Morning Report

Nov, 17th 2009

Supervised by : dr. Edi P.W. SpOG

Medical Student:
Syarif
Winda
Helmiati
Halia
Cases
resume :

G1P0A0L0 A/S/L/IU head presentation

neglected active phase first stage of labor

G1P0A0L0 42 week/S/L/IU head presentation with

oligohidramnion

Normal labor

with

Admitted
to
Hospital

Name/adress

: Mrs. S / Sesaot

Age

20 years old

Address
Time

Narmada
Subject

Object

Patient came to Mataram GH

referred by Sedau PHC with
G1P0A0L0
A/S/L/IU
head
presentation with neglected active
phase first stage of labor
Chronologist :
Patient came to Sedau PHC at 07.00
(17/11/09) refered by polindes
confess abdominal pain since 06.00,
AM (+) ,fetal movement (+), history of
hipertension (-), and history of DM (-).
LMP : forgot
ANC : 6x at PHC, last 15 nov 2009
Examination at PHC :
BP: 120/80 mmHg
PR: 84 bpm
RR: 16 bpm
T: 36 C
VT : CD 4 cm, AM (+), head palpable,
descend HI.

Examinaton at ER :
BP :120/80 mmHg
PR : 84 bpm
RR : 20 tpm
Temp : 36,3 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :30 cm
EFW : 2945 g
FHR :136 bpm
UC :2x10-25
VT :CD 4 cm, eff 40%, AM (+),
head palpable, descend HI+,
denominator fontanella minor
anterior, small part of fetal and
umbilical cord unpalpable

22.20

Th/: infus RL

Lab. Examination :
Hb : 11,7 gr%
Leko : 16.200 mm3
Trombo : 224.000 mm3
Hct : 37,3
HBsAg : -

17 Nov 2009

22.20 wita
Assesment

Planning

G1P0A0L0
A/S/L/IU head
presentation with
neglected active
phase first stage
of labor

Obs. Mother and fetal

wellbeing
Report to supervisor:
Propose: acseleration with
oxcytocin drip
CTG
Advice: acseleration agree

Time

Subject

Object
Pelvic evaluation:
Os coccygeus mobile
Archus pubis >90
Spina ischiadica not prominent

0%

Examinaton at VK :
General condition: good
BP :120/80 mmHg
PR : 80 bpm
RR : 20 tpm
Temp : 36 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :30 cm
EFW : 2945 g
FHR :136 bpm
UC :2x10-25
CTG baseline : 145 bpm
Obstetric status:
1.This
Contraception history : inject 3
month
Contraception planing : inject 3
month

Assesment

Planning

Time

Subject

Object

Assesment

Planning

G1P0A0L0 A/S/L/IU head

presentation with neglected
active phase first stage of
labor

Aceleration with
oxytocin 5 IU in D5%
500 cc start at 8 dpm
Observed UC and
FHR 30 minutes again

23.30

Abdominal pain >

UC: 2x10~25
DJJ : 11 12 11 bpm

24.00

Abdominal pain >>

UC: 3x10~30
DJJ : 11 12 11 bpm

Observed UC and
FHR 30 minutes again

00.30

Abdominal pain >>

UC: 3x10~30
DJJ : 11 12 12 bpm

Observed UC and
FHR 30 minutes again

01.00

Abdominal pain >>

UC: 3x10~30
DJJ : 12 12 11 bpm

Observed UC and
FHR 30 minutes again

01.30

Abdominal pain >>

UC: 3x10~35
DJJ : 12 11 11 bpm

Observed UC and
FHR 30 minutes again

01.50

Watery vaginal discharge

UC:3x10/40
FHR:11-12-11 bpm
VT :CD complete, AM (-),
green thin, head palpable,
descend HIII, denominator
fontanella minor anterior,
small part of fetal and
umbilical cord unpalpable

02.00

Abdominal pain>>>,
want to bear down

FHR: 13-12-12
Doran teknus perjol vulka

02.20

mother

G1P0A0L0 A/S/L/IU head

presentation second stage of
labor

Educate to prepare for

delivery of baby

Conduct mother to
bear down
Stage 2 of labor

Stage 3 of labor

Baby was born female,

2600 gram, A-S 6-8
Amniotic fluid green
thin
Rupture Perineum
grade 2
Placenta was born 5
minutes later

Time

Subject

Object

04.20

BP :110/70 mmHg
PR : 88 x/
RR : 16x/
Temp : 36,9C
UC : good
FUH: 2 finger below umbilicus
Active vaginal bleeding (-)

07.00

BP :110/60 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,5C
UC : good
FUH: 2 finger below umbilicus
Active vaginal bleeding (-)
Baby :
RR : 36 tpm
HR: 120 bpm
T:36,5C

Assesment
2 hours post partum

Planning
Referred mother
and baby to melati
room

Admitted
to
Hospital

Name/adress

: Mrs. F/Gunung Sari

Age

21 years old

Address
Time

Narmada
Subject

Object

Patient reffered by Gunung Sari PHC

with G1P0A0 42-43 w/S/L/IU head
presentation. Patient came to out patien
care Mataram GH confess pregnant
more than 9 month. Fetal movement (+),
history of hipertention (-), DM (-).
Examination in PHC:
General condition: good
BP :110/80 mmHg
PR : 80bpm
LMP:25/1/09
EDD: 2/11/09
UFH: 35 cm
Examination in OPC
BP :130/80 mmHg
PR : 84bpm
RR : 16 tpm
Temp : 36,5 C
An -/-, ict -/Ext : oedema -/LMP:25/1/09
EDD: 2/11/09
ANC 7 x, last 16 nov 2009.
Obstetric status :
L1 : breech
L2 : fetal back on the right side
L3 : head
L4 : was in pelvic inlet 4/5

Examinaton at VK :
BP :110/80 mmHg
PR : 84 bpm
RR : 16 tpm
Temp : 37 C
An -/-, ict -/Cor & pulmo : in normal range
Abd : normal range
Ext : oedema -/Obstetric status :
L1 : breech
L2 : fetal back on the left side
L3 : head
L4 : was in pelvic inlet 4/5
UFH :33 cm
EFW : 3410 gr
FHR :12-13-12 bpm
UC :VT: CD 1 cm, eff 25%, AM (+), head
palpable,
denominator
unclear,
descend H1 +, unpalpable small
part of fetal and umbilical cord
Lab. Examination :
Hb : 11,3 gr%
Leko : 11.600 mm3
Trombo : 179.000 mm3
Hct : 30,7 gr%
HBsAg : PS: 5

12.00

17 Nov 2009

12.00 wita
Assesment

Planning

G1P0A0L0 42-43
week/S/L/IU head
presentation with
oligohidramnion

Obs. Mother and fetal

wellbeing
CTG
Report to supervisor (11.00)
Induction with oxytocin drip

Time

Subject
UFH :33 cm
EFW : 3410 gr
FHR :12-12-12 bpm
UC : USG:
Fetal S/L/IU head presentation
amnion clear and little
Obstetric status:
1.Now
History KB (-)
Planing KB (-)

Object
Pelvic evaluation:
Os coccygeus mobile
Archus pubis >90
Spina ischiadica not prominent

Assesment

Planning

Time

Subject

Object

Assesment

14.00

Abdominal pain-

CTG baseline : 145 bpm

UC :-

14.30

Abdominal pain-

UC:FHR:11-12-12

Observed UC and FHR 30

minutes again

15.00

Abdominal pain-

UC:FHR:12-12-12

Observed UC and FHR 30

minutes again

15.30

Abdominal pain-

UC:FHR:11-12-11

Observed UC and FHR 30

minutes again

16.00

Abdominal pain-

UC:FHR:13-12-12

Observed UC and FHR 30

minutes again

16.30

Abdominal pain>

UC: 1x10/20
FHR:16-13-16

17.00

Abdominal pain>

UC: 1x10/20
FHR:14-12-13

Obs. Mother and fetal

wellbeing

17.30

Abdominal pain>

UC: 2x10/25
FHR:12-12-13

Obs. Mother
wellbeing

0%

G1P0A0L0 42-43
week/S/L/IU head
presentation with
oligohidramnion

Planning

G1P0A0L0
42-43
week/S/L/IU
head
presentation
with
oligohidramnion+fetal
distress

Induction with oxytocin 5 IU

in D5% 500 cc start at 8
dpm
Observed UC and FHR 30
minutes again

Report to supervisor:
Propose: stop drip oxytocin,
resucitation:
RL:D5=2:1
O2 5 ltr
Left lateral position
Advice: propose aggre and
SC at morning.

and

fetal

Time

Subject

Object

Assesment

Planning

18.00

Abdominal pain>

UC: 2x10/30
FHR:12-12-13

Obs. Mother and fetal

wellbeing
Observed UC and FHR 30
minutes again

18.30

Abdominal pain>

UC: 3x10/30
FHR:12-12-12

Obs. Mother and fetal

wellbeing
Observed UC and FHR 30
minutes again

19.00

Abdominal pain>

UC:3x10/40
FHR:12-12-12

Obs. Mother and fetal

wellbeing
Observed UC and FHR 30
minutes again
Evaluation 2 hours again

19.30

Abdominal pain>

UC:3x10/40
FHR:11-12-11

Obs. Mother and fetal

wellbeing
Observed UC and FHR 30
minutes again

20.00

Abdominal pain>>

UC:3x10/40
FHR:13-12-12

Observed UC and FHR 30

minutes again

20.30

Abdominal pain>>

UC:3x10/40
FHR:11-12-12

Observed UC and FHR 30

minutes again

21.00

Abdominal pain>>>

UC:4x10/40
FHR:11-12-12
L4:2/5
VT :CD 8 cm, eff 80%, AM (+), head
palpable, descend HII, denominator
fontanella minor anterior, small part of
fetal and umbilical cord unpalpable

21.30

Abdominal pain>>>>

UC:4x10/40
FHR:11-12-12

G1P0A0L0
42-43
week/S/L/IU
head
presentation
of
active
phase first stage of labor
with oligohidramnion

Observed UC and FHR 30

minutes
VT 2 hour again
again

Observed UC and FHR 30

minutes again

Time

Subject

Object

22.00

Watery vaginal discharge

UC:4x10/40
FHR:11-12-11
VT :CD complete, AM (-), clear, head
palpable, descend HIII, denominator
fontanella minor anterior, small part of
fetal and umbilical cord unpalpable

22.15

Abdominal pain>>>>, mother

want to bear down

FHR: 13-12-12
Doran teknus perjol vulka

22.45

Assesment
Stage 2 of labor

Stage 3 of labor

BP :100/60 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,8C
UC : good
UFH : 2 finger below umbilicus
Active vaginal bleeding (-)

06.30

BP :110/80 mmHg
PR : 76 x/
RR : 16x/
Temp : 36,5
UC: good
FUH: 2 finger below umbilicus
Active vaginal bleeding (-)
Baby:
T:36,6 C
RR: 36 tpm
HR : 120 bpm

Educate to prepare for

delivery of baby

Conduct mother to bear

down
Stage 2 of labor

00.45

Planning

2 hours post partum

Baby was born female, 3300

gram, A-S 7-9
Amniotic fluid clear
Rupture Perineum grade 2
Postterm sign:
Stadium I
Placenta was born 8 minutes
later
Referred mother and baby to
melati room

Motivated to breastfeeding