Morning Report

18 August 2013
Supervisor : dr.I Made Putra Juliawan, Sp.OG.
Normal Labor : 2
Pathologic Labor : 2
1.G5P4A0L4 A/S/L/IU head presentasion with
2.G1P0A0L0 ___weeks head presentasion with

Identity
Name
: Mrs. R
Age
: 40 yo
Address
: Pringgabaya
Lombok Tengah
Admitted : August, 18th 2013 at
15.15wita
MR
: 520258

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

17/08/2013
15.15

Patient referred from GH Praya with

G5P4A0L4 41-42 A/S/L/IU with
prolonged
PEB
+
impending
eclampsia.
Patient
confessed
abdominal pain spread to frank since
14.00 (16/08/2013). Patient confessed
water leak out from her womb since
13.00 (16/08/2013), bloody slim (-)
FM (+). Headhace (-), blur vision
(-),epigastial pain (-).

General Status :
GC : well
BP : 160/100 mmHg
PR : 92 bpm
RR : 32 bpm
T : 36,8 oC
Eye : anemis (-/-), icteric (-/-)
Cor : S1S2 single regular, murmur (-),
gallop (-).
Pulmo : vesicular (+/+), wheezing (-/-),
ronkhi (-/-).
Abdomen : scar (-), stria gravidarum
(+), linea nigra (+).
Extremity : edema (-/-), warm acral (+/
+).

G5P4A0L4
A/S/L/IU head
presentasion laten
phase 1st of labor
with PROM +
PEB.

Observation mother
fetal well being.
Check CBC, UC & HbsA
O2 5L/m
Infuse RL+drip MgSO
(from GH Praya)
DM co to GP pro observa
Advice GP :
- Observation
- CTG (when CTG reaktiv
pro induksi)

No history of DM, HT, asthma.

LMP : Forgot
EDD :History of ANC : 4x at Posyandu
History of USG : History of family planning : injection
3 months.
Next family planning :IUD
Obstetrical History :
I.9 month, at home, shaman, Male, 20
yo, Life
II.9 month, at home, shaman, Male,
19 yo, Life
III.9 month, at home, shaman, Male,
15 yo, Life
IV.8 month, at home, shaman, Male,
20 yo, Life
V.This

Obstetrical Status :
L1 : breech
L2 : back on the right side
L3 : head
L4 : 4/5
UFH : 32 cm
EFW : 3255 gram
UC : 1x10-20
FHB : 12-12-13 (148bpm)
VT : 2 cm, eff 25%, amnion (-)
clear,
head
palpable

HII,
denominator unclear, impalpable small
part and umbilical cord.

TIME

SUBJECTIVE
Chronologist: -

OBJECTIVE
Lab (at GH NTB, )
WBC : 16,0
HB: 12,6
RBC: 4,86
HCT: 37,4
PLT: 437
HbSAg: non reaktive
Proteinuria : +3

ASSESTMENT

PLANNING

TIME

SUBJECTIVE

17.00

Headhace (+), blur vision (+)

OBJECTIVE
General Status :
GC : well
BP : 160/110 mmHg
PR : 96 bpm
RR : 30 bpm
T : 36,5 oC

ASSESTMENT

PLANNING

G5P4A0L4 A/S/L/IU
head presentasion laten
phase 1st with PEB +
impending eclampsia.

Observation mother
& fetal well being.
Result CTG, DM
co to GP : ProCS
(GP agree)
GP co to SPV :
- Resusitasi
Intrauterine (RL:DL
2:1)
- ProCS 21.00

G5P4A0L4 A/S/L/IU
head presentasion laten
phase 1st with PEB +
impending eclampsia

Observation mother
& fetal well being
CIE mother and
family to CS, Acc
CS.

Obstetrical Status
UC : 2x10-35
FHB : 11-11-13 (bpm)
VT : 3 cm, eff 25%, amnion (-)
clear, head palpable HII,
denominator unclear, impalpable
small part and umbilical cord.
18.30

General Status :
GC : well
BP : 150/110 mmHg
PR : 80 bpm
RR : 40 bpm
T : 36,5 oC
UC : 1x10-30
FHB : 11-11-11 (bpm)

20.00

General Status :
GC : well
BP : 160/120 mmHg
PR : 80 bpm
RR : 40 bpm
T : 36,5 oC
UC : FHB : 13-13-14 (bpm)

G5P4A0L4 A/S/L/IU
head presentasion laten
phase 1st with PEB +
impending eclampsia

Observation mother
& fetal well being
Pre op

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

21.20

PLANNING
CS begin

21.25
Baby was born, male,
, A-S : 7-9, BB
3300gr, BL : 50 cm,
anus (+), congenital
anomaly (-)
Placenta was born
manual complete,
bleeding 500 cc
23.25

GC: well
Consciousness: E4V5M6
BP: 130/80 mmHg
PR: 80 bpm
RR: 20 tpm
T: 36,5oC
UC : (+)
Active bleeding (-)
Lochea rubra (+)
UFH : 2 fingers below umbilical

2 hours post CS

-Observation vital
sign and bleeding
-Suggest mother to
breast feeding
-Suggest mother to
eat, drink, and
mobilization

TIME
18/08/13
06.00

SUBJECT

OBJECT
GC: well
Consciousness: E4V5M6
BP: 120/80 mmHg
PR: 84 bpm
RR: 20 tpm
T: 36,6oC
UC : (+)
Active bleeding (-)
Lochea rubra (+)
UFH : 2 fingers below umbilical
Baby in NICU:
HR : 144 bpm
RR: 40 x/m
Temp : 36,7oC

ASSESSMENT
1 day post CS

PLANNING
- Observation vital sign and
bleeding
- Suggest mother to breast
feeding
- Suggest mother to eat, drink,
and mobilization