
- Cefriaxone1g/12 hours iv
- Laboratory examination
P/ Abdominal delivery
Consult to Dr. H. Azhari, SpOG(K) Agree for abdominal delivery
Female life baby was born, BW 2900 gr, BL 47 cm, AS 8/9 FTAGA
Placenta was delivered completely, PW 500 g, UCL: 48 cm, 19x 18cm
Mother was in good condition.

Brandt Andrews manuevre


Mrs.
IIS/42/UA/RIC/RNI
D/ P5A0 post spontaneous delivery (outside) + retained
placenta cb incarserated placenta
M/ - Observed vital sign, contraction, bleeding
- O2 5L/m
- IVFD RLgtt xx/m
- Laboratory examination
P/ Brandt Andrews manuevre
Mother was in good condition.
Spontaneus delivery
Mrs.
AND/37/UA/FEL/RNI
D/ G5P4A0 37 weeks gestational age not inlabor with
hiperthyroid SLF cephalic presentation
US ER (DIK):
SLF cephalic presentation
Biometry :
BPD : 91 mm
AC : 318 mm
EFW : 2778 g
HC : 312 mm
FL : 64 mm
Placenta at anterior corpus
Amniotic fluid was enough
C/ 37 weeks gestational age SLF cephalic presentation

TSH:
0,30mIU/ml

08.00 PM

01-02-16
00.00 AM
2 cm
UC 2x/10/25

04.00 AM

3 cm
UC 2x/10/25

08.00 AM
4 cm
UC 3x/10/35

00.00 PM
8 cm
UC 4x/10/40

M/ - Observed vital sign, FHR, uterine contraction


- IVFD RL gtt xx/m
- Laboratory examination
- Consul to internal department
P/ Vaginal delivery
Internal department reply:
C/ Subclinic hiperthyroid
P/ - Th/ Obgyn department
- Laboratory examination free T4, TSH, next month
D/ G5P4A0 37 weeks gestational age not inlabor with
hiperthyroid SLF cephalic presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RL gtt xx/m
P/ Vaginal delivery
D/ G5P4A0 37 weeks gestational age inlabor 1st stages
laten phase with hyperthyroid SLF cephalic
presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RL gtt xx/m
P/ Vaginal delivery
D/ G5P4A0 37 weeks gestational age inlabor 1st stages
laten phase with hiperthyroid SLF cephalic
presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RL gtt xx/m
P/ Vaginal delivery
D/ G5P4A0 37 weeks gestational age inlabor 1st stages
active phase with hiperthyroid SLF vertex presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RL gtt xx/m
P/ Vaginal delivery
D/ G5P4A0 37 weeks gestational age inlabor 1st stages
active phase with hiperthyroid SLF vertex presentation
M/ - Observed vital sign, FHR, uterine contraction
- IVFD RL gtt xx/m

P/ Vaginal delivery
01.30 PM
Partograph
01:40 PM
01.50 PM
Hb : g/dl
WBC : /mm3
PLt : /mm3

D/ G5P4A0 37 weeks gestational age inlabor 2nd stages


with hiperthyroid SLF vertex presentation
M/ Conduct the labor
Female life baby was born, BW 3000 g, BL 45 cm, AS 8/9 FTAGA
Placenta was delivered completely, PW 500 g, UCL: 47 cm,
18x 19cm
Mother and baby were in good condition